New research highlights potential strategies for improving pain management during intrauterine device (IUD) placement.

Pain during placement can be a barrier to IUD use, while options for effectively managing it remain limited. Two studies published in JAMA examined different approaches to the problem. One found that intrauterine administration of the local anesthetic mepivacaine significantly reduced pain compared with a placebo during IUD placement. Another found that 1 in 5 patients chose intravenous (IV) moderate sedation when it was routinely offered.

Better pain control may influence whether patients choose an IUD in the first place.

“Pain during IUD placement should be taken seriously,” said Karin Elgemark, MD, PhD candidate in the Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet in Sweden and first author of the study. “Improving pain management may help ensure that fear of placement pain does not become a barrier for people who would otherwise consider an IUD.”

“We should be moving toward a model where patients are offered a range of evidence-based pain management options, rather than clinicians assuming that one approach will work for everyone,” said Michael Solotke, MD, clinical assistant professor in the Department of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine in Chicago, who was not associated with either study.

Recent American College of Obstetricians and Gynecologists guidance calls the need for pain management during gynecologic procedures urgent but notes that studies have not established a clear best approach.

Intrauterine Mepivacaine Reduced Placement Pain

In a randomized, double-blind, placebo-controlled trial, researchers enrolled 370 women aged 18-31 years, who had never given birth, at 11 clinics in Sweden between 2021 and 2024.

Participants received either mepivacaine or saline administered into the uterus through a catheter before IUD placement. Participants rated their pain on a 100-point visual scale before the procedure, at the time of drug or placebo administration, during IUD placement, and 10 minutes after speculum removal.

During IUD placement, patients who received mepivacaine reported average pain scores of 44 vs 59 for the placebo group (P < .001). They were also about half as likely to experience severe pain (18% vs 35%).

Patients who received the drug were less likely to say the procedure was more painful than expected (15% vs 34%) and less likely to experience vasovagal reactions, such as feeling faint (8% vs 18%). They were also more likely to say they would choose an IUD again (93% vs 82%) and recommend one to others (79% vs 69%).

“A pain score alone does not tell us how someone experienced the procedure,” Elgemark said. “Whether the pain was tolerable, whether the procedure was worse than they expected, and whether they would choose an IUD again give us a broader picture of whether the pain relief made a meaningful difference to them.”

1 in 5 Patients Chose IV Sedation When Offered

A separate JAMA study examined a different question: When moderate IV sedation is routinely available for IUD placement, how many patients choose it?

Researchers retrospectively reviewed 1324 IUD placements at family planning clinics in Massachusetts between 2024 and 2025. Patients were routinely offered nonsteroidal anti-inflammatory drugs and a paracervical lidocaine block, as well as the option of moderate IV sedation with fentanyl and midazolam.

About 20% of patients chose moderate sedation.

“The fact that 1 in 5 patients chose IV sedation when it was routinely offered suggests there is a meaningful demand for comprehensive pain management options during IUD placement,” Solotke said. “I have had patients cry tears of relief when I offered IV sedation for IUD insertion.”

Patients who received IV sedation were more likely than those who did not receive it to have not given birth (94% vs 85%), have depression or anxiety (65% vs 46%), or have pelvic pain (6% vs 2%). They were also more likely to identify as White (65% vs 53%), not cisgender (10% vs 6%), and not to use an interpreter (99% vs 96%), indicating some level of barriers to access might be at play, Armide Storey, MD, said.

“Every patient should be counseled on the array of pain management options available to them at their local clinic and perhaps also with referral,” said Storey, clinical fellow in the Department of Obstetrics and Gynecology, Complex Family Planning Division at Brigham and Women’s Hospital in Boston and first author of the study. Clinicians should be further encouraged to consider how some of these patient populations may benefit from a more thorough discussion of effective pain management modalities, she said.

Storey said that significant pain is not universal during IUD placement, but that should not diminish the experiences of patients who do have substantial pain.

“There is a large population of patients who are able to have comfortable IUD insertions without any pain management,” she said. “It’s just not everyone. And by pretending that it is, we are silencing the people who have suffered.”

Elgemark, Solotke, and Storey reported no relevant financial conflicts.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.