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Not Just A Pinch
Pain relief is not a luxury, it's a right!
Having an Intrauterine Device (IUD) placed is not a painless procedure. It is uncomfortable at best, painful for most, and traumatizing for some. Currently, there are no standardized practice guidelines for evaluating and planning for pain management during the insertion of an IUD in British Columbia. This results in a “one size fits all” approach where most commonly the recommendation is to take a non-steroidal anti inflammatory drug (Advil or Aleve) prior to the procedure with the expectation that this will be sufficient pain management for everyone. This is not the case!
Pain is Complicated
We know everyone experiences pain differently. For the placement of an IUD, an individual who has been pregnant at least once is more likely to tolerate the discomfort of the procedure compared to a person who has never been pregnant. The fact that psychological experiences, such as a history of trauma or an anxiety disorders, increase the pain a person feels is becoming more widely accepted.
Also, when a person experiences fear around a medical procedure, they are also likely to report more significant pain from that procedure. And ultimately, the thought of going through a painful and possibly traumatizing experience is a barrier keeping people from accessing this now free long-acting reversible contraception (LARC).
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My Pain Matters!
There is a long-standing and systemic minimization of the pain experienced by individuals undergoing gynecological experiences. Traditionally, the patriarchy dictates that pain with these procedures is both “not that bad” and is to be endured with stoicism as part of the “female experience.”
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We say pain is to be believed and managed! There is no good reason for pain to be endured when something can be done to minimize it. We acknowledge that having an IUD placed is painful for most people, that pain is important, and we want to decrease that pain for British Columbians.
It’s Not Just A Pinch!
So why is having an IUD put in so painful? The pain comes from several sources during the procedure. The primary source of pain is from the clamping and manipulation of the cervix by a tenaculum. This causes a sharp pain. The second type of pain experienced is cramping. This comes from prostaglandins released from the cervix when it is manipulated. These cramps can last for several days after the procedure.
How Can We Manage Pain?
The good news is that there are many options to minimize the pain associated with this procedure! First, a consultation with the provider that goes through the procedure and the possibility of pain can lead to more comfort from feeling heard and supported. Pain can be minimized without the use of medications. The use of comfort measures such as music, a soothing environment, and comfort items can all be very effective.
Getting an IUD can cause some people a lot of anxiety. If this is communicated with the care provider during the consultation, anxiolytic medications such as Ativan can be prescribed to be taken shortly before the procedure. This foresight could potentially save people a lot of nervousness going into the clinic.
There are several options for drug-based pain relief too. Taking an NSAID such as Advil or Naproxen prior to the procedure can help with the cramping that commonly is experienced. An inhaled pain medication called Penthrox is becoming popular. It is similar to laughing gas, is controlled by the patient, acts immediately, and clears the body very quickly. Various lidocaine uses can decrease the sharp pains and cramping associated with the procedure. It can be applied to the surface of the cervix in the form of a cream, sprayed inside the uterus, or injected directly into the cervix itself.
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For some people, the experience of getting an IUD is so stressful, or they have a history of significant discomfort with gynecologic procedures, that being sedated is the best option. With a thorough consultation, this need can be identified and planned for. Having an IUD placed under light or total sedation is more involved, expensive, and uses more resources, but there’s no reason it can’t be an option for people who need that level of care.
Where Is BC Now?
In 2023, precedent-setting legislation went into effect in BC that universally covers the cost of all prescription contraception, including IUDs. In the year following the implementation of this the use of long-acting reversible contraceptives (LARCs), including IUDs, increased dramatically. While having the cost barrier removed for those wishing to access IUDs, there are other barriers that can be experienced. One of which is the time needed off work or school to have the procedure done, and recover from it.
In BC, there is a fee code for physicians to pay for paracervical blocks (lidocaine) for the insertion of IUDs, but this is the only direct care targeted specifically for gynecologic procedural pain management in BC. The physicians of BC largely follow recommendations set by the Society for Obstetricians and Gynecologists of Canada (SOGC) for direction on how best to provide care, but there are no BC specific guidelines.
What Are We Asking For?
We are calling on the Province of BC to:
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Set Clear Provincial Standards: Develop and implement BC-specific clinical guidelines for IUD insertions that standardize pain management protocols, establish mandatory competency-based training requirements for all practitioners (including those with expanded practice scope), and address the cultural minimization of gynecologic pain.
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Remove Financial Barriers and Fix Billing Codes: Implement appropriate Medical Services Plan (MSP) billing mechanisms for pain control interventions during IUD insertions, remove structural disincentives for quality care, and ensure equitable access to pain management regardless of geographic location or provider.
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Improve Training and Education: Work with educational institutions to develop and implement standardized, competency-based training for all practitioners who perform IUD insertions. This training should include pain management techniques, trauma-informed approaches, and cultural sensitivity. Make this training mandatory across all healthcare disciplines authorized to perform IUD insertions.
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Ensure Regional Equity: Implement strategies for equitable access to pain management during IUD insertions across all regions by establishing standardized provincial protocols that make pain management options mandatory rather than discretionary, increasing funding for underserved areas, deploying mobile health services to reach remote communities, and providing telemedicine support to help local providers deliver consistent pain management.
