ACOG Calls for Pain Management for IUD Insertion, Other In-Office Procedures

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Shared decision making and comprehensive pain management counseling now recommended

by
Rachael Robertson, Enterprise & Investigative Writer, MedPage Today
May 16, 2025 • 3 min read

MINNEAPOLIS — Clinicians should counsel patients on various pain management options for in-office uterine and cervical procedures, like intrauterine device (IUD) insertion, according to a new clinical consensus released by the American College of Obstetricians and Gynecologists (ACOG) at their annual meeting.

The guidance states that providers should utilize shared decision making and counsel all patients on the risks and benefits of pain treatment options for IUD insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy, which can be uncomfortable or even painful for some patients.

These pain management strategies include local anesthetics, like lidocaine spray, lidocaine-prilocaine cream, and paracervical block, as well as topical or injected anesthetics, nonsteroidal anti-inflammatory drugs, and misoprostol. While the guidance focuses on in-office procedures, counseling on intravenous sedation, monitored anesthesia, and general anesthesia is also recommended for patients interested in those options.

Christopher Zahn, MD, chief of clinical practice and health equity and quality for ACOG, noted that pain management strategies have been shaped by limited and conflicting evidence, as well as systemic racism and bias.

“This guidance is an important step toward both identifying evidence-based approaches to pain management and reducing those biases by offering all patients more autonomy in deciding how to best approach the pain they experience,” Zahn said in a press release.

Moreover, the guidelines highlight that, historically, “Black patients have received less analgesics than white patients, and women have received less attention to their pain than men undergoing similar procedures.”

Much of the conversation in recent years has specifically focused on IUD insertion as more patients have shared their experiences with pain. Last year, the CDC recommended that clinicians counsel patients on potential pain associated with IUD insertion as part of the agency’s practice recommendations on contraception.

ACOG’s new guideline states that “every patient who has an IUD placed should receive thorough counseling about the potential for pain associated with this procedure and should be provided with options to mitigate potential pain.”

Danielle Tsevat, MD, MSCR, an ob/gyn and research fellow at the University of North Carolina at Chapel Hill, told MedPage Today that for in-office procedures like colposcopy and IUD placement, “patients’ pain has historically been underrecognized and undertreated,” and patients’ own advocacy has been critical in changing the conversation.

“I am hopeful that this new guideline will help to standardize pain management practices to reduce these disparities and normalize recognition by clinicians that these procedures can be very painful and even traumatic for some patients,” Tsevat said, adding that factors like where a patient seeks care and implicit bias among physicians leads to significant differences in what pain management options are offered.

Melissa Simon, MD, an ob/gyn at Northwestern Medicine in Chicago and director of the Center for Health Equity Transformation, told MedPage Today that when procedures are done without adequate pain control, patients may fear going through with them.

“These guidelines help support clinicians in the shared decision-making processes essential to ensuring adequate pain control for patients who need one of these procedures,” she said.

Guideline co-author Kimberly Hoover, MD, an ob/gyn at the University of Alabama at Birmingham, emphasized that shared decision making gives patients more say in what happens to their bodies and ensures it aligns with their priorities.

“I have some patients for whom the paracervical block, for example, is quite helpful for their IUD insertion experience. I have other patients who would prefer to avoid needles and may want to try another approach,” Hoover said in the press release. “Presenting patients with all the options and using shared decision making is best practice.”

Zahn also noted that he hopes that with this guidance, clinicians take away “the absolute importance of comprehensive pain management counseling — not just for mitigating pain in the moment but also for improving trust with our patients and ensuring better access to gynecologic healthcare for every person.”

For this clinical consensus, ACOG medical librarians searched Ovid Medline and PubMed for relevant English-language studies on gynecologic procedures, health equity, and pharmaceutical and nonpharmaceutical methods, published between 2000 and September 2023.