IUD insertions can hurt — a lot. Can Canada learn from new U.S. pain management guidelines?

The first time Devon Cantwell-Chavez had a long-lasting form of birth control inserted — an intrauterine device, or IUD — it was a smooth, painless experience.

That was in 2018, through her gynecologist in Salt Lake City, Utah. Cantwell-Chavez was provided painkillers, along with a low dose of an anti-anxiety medication with sedative properties.

"It was a very easy experience," she recalled, "and I honestly don't remember it."

A few years later, while pursuing her PhD in Ottawa, the 34-year-old needed to have her three-year IUD swapped out — and was told at a student sexual health clinic that she'd only need over-the-counter painkillers.

Cantwell-Chavez was stunned. She told the clinic's physician that she passes out during routine pap smears, and fought to get a letter of support from her gynecologist back home in the U.S. to include a sedative, as well. The Ottawa team relented, but she said there was still a lot more pain with that procedure, with the clinic's on-site doctor later saying she was likely "making up the pain in her head."

"It seems, more often than not, that's the response people get in Canada," she said. "It's frustrating that we continue to have paltry pain management options."

The cross-border debate over how to best handle IUD insertions is heating up this week, after the U.S. Centers for Disease Control and Prevention (CDC) released sweeping new guidance on pain management.

Now, for the first time, the CDC is encouraging health-care providers to counsel patients on their options for the typically quick but potentially painful procedure, which inserts a tiny T-shaped device through the vagina and cervix and into the uterus to provide years of highly effective contraception.

Published on Thursday, the guidelines note that a growing body of evidence suggests lidocaine — either administered as an injection, or a topical cream, gel, or spray — may be useful for reducing pain. Not all trials reached the same conclusions, however, with some studies suggesting there were no reductions in pain following use of that local anesthetic.

Misoprostol, meanwhile, is "not recommended for routine use" for IUD placement. 

The CDC said evidence does suggest the cervix-softening drug, which is also used to induce labour, may help with pain relief in certain circumstances, such as for patients with a recent failed placement of their IUD.

"When considering patient pain, it is important to recognize that the experience of pain is individualized and might be influenced by previous experiences including trauma and mental health conditions, such as depression or anxiety," the guidelines state. 

Dr. Renée Hall, medical co-director of the Willow Reproductive Health Centre in B.C., said more Canadian clinicians need to be aware of the breadth of pain control options and open a dialogue with their patients.

"We've been arguing back and forth in the medical profession about … what works well [for pain management] and what doesn't," she said. "But at the end of the day the most important thing is having this conversation with patients themselves."