Intrauterine devices (IUDs) are among the most effective forms of contraception, and approximately one in five sexually experienced women between the ages of 15 and 49 has ever used one.1 For many patients, the placement of an IUD is painful and can cause uterine cramping, bleeding and vasovagal symptoms during and after insertion.2 In August 2024, the Centers for Disease Control and Prevention (CDC) issued the first U.S. guidance on pain management during IUD insertion.3 As these guidelines are incorporated into provider practice, understanding how often pain management is administered, which patients receive pain management and which provider types administer it can highlight where the largest gaps in care exist.
IUDs are a form of long-acting reversible contraceptives (LARCs) available in hormonal and non-hormonal formulations. IUDs are one of the most effective forms of birth control, and they can last three to 12 years.4,5 The share of sexually experienced women ages 15-44 who have ever used an IUD nearly tripled between 2006-2010 and 2015-2019.6 As of 2023, 15.8% of women ages 15–49 using contraception used an IUD.7 Among these women, 78% reported experiencing moderate to severe pain during insertion.8 Younger age, dysmenorrhea (i.e., painful menstrual periods), nulliparity (i.e., no births) and low parity (i.e., one or two previous births) increase the likelihood of pain during IUD insertion, as do psychological and demographic factors, such as preprocedural anxiety and lower educational attainment.9 In a 2024 study, 41.6% of women undergoing an unmedicated IUD insertion reported unacceptable levels of pain, and 59.0% of those patients reported that they would have chosen a numbing medication if it had been offered to them.10
Pain management options range from taking a high dose of over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription opioids to provider-administered local anesthetics or even sedation.11 Despite patients experiencing pain, physician guidelines did not explicitly recommend routine pain management until 2024.12 In the 2024 U.S. Selected Practice Recommendations for Contraceptive Use, the CDC recommended that all patients be counseled about pain and offered a plan based on their preferences. The guidelines recommended lidocaine, as either a paracervical block or a topical application, to reduce pain.13 In 2025, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines recommending that providers not underestimate patient pain during IUD insertion and offer an anesthetic cream, spray or an injected local anesthetic for discomfort.14
Whether providers offer pain management likely depends on awareness of current guidelines, as well as practical barriers such as limited time, office availability of certain pain medications and training in paracervical blocks.15 In addition, add-on pain management is not universally covered by payers.16 Clinicians have also been shown to underestimate women’s pain, particularly for women of color, which may affect whether pain management is offered at all.17 Anticipated pain is a recognized barrier to IUD use, and the prevalence of anticipated pain and anxiety has only grown as a result of negative social media discourse.18,19,20 Proactively discussing and offering pain management is one way providers can address that fear, making provider practice a key factor in IUD access.
Although the CDC and ACOG now recommend that pain management be offered to every patient, little is known about how many women receive it, the demographics of those who do or how access varies by provider and geography. This study examines how often provider-administered pain management accompanies IUD insertion and how that rate varies across patient, provider and geographic factors.
Leveraging the Trilliant Health national all-payer claims database, IUD pain management trends were examined among women ages 15-49 between 2019 and 2025. IUD insertions were identified by CPT code 58300 with a supporting diagnosis of Z30.430 (encounter for insertion of an intrauterine contraceptive device), with device type identified by HCPCS codes J7297 (Liletta®), J7298 (Mirena®), J7300 (Paragard®) and J7301 (Skyla®). Insertions were excluded if they occurred on the same day as another gynecologic procedure (CPT 58100, 58555, 58558, 57420 or 57421), laparoscopy or surgical anesthesia, if they took place within three months of a prior IUD procedure (CPT 58301) or if they were within six weeks of a delivery.
Pain management was defined as an IUD insertion with an administered paracervical block (CPT 64435) or injectable lidocaine (HCPCS J2001 through September 2024; J2002, J2003 and J2004 from October 2024) during the same visit. The overall pain management rate was calculated as the number of insertions with administered pain management divided by the total number of insertions. This study did not examine topical lidocaine, nitrous oxide or use of prescription or OTC medications.
Patient characteristics were analyzed by age group, preexisting conditions and geographic region. A provider-level pain management rate was calculated as the number of IUD insertions with administered pain management divided by the provider’s total IUD insertions from 2019 through 2025. Providers with fewer than 10 insertions were excluded. Descriptive statistics were used to examine the distribution of the provider-level pain management rate, and the characteristics of providers who did and did not render pain management were compared. The share of providers administering pain management at more than 0% of insertions was also calculated by provider age group, sex and provider type.
The share of IUD insertions with pain management ranged from 0.9% to 1.3% between 2019 and 2024. In 2025, this increased to 2.2% (Figure 1).
The rate of pain management is consistently low across patient age groups. Pain management was highest among patients ages 15-19 (1.3%) and 45-49 (1.2%) and lowest among patients ages 30-34 (1.0%) (Figure 2). However, patients with endometriosis, PMOS or pelvic pain were more than twice as likely to have pain management as patients without a history of these conditions. Among patients with endometriosis or PMOS, 2.6% of insertions had pain management, compared with 2.5% among patients with pelvic pain and 1.1% among patients without each condition. The difference was smaller for dysmenorrhea, at 1.7% compared with 1.1% among those without the diagnosis.
From 2019 to 2025, the national rate of administered pain management during IUD insertions was 1.1% but varied by region. Patients in the West had the highest pain management rate of 1.8%, 2.6x the rate of patients in the Midwest (0.7%) and twice that of patients in the South (0.9%) (Figure 3). The Northeast had a pain management rate of 1.4%.
Of providers performing at least 10 IUD insertions, 90.7% never administered pain management (Figure 4). In a sensitivity analysis that required a minimum of 100 insertions, this share decreased to 88.3% of providers. Of the 9.3% of providers who administered pain management at least once, the median pain management rate was 4.5%, and 88.3% of these providers administered pain management in 25% or fewer of their insertions.
In summary, administered pain management was highly concentrated among a small group of providers. When providers were ranked by their number of insertions with administered pain management, the top 1% of providers performed 2.4% of all insertions but accounted for 63.7% of all insertions with administered pain management (Figure 5).
There were minor differences in pain management administration by observable provider characteristics (Figure 6). For example, using any pain management was most common among providers ages 35-44 (10.0%) and least common among providers under 35 (7.6%). Female providers administered pain management at a slightly higher rate than male providers, 9.5% compared with 8.3%. Across provider types, physicians had the highest rate of administering pain management (10.9%), compared with 6.0% of physician assistants (PAs) and 4.8% of nurse practitioners (NPs) or midwives.
Administering pain management during IUD insertion remains uncommon, with the rate of pain management ranging from 0.9% to 1.1% from 2019 through 2024 before increasing to 2.2% in 2025. The increase from 2024 to 2025 is likely attributable to the updated 2024 CDC and 2025 ACOG guidance, which moved pain management from an optional practice toward an expected part of IUD care.21,22 In addition, the increase in IUD pain management may reflect greater patient demand and changes in how lidocaine is billed beginning in October 2024, which may have made use more visible in claims.23,24
Because this analysis is limited to provider-administered paracervical blocks and injectable lidocaine, topical lidocaine, nitrous oxide and OTC or prescription medications (including opioids and NSAIDs) are not captured. Moreover, claims cannot distinguish pain management that was offered and declined from pain management that was never offered. However, the CDC and ACOG call on providers to routinely discuss and offer evidence-based pain management, meaning a low administered rate is likely more indicative of provider practice patterns than patient preference.
Given longstanding patient complaints about pain and anxiety from IUD insertion, it seems unlikely that women routinely decline an offer of pain management. This puts the modest increase in pain management administration from 2024 to 2025 in context: administration remains low overall and highly concentrated among a small share of providers. highlights the problem of utilization concentration. Only 9.3% of providers administered pain management at any insertion, and the median pain management rate was 4.5%, suggesting either a lack of patient empathy, awareness of current guidelines or clinical skill.
Of those alternatives, a lack of clinical skill is most defensible. Paracervical blocks require training, certain medication and supplies on hand, longer appointment times and payment for a service that may be reimbursed separately or not at all.25 Physician practices considering offering paracervical blocks would need to train providers, standardize procedure kits with appropriate supplies, update schedules to allow time for the additional procedure and increase coding and billing support. The lower pain management rates among NPs or midwives (4.8%) and PAs (6.0%) compared with 10.9% for physicians may reflect differences in paracervical block techniques or in scope of practice. Similar differences by provider type and experience have been documented in a study of a single academic health system, which found NPs were less likely than attending physicians to use paracervical blocks, which could be addressed through expanded training.26
“Consumer-driven” and “consumer-focused” healthcare are mantras among health economy stakeholders, which calls into question why pain management is not the standard of care for IUD insertion, a method used by 6.8M of the 74.9M American women between the ages of 15 and 49.27 If national guidance now calls for pain management to be offered to every patient, why do nine in ten providers (90.7%) still administer none, and why did patients go without it in 97.8% of insertions in 2025?