Expanding IUD Use Through Tailored Counseling and Pain Management Solutions

Announcer:
You’re listening to Advances in Women’s Health on ReachMD, and this episode is sponsored by Bayer. Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle:
This is Advances in Women's Health on ReachMD, and I'm your host, Dr. Jennifer Caudle. And joining me to share best practices for IUD counseling and pain control is Dr. Sheila Mody. She's a complex family planning specialist at UC San Diego Health and a Professor of Obstetrics, Gynecology, and Reproductive Sciences at the UC San Diego School of Medicine. Dr. Mody, thank you so much for being here today.

Dr. Mody:
Thank you. It's my pleasure.

Dr. Caudle:
To kick things off, Dr. Mody, what available tools or resources can help us identify the right contraceptive option based on each patient's reproductive goals?

Dr. Mody:
I think the best resource we can give patients is specific online resources that they can go to and do their research before they come into clinic. I think there is definitely this desire to advocate for themselves and to really hear other people's experiences. And that's the best way to give them the autonomy to do their own research and give them a vetted source.

One of the resources I often recommend is www.bedsider.org. This particular website was vetted by experts in our field and has the ability to visualize the different methods, has question and answers, and the ability to compare different methods. But what I like the most about it is that it has patient experiences. There are videos and testimonies of patients that have used the various methods. And it's really a nice way for patients to not only hear about contraceptive methods from clinicians, but also from their peers.

With regards to personalizing care for patients and having them find what meets their reproductive needs, I think it's all about having very open-ended questions and asking patients to tell you what's important to them in terms of finding a contraceptive method. It might be that they want to have the most highly effective method, but it could be something very different, like they don't want it to impact their skin. They want to make sure it doesn't cause any weight gain. They want to be able to have something they don't have to take every day. So it's really important to have them vocalize what's important and really focus that conversation.

Dr. Caudle:
And when it comes to counseling patients on IUDs, in particular, how can we tailor our approach for specific populations, like adolescents or postpartum patients?

Dr. Mody:
Thank you for that question. I think it's really important to think about special considerations for various populations, but then to also tailor it for that particular patient.

For adolescents, in particular, I think something that is not very high maintenance can sometimes be a nice thing to talk about. They are also very much wanting to have the ability to understand the side effects. I think side effects are huge for adolescents, particularly for weight gain, skin, or bleeding patterns. Those are things that are high priority in my experience from working with adolescents. So really try to take a deeper dive into side effects and make sure that they are okay with those side effects. The other thing is I think adolescents may also be really interested in an IUD, but they may be concerned about pain, and so have a thorough conversation about the insertion and what that's going to look like. A lot of them have never had speculum exams, so walking through them the whole process is incredibly important.

For other patients, like postpartum patients, they may want to know how it's going to impact their breastfeeding, so make sure that you’re reassuring them that none of these methods are going to impact breast milk supply or safety of breastfeeding; it’s very important to address those concerns.

Other concerns that patients often have with various medical conditions is if it's safe with their medications. I have some patients with epilepsy or on mood stabilizers, and it's really important to make sure that you have recognized their medical conditions and their medications, and now you're coming with a tailored conversation about what would be safe methods for them to use, and then hearing about what concerns and desires they have in terms of the contraceptive method, the duration, and if they have control of whether they can stop it—just marrying the medical expertise of the clinician with the patient's desires with regards to side effects and duration of use.

Dr. Caudle:
Now, as a follow-up to that, patients are often hesitant about IUDs. Based on your experience, what are some of the most common concerns, and how can we proactively address them?

Dr. Mody:
Yeah, I think there's two big classes of concerns with IUDs. One of them is just the concern about hormones. I think currently, there is a lot of stuff online or in social media about concerns about hormones. And I think also patients may have had poor experiences with hormones in the past. And so it's really important to make sure they understand that the hormonal IUDs that we have are very low dose. The progestin is 1/10^th of what they would get in a birth control pill or less, depending on which one they pick, and there aren't as many systemic side effects as other birth control methods that have hormones.

The other thing that I hear quite often is patients' concerns about the ability to control—you know, if they don't like it, are they going to be able to be able to have it removed?—as well as pain with the procedure, which is a huge area of concern right now and something that we definitely need to listen to from our patients and meet them where they're at in terms of their concerns.

Dr. Caudle:
Thank you for that. And for those of you who are just tuning in, you're listening to Advances in Women's Health on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. Sheila Mody about how we can counsel our patients on IUDs.

So, Dr. Mody, let's switch gears a bit now and focus on the American College of Obstetricians and Gynecologists' 2025 guidance for managing pain during in-office uterine and cervical procedures. One of the key updates is that local anesthetics should be offered to reduce pain during IUD insertion. From your vantage point, does this reflect a broader shift in the way we're thinking about pain management in reproductive care?

Dr. Mody:
Yes, I do think that there's a shift not only in the way we're thinking about it, but just the population that we're serving; there has been a shift in terms of the population that are pursuing IUDs. It used to be one of those things that patients pursued IUDs after having deliveries, and it was kind of in that birth space, which is still used in that way.

But we really have had more young people who haven't had children before want something highly effective and are very motivated to utilize these IUDs. And so I think that shift itself is a different patient experience in terms of pain with the procedure. And so we've had a lot of patients be very vocal about their own painful IUD placements.

And this is something that we have not had research in the past about interventions that could help with this pain for these patients who haven't had deliveries before, but we do have newer studies that show that there are interventions, such as the local anesthetics, that can decrease the pain with the procedure.

So I think ACOG and the CDC are mirroring the demand from patients for pain control conversations with newer studies that show that there are things that we can offer. I think this is the right way to go in terms of meeting patients' demands and concerns and highlighting new evidence that we can incorporate into our practices.

Dr. Caudle:
Now, the guidelines also caution that one local anesthetic agent, paracervical lidocaine block, may cause some pain when it's administered. So with that being said, are there any other potential risks or side effects related to pain management options that we should be aware of? And if so, how should we talk to our patients about them?

Dr. Mody:
Yeah, so I think that was the big question with a paracervical block, whether the discomfort with the injection was more than the actual IUD placement. And I have done studies in this space, as well as others, and our studies have shown that the injection discomfort is less than the pain with the IUD if you do not get the lidocaine block.

So the way that I approach this topic with patients is that I say there is potentially some discomfort with an IUD placement. There is something that we can offer that can decrease the pain; it is a local injection of lidocaine. There is some discomfort with the lidocaine—on a scale of 1 to 10, it's about a 3—but it does decrease the pain with the procedure and afterwards. And  I would say 95 percent of patients take me up on this offer and have much better experiences than they had anticipated with the IUD placement itself.

There are very little risks with doing a paracervical block. There are standard measures that we take, like drawing back when we do the injection to make sure that we're in a safe space, but it's less invasive than doing an IUD insertion itself. So I think if you feel comfortable doing an IUD insertion, you should feel comfortable doing a paracervical block for your patient as well.

Dr. Caudle:
Well, that's very helpful. And we've certainly covered a lot today, but before we wrap up, Dr. Mody, can you share some practical ways we can implement these counseling and pain management strategies into busy clinical workflows?

Dr. Mody:
Yes. I think it’s important to have that mindset that you know the patient's going to come in with concerns about pain control and incorporate it in the counseling beyond signing the consent forms and all those things; just take a moment to tell patients, “these are the things that we can offer you.” We know that naproxen can help with cramping afterwards. Ibuprofen is not helpful for IUD placement pain. Just having those conversations with patients and then offering them local anesthetics that can decrease the pain with the procedure is one way that we can incorporate it into our counseling. It doesn't take very long. It takes maybe a couple minutes just to bring it up, and the patients want you to bring it up.

The other thing that we can do is if you know that you have some patients that are nulliparous that are coming in, just have some lidocaine blocks ready. That's not an extra step that you need to take in a busy clinic, and it’s another way that we can seamlessly incorporate it. And just have people on board; make sure you educate your staff that this is something that does help and is worthwhile.

Dr. Caudle:
Excellent. As those final comments bring us to the end of today's program, I'd like to thank my guest, Dr. Sheila Mody, for joining me to share her insights on counseling patients and implementing IUD pain management techniques into practice. Dr. Mody, it was great having you on the program.

Dr. Mody:
Thank you so much. It's such a pleasure. I'm so grateful for this opportunity and so grateful for some attention being put on this very important topic.  

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This episode of Advances in Women’s Health was sponsored by Bayer. To access this and other episodes in our series, visit Advances in Women’s Health on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!