Addressing Pain Management in Intrauterine Device Insertion Post-Universal Coverage in British Columbia

Addressing Pain Management in Intrauterine Device Insertion Post-Universal Coverage in British Columbia | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 June 2025 V2 Latest version Share on Addressing Pain Management in Intrauterine Device Insertion Post-Universal Coverage in British Columbia Authors : Sara Sunderji 0009-0001-0098-8448 [email protected] , Anahita Seraji , and Victoria Greene 0009-0001-1293-5781 Authors Info & Affiliations https://doi.org/10.22541/au.174890190.04694623/v2 339 views 120 downloads Contents Abstract Introduction Practice and Training Gaps Essential Reforms Training Model Conclusions Acknowledgments References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Universal contraceptive coverage in British Columbia (2023) has increased access to intrauterine devices (IUDs), yet procedural pain remains a critical barrier, with over 80% of nulliparous individuals reporting moderate to severe pain and 41% indicating deterrence from future use. Methods: We reviewed national guidelines and evaluated international best practices in IUD insertion pain management and training frameworks. Results: Only 52.9% of physicians routinely offer pain control during insertion, with implementation varying due to inadequate training and resource limitations. Discussion: This gap between international guidelines and clinical practice reveals the need for standardized pain management training. Conclusions: We propose a centralized Hybrid Simulation Training framework integrating evidence-based pain management, shared decision-making, and trauma-informed care principles to improve IUD accessibility in British Columbia. Introduction Intrauterine devices (IUDs) are among the most effective contraceptive modalities in reproductive healthcare, recommended as a first-line option for both nulliparous and multiparous individuals, with typical-use failure rates below 1%. 1,2 These devices play a pivotal role in preventing unintended pregnancies and promoting family planning across diverse populations. Beyond their contraceptive function, hormonal IUDs offer substantial non-contraceptive benefits, including marked reductions in menstrual bleeding and dysmenorrhea, management of endometriosis and polycystic ovarian syndrome, and a potential decrease in uterine cancer risk. 3,4,5,6,7,8 These broader applications reinforce the IUD's importance as a multipurpose intervention in contemporary reproductive healthcare. The introduction of universal no-cost prescription contraception in British Columbia in 2023 has expanded access to over 306,000 individuals within twenty months, 24.5% of whom chose IUDs (V. Greene, personal communication, March 3, 2025). This reflects a broader trend, as IUD uptake among contraceptive users in Canada has risen by up to 28% over the past 15 years. 9 However, despite the removal of financial barriers, procedural pain remains a critical deterrent to broader IUD uptake. 10,11 According to one study, over 80% of nulliparous adolescents and young women report moderate to severe pain during IUD insertion, and 41% say the experience would likely deter them from choosing the method again. 10 Furthermore, a recent survey indicated that more than 40% of participants described their pain experience as unacceptable, and often named it as the primary reason for avoiding or discontinuing IUD use. 12 Concerns around IUD insertion are frequently linked to fear, mistrust, and even trauma, particularly when informed consent and pain management are inadequate. 13 Growing evidence demonstrates that IUD insertions can be a painful experience, prompting multiple international health bodies to recommend routine pain management during the procedure. The Centers for Disease Control and Prevention's (CDC) Selected Practice Recommendations for Contraceptive Use (2024) recommend a proactive, patient-centred approach to IUD placement, suggesting the use of local anesthetics, such as lidocaine, to minimize pain and discomfort. 14 The CDC guidelines are adapted from the World Health Organization’s recommendations, underscoring shared priorities of patient comfort and equitable access to services on a global scale. 14 Reviews of international practice further indicate that, although various pharmaceutical options, including local anesthetics and NSAIDs, have been explored, there is no universally accepted protocol for pain management during IUD insertion. 15 The American Academy of Family Physicians supports both pharmacologic approaches, including lidocaine blocks, and non-pharmacologic strategies such as counselling and aromatherapy. 16 Current research, indicating that techniques such as lidocaine paracervical blocks significantly improve patient satisfaction and IUD uptake, helps validate these guidelines and highlight their significance. 17 Unfortunately, however, implementation of standardized pain management remains inconsistent due in part to gaps in provider training and limited resources. 18 Practice and Training Gaps National data underscores the urgent need for standardized training in pain management during IUD insertion. A survey revealed that only 52.9% of physicians routinely offer pain control, with many relying on patient requests rather than proactively addressing pain. 19 Only about 52% of academic family physicians in Canada feel very comfortable performing IUD insertions, and around 50% refer patients elsewhere, concentrating care among a minority of clinicians, many of whom also lack structured training in pain relief. 20 In a multi-centre Ontario survey, 52.9% of physicians who perform IUD insertions reported routinely providing pain control, while 47.1% did not—often due to logistical barriers, beliefs about the necessity of analgesia, or lack of training and education regarding pain control options. 19 Despite this evidence, the Canadian Contraception Consensus developed by the Society of Obstetricians and Gynaecologists of Canada (SOGC), omits pain management from its clinical recommendations. 2 It cites a study suggesting that most patients experience minimal discomfort, yet fails to disclose that 93% of participants of that study received intrauterine lidocaine. 21 This omission misrepresents the evidence and obscures the role of analgesia in patient experience. By downplaying pain, the guideline reinforces a clinical culture that normalizes rather than treats insertion-related discomfort. 18 As Canada’s national authority on reproductive healthcare, the SOGC shapes institutional policy, clinical norms, and provider education. Its failure to include pain relief in IUD protocols implies that physician competency in this area is non-essential. This contributes to inconsistent practices nationwide and a widespread misunderstanding about the necessity of pain management. In British Columbia, there is no standardized training in procedural pain management; clinicians often rely on informal mentorship, outdated self-study, or must pay out of pocket for external workshops. 19 (A. Seraji, personal communication, May 7, 2025; A. Seraji, personal communication, March 31, 2025) Continuing professional development (CPD) frameworks similarly lack mandates for pain management competencies across providers, including nurse practitioners and midwives. 22 These systemic gaps leave many primary care providers with low procedural confidence and limited knowledge of analgesic options, contributing to inequities in care, delays in IUD uptake, and growing patient mistrust. 17,20,23,24 Essential Reforms Deficiencies in IUD insertion pain management require reform of provider training in British Columbia. A standardized education program must include: mandatory IUD insertion competencies for contraceptive providers; evidence-based pain management protocols; and trauma-informed care with shared decision-making. We recommend that IUD insertion training be centralized through a dedicated provincial institute in British Columbia. This would replace the current patchwork of non-standardized educational pathways—including the University of British Columbia’s Continuing Professional Development, clinical preceptorships, and ad hoc training–with a unified, evidence-based program. 25,26,27 Centralizing education in this way would ensure consistency across provider skillsets and institutional protocols. Most importantly, this would create a standardized platform where provincial health authorities, patients, and providers can implement our recommendation to make pain management an essential, mandatory component of all IUD training. In identifying an educational framework for British Columbia’s IUD insertion program, established gynaecologic approaches offer validated solutions. Best practices encompass problem-based learning (PBL) for clinical reasoning, high-fidelity simulation for procedural skills, and video-based instruction for pain management and patient communication. 28,29,30,31 The Hybrid Simulation Training (HST) model effectively integrates these essential elements, providing a comprehensive framework adaptable to our identified requirements for standardized pain management and trauma-informed care. 32 The HST model combines four key components: didactic teaching, video demonstrations, hands-on practice with pelvic models, and simulated patient interactions. Trainees progress through foundational materials before completing OSCE-style assessments to evaluate history-taking, procedural technique, and counselling competencies. Standardized patients are specifically trained to present clinical scenarios and express procedural discomfort, requiring providers to demonstrate both technical proficiency and empathetic communication. Authors using HST for IUD insertions, documented significant improvements in learner knowledge, procedural ability, and counseling skills following HST implementation. 32 Participants consistently rated the approach highly, particularly noting increased confidence and satisfaction with their training. The framework's pedagogical value and adaptability across settings make it well-suited for addressing British Columbia's identified training deficiencies. 33 Training Model Our adaptation of the HST framework integrates three core competencies: pain management, shared decision-making, and trauma-informed care. Drawing from Best Practices for Pain Management During IUD Insertion, the model combines pharmacologic interventions (NSAIDs, lidocaine—topical, intrauterine, and paracervical blocks) with evidence-based behavioral approaches including anxiety management through benzodiazepines, breathing techniques, and environmental modifications. 13 The curriculum embeds a shared decision-making framework throughout training. 34 Through didactic instruction, videos, and structured discussions, providers develop competency in neutral contraceptive counselling and transparent risk-benefit communication. Anticipatory counselling teaches providers to explain procedural steps, validate concerns, and ensure patient control over pacing. Informed by previous studies, the trauma-informed component establishes specific communication strategies that foster trust and safety. 35,36 A second and third study guide the integration of trauma-informed approaches with standard healthcare protocols, and demonstrate how this improves both patient experience and provider confidence. 37,38 Assessment employs previously established standardized patient scenarios and an evaluation framework to measure competency in all three domains. 32,39 Providers must demonstrate proficiency in pain management protocols, shared decision-making, and trauma-informed care to be certified. Conclusions British Columbia's deficiencies in IUD insertion pain management demand urgent reform through standardized provider training. By implementing a centralized HST-based educational framework that integrates evidence-based pain control protocols, shared decision-making practices, and trauma-informed care principles, we can transform current inconsistent practices into a unified standard of care. This comprehensive approach will not only enhance provider competency and patient experience but also maximize the potential of universal contraceptive coverage by removing a significant barrier to IUD uptake among British Columbians. Acknowledgments The authors would like to acknowledge their collaborative work with AccessBC, a campaign that successfully advocated for universal contraceptive coverage in British Columbia and continues to champion improvements in reproductive healthcare delivery, including addressing pain management during IUD insertion. This research builds upon AccessBC's ongoing efforts to ensure equitable access to comprehensive contraceptive care. Finalized on May 31, 2025. References 1. 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Keywords british columbia hybrid simulation training intrauterine devices medical education pain management Authors Affiliations Sara Sunderji 0009-0001-0098-8448 [email protected] View all articles by this author Anahita Seraji View all articles by this author Victoria Greene 0009-0001-1293-5781 View all articles by this author Metrics & Citations Metrics Article Usage 339 views 120 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Sara Sunderji, Anahita Seraji, Victoria Greene. Addressing Pain Management in Intrauterine Device Insertion Post-Universal Coverage in British Columbia. Authorea . 09 June 2025. DOI: https://doi.org/10.22541/au.174890190.04694623/v2 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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