Intrauterine Procedures — Pain Management & Counselling

Shared decision-making tool for patients and physicians

Clinical Tool

Procedure Mode:

Pre-Procedure Counselling Checklist

Check off each topic reviewed with the patient before proceeding

Checklist progress
0 of 9 complete
IUD / IUS type
Contraindications
IUD Insertion
Active vaginal infection / STI
Known uterine anomaly
Pregnancy
Wilson's disease (copper IUD)
Undiagnosed abnormal uterine bleeding
Procedure Information Reviewed
Expected side effects discussed
Pain during and after insertion, cramping, spotting/unpredictable bleeding for the first 3–6 months
Adverse events reviewed
Unable to insert, intrauterine infection, expulsion (~5% risk), uterine perforation (rare, between 1/1,000 and 1/10,000)
STI prevention counselled
IUDs do not protect against STIs — barrier methods (condoms) discussed

Endometrial Biopsy Counselling

Indications, contraindications, and counselling documentation

Will endometrial biopsy be performed?

During Procedure

Pre-procedure, topical, and inhaled pain management

Pre-Procedure (oral)
NSAIDs — Ibuprofen / Naproxen
e.g. Ibuprofen 400–600 mg PO, 1 hour before. Evidence shows inconsistent to no effect on insertion pain — most useful for post-procedure cramping.
Documentation Status
Patient Response
During Procedure (topical & inhaled)
Penthrox® — Methoxyflurane (Inhaled)
Self-administered inhaler ("Green Whistle"). If used, avoid same-day NSAIDs — resume next day.
Documentation Status
Patient Response
Penthrox Screening — Check any that apply
Absolute Contraindications (Health Canada Product Monograph, Section 2)
Precautions / Relative Contraindications (use with caution — not formal Section 2 CIs)
How Much Does Numbing Help?
Average pain scores (0–10 scale) — lower is better:
Option Moment With numbing Without numbing
EMLA® Cream
Lido-prilocaine 5%		 Clamp
3.0
4.5
Insertion
2.1
3.7
Lido 10% Spray
△ irritation risk		 Clamp
0.8
2.4
Insertion
3.0
5.0
Lido 2% Gel Clamp
3.2
5.6
Insertion No significant difference from placebo in most studies
Adapted from TFP #405 (CFPC): cfpclearn.ca/tfp405/. Clinically meaningful difference = 1.3–2 points.
EMLA® Cream — Lidocaine-Prilocaine 5%
2 mL via cotton swab to cervix, 5 min before procedure.
Documentation Status
Patient Response
Lidocaine 10% Spray
4 puffs to cervix, 3 min before. Side effect of possible vaginal irritation.
Documentation Status
Patient Response
Lidocaine 2% Gel — Topical
Cotton swab application.
Documentation Status
Patient Response

Post-Procedure Pain Management

Discharge instructions and take-home pain relief

Pain Relief
Ibuprofen (Advil® / Motrin®) — OTC
Up to 800 mg (4 tablets) every 8 hrs with food. Start when cramping begins; continue 2–3 days of period. Helps reduce bleeding and cramping. ⚠ If Penthrox was used today, resume ibuprofen next day only.
Documentation Status
Patient Response
Acetaminophen (Tylenol®) — OTC
Alternative or adjunct to ibuprofen. Use if ibuprofen is contraindicated or not tolerated. Compatible with Penthrox.
Documentation Status
Patient Response

Generate Documents

EMR note and patient handout

EMR / Clinic Note
✓ Copied to clipboard!
Patient Handouts

IUD Further Reading

Evidence detail for each pain management option

Getting an IUD can be uncomfortable. There are several options that may help manage pain — and it helps to know what the research actually says about each one.

The options below include numbing creams or sprays applied to the cervix just before the procedure, an inhaled pain reliever you control yourself, and anti-inflammatory medications taken beforehand or afterward. The evidence for each pain option varies; the evidence is based on research such as systematic reviews and randomized controlled trials.

Numbers like "3.0 vs. 4.5" are average pain scores on a 0–10 scale. A difference of 1.3–2 points is considered meaningful. Talk to your provider about which options make sense for you.

Source: Braschi E, Kostov S, Kirkwood J. "Taking the 'ouch' out of IUD insertion." TFP #405. CFPC, Jan 2026.  cfpclearn.ca/tfp405/ →  Meaningful difference: 1.3–2 pts
Pre-Procedure
NSAIDs Ibuprofen / Naproxen

Dosing: Ibuprofen 400–600 mg PO, 30–60 minutes before procedure.

Evidence:

  • Systematic Review: inconsistent to no effect on insertion pain
  • May provide benefit for post-procedural cramping
  • Low risk, low cost — reasonable as adjunct

Braschi E, Kostov S, Kirkwood J. TFP #405. CFPC, Jan 2026.

During Procedure
Penthrox® Methoxyflurane — Inhaled

Administration: Self-administered via handheld inhaler. Relief onset: 6–10 breaths; continuous use 25–30 min; intermittent up to 60 min.

Evidence:

  • IUD-specific Randomized Controlled Trial data is limited (Sairally BZF et al., BMJ Open 2025)
  • Evidence extrapolated from other procedural pain settings
  • Approved in Australia & New Zealand since 1970s; Canada since 2022
  • 5.5M+ doses worldwide with low serious adverse event rate
  • Compatible with acetaminophen; avoid same-day NSAIDs

Bullets 1–2: Sairally BZF, De Silva P, Smith P, Clark TJ. Inhaled methoxyflurane (Penthrox) use in the outpatient and ambulatory setting: a systematic review. BMJ Open 2025;15:e089031.  |  Bullets 3–4: Health Canada / canada.ca (product information).  |  Bullet 5: Health Canada. Penthrox Product Monograph, revised Jan 31, 2025.

EMLA® Cream Lidocaine-Prilocaine 5%

How it is applied: Apply 2 mL to the cervix using a cotton swab 5 minutes before the procedure. No removal required before insertion.

Evidence:

  • Systematic Review (2 Randomized Controlled Trials, n=212): 2.3–2.8 point reduction in clamp pain vs. placebo
  • 2–2.8 point reduction in copper IUD insertion pain vs. placebo
  • Patient satisfaction (10-pt scale): 8.4 vs. 6.5 placebo
  • No significant vaginal irritation in available studies

Braschi E, Kostov S, Kirkwood J. TFP #405. CFPC, Jan 2026. Refs 1–3.

Lidocaine 10% Spray △ irritation risk

How it is applied: Apply 4 puffs directly to the cervix, wait 3 minutes before proceeding.

Evidence:

  • 2 Randomized Controlled Trials (n=200–324): pain score ≥4 in 6% vs. 41% placebo (NNT = 3)
  • Mean pain at clamp: 0.8 vs. 2.4 placebo; at insertion: 3.0 vs. 5.0 placebo
  • Side effect: 55% vaginal irritation vs. 1.6% placebo

Braschi E, Kostov S, Kirkwood J. TFP #405. CFPC, Jan 2026. Refs 4–5.

Lidocaine 2% Gel Topical

How it is applied: Apply to the cervix using a cotton swab.

Evidence:

  • Systematic Review (2–3 Randomized Controlled Trials, n=345–409): no significant difference from placebo
  • 3 additional Randomized Controlled Trials (n=59–220): no significant difference in most; one small trial (n=59) showed benefit at clamp only (3.2 vs. 5.6)

Braschi E, Kostov S, Kirkwood J. TFP #405. CFPC, Jan 2026. Refs 2, 6–9.

Post-Procedure
Post-Procedure Ibuprofen / Acetaminophen

Dosing: Ibuprofen up to 800 mg every 8 hours with food, starting when cramping begins. Acetaminophen as alternative or adjunct; compatible with Penthrox.

Evidence: Ibuprofen reduces menstrual cramping and bleeding. Standard first-line post-procedure analgesia.

About This Tool

Credits and acknowledgements

This decision aid supports shared decision-making around pain management for intrauterine procedures. It is intended as a clinical tool to facilitate conversation between patients and providers — not as a substitute for individualised medical advice.

Created by
Akanksha Bhargava
MacEwan University Health Centre
Special thanks
Dr. Kostov and Dr. Salvalaggio
Evidence base

Braschi E, Kostov S, Kirkwood J. "Taking the 'ouch' out of IUD insertion." Tools for Practice #405. College of Family Physicians of Canada, January 2026.

cfpclearn.ca/tfp405/ →
Feedback

Please contact us at bhargav4@ualberta.ca for any feedback regarding this tool.

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