This might be too much information, but this article began with me sitting on an examination table wondering whether I should ask my doctor for lidocaine for my upcoming intrauterine device (IUD) replacement. Why the IUD? To each their own when it comes to medication and contraception, but it’s a popular choice compared to something like the pill. If you ask me, I’d happily trade a few mins of discomfort every five years for not having to remember contraception 1,825 times in between.
As if my algorithm read my mind, my feed since has been filled with discussions about pain management during IUD insertion. Many OB-GYNs and women's health advocates are making content urging patients to advocate for themselves in the exam room, and in the case of IUDs, that discussion could involve local anesthetic. The logic seems straightforward enough. Lidocaine numbs tissue. Numb tissue hurts less. Therefore, lidocaine should make IUD insertion less painful. Amazing, sign me up!
However, my daydreams of pain-free, contraceptive bliss were rudely interrupted when a friend informed me that the evidence supporting lidocaine during IUD insertion was, at best, mixed. This immediately offended my sense of scientific order. How could that possibly be true? If lidocaine can make having a tooth drilled feel tolerable, why shouldn't it help when someone is placing an IUD? As it turns out, the answer is more complicated than I expected.
The Pain Problem
IUDs are among the safest and most effective forms of reversible contraception available. They're also widely used for menstrual suppression and management of heavy bleeding.
While many patients report only mild to moderate discomfort, a significant minority experience substantial pain during and after insertion. Unsurprisingly, fear of that pain has become one of the biggest barriers preventing some people from choosing an IUD in the first place. Studies have found that both patients and healthcare providers cite insertion pain as a reason the method is underutilized despite its effectiveness.
This presents an obvious challenge: if pain is discouraging people from accessing one of the most effective forms of contraception available, finding ways to reduce it should be a priority. Unfortunately, identifying interventions that consistently work has proven more difficult than it sounds.
The Evidence Isn't Exactly Overwhelming
A 2020 review examined a simple clinical question: what pain-management strategies actually work during IUD insertion?
Among the options studied, the strongest evidence supported a lidocaine-prilocaine cream applied before the procedure. Compared to placebo, this combination reduced pain associated with tenaculum placement by roughly 24% and pain during IUD insertion by about 28%. That sounds promising, and it is, at least compared to many of the alternatives.
Another study found that a 4% topical lidocaine solution applied to the cervix reduced pain following the procedure by approximately 16%. Whether a 16% reduction is clinically meaningful depends on who you ask. If you're the person experiencing the pain, you may decide that any reduction is worthwhile.
Unfortunately, that's about where the certainty ends. One frequently cited study reporting benefits from a combination of misoprostol and lidocaine was later retracted. In science, a retracted paper occupies roughly the same evidentiary status as a witness who has been caught lying under oath. It doesn't necessarily prove the opposite conclusion, but it certainly doesn't strengthen the case.
The Placebo Effect Strikes Again
As often happens in medicine, for every study supporting a treatment, there seems to be another questioning whether it works at all.
A 2015 systematic review found that several commonly proposed interventions, including topical lidocaine gels, misoprostol, and ibuprofen, did not meaningfully reduce pain during insertion. Evidence regarding NSAIDs remains particularly conflicted. Some studies report small benefits, while others suggest the effects may be largely attributable to expectation rather than pharmacology.
Another important consideration is the source of the pain. A 2025 study built upon prior reviews to explore procedural modifications that could ease the experience including the pace of tenaculum (an instrument that pierces the cervix to stabilize it) use or ditching the tenaculum altogether. Some researchers have also questioned whether the traditional tenaculum itself may be responsible for a meaningful portion of procedural discomfort, while others have highlighted the importance of patient preparation, verbal distraction, and anxiety reduction as additional opportunities to improve the experience.
Which brings us to another point: pain is not simply a measure of tissue damage. It is also influenced by anxiety, anticipation, prior experiences, and context. In fact, some experts have described the importance of good counselling, patient trust, and a calm clinical environment as a form of "verbal anaesthesia."
So, Should You Ask for Lidocaine?
Probably, if you think it might help. The evidence for lidocaine during IUD insertion is not overwhelmingly strong, but neither is it entirely absent. Some formulations appear to provide modest benefits, even if those benefits are smaller than many people assume.
More importantly, feeling informed, supported, and in control of your healthcare experience has value in its own right. If requesting lidocaine reduces anxiety and makes you feel more comfortable approaching the procedure, that may improve your experience regardless of whether the mechanism is pharmacological, psychological, or some combination of the two.
Of course, there is one downside to reading an article like this. If the placebo effect was helping, I may have just ruined it for the both of us.
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