Lowering IUD Insertion Pain with Intranasal Mild Sedation

Typical intrauterine device (IUD) placement is known to be a painful in-office procedure with limited pain management options. But Tricia Huguelet, MD, and Children’s Hospital Colorado’s Department of Pediatric and Adolescent Gynecology is setting a new standard for IUD placement.

“The placement can be incredibly painful and that does a disservice to our patients,” Dr. Huguelet says. “Period pain should never get in the way of quality of life, and patients shouldn’t hesitate to get an IUD because they’re fearful of the pain of the procedure. Now, we have another option.”

Since September of 2023, Dr. Huguelet and her team have offered adolescents getting IUDs this new option for pain management — intranasal midazolam (Versed), a nasal spray that helps with anxiety and provides mild sedation.

“It’s a game changer,” Dr. Huguelet says.

The American College of Obstetricians and Gynecologists (ACOG) recently updated guidelines for IUD placement to focus more on prioritizing pain management and patient counseling about the options available to them — something that Children’s Colorado has already been prioritizing. 

Adapting to adolescent gynecology

Prior to offering intranasal midazolam, a significant number of adolescent patients opted to be placed under general anesthesia for IUD placement, making it a higher risk procedure, booking up operating rooms and requiring the patient to take more time away from school.

“We were having to recommend a procedure that comes with a lot of well-known pain, but not really much we could offer besides oral medications,” Dr. Huguelet says.

She remembers hearing how other specialties, such as orthopedics and dermatology, were implementing intranasal midazolam in their practices and decided to explore how that simple protocol could be adapted to adolescent gynecology to make IUD placement less painful.

Now two years later, Dr. Huguelet and the adolescent gynecology team are one of the only pediatric teams in the nation offering this pain option for patients. This option means patients come in for their placement appointment after their initial consultation visit and receive the intranasal medication with constant one-on-one monitoring. After only 10 minutes, the doctor comes in to do the five-minute procedure, and patients just need to wait 30 minutes after the procedure before they can head home.

“There’s definitely a difference when a patient gets intranasal midazolam,” Dr. Huguelet says. “The majority of the patients are so much more relaxed and comfortable. They are so much more able to tolerate the procedure and report lower pain scores.”

Opting in for in-office procedures

Since offering this new pain management option, Dr. Huguelet and her team have seen an increase in patients opting to have the IUD placed in the office rather than the operating room under anesthesia. Over the past two years, they have seen over a 28% increase in patients opting for the in-office procedure, and Dr. Huguelet expects that number to continue to grow as more families learn about this option.

The patients that opt for the intranasal mild sedation report a pain score of 2.9 out of 10 for the procedure, compared to previously reported higher scores.

Dr. Huguelet and her team have already shared this protocol with interested physicians across the country, but they plan to publish it to reach more adolescent gynecology departments with the hope that more patients will have access to a more pain-free procedure.

“Patients deserve to get good, comfortable care.” Dr. Huguelet says.