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  • Review
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13 May 2026

10 Pages

A Narrative Review Exploring the Associations Between Emphasis on Pain Education in Medical Curricula and Discrepancies Associated with Pain Management Related to IUD Insertions

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and
1
University of Illinois College of Medicine Peoria (UICOMP), Peoria, IL 61605, USA
2
Department of Health Sciences Education and Pathology (HSEP), University of Illinois College of Medicine Peoria (UICOMP), 1 Illini Drive, Peoria, IL 61605, USA
3
American University of the Caribbean (AUC) School of Medicine, 2 University Drive, Cupecoy, Sint Maarten, The Netherlands
*
Authors to whom correspondence should be addressed.
Int. Med. Educ.2026, 5(2), 47;https://doi.org/10.3390/ime5020047
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Abstract

Increasing use of intrauterine devices (IUDs) makes effective pain management essential for high-quality care. However, gaps between patient and clinician pain perceptions, along with limited training in managing IUD-related acute pain, contribute to barriers in IUD use and patient–provider mistrust. This narrative review aims at (1) summarizing current IUD-related pain management, (2) evaluating the emphasis on pain education and management, including IUD insertion pain, in medical education, and (3) examining how gaps in pain education and management may affect clinicians’ preparedness to manage patients’ IUD-related pain. Relevant literature was identified through keyword searches across major databases and national organizations. Studies on IUD pain management approaches and pain education in undergraduate medical education (UME), graduate medical education (GME), and residency programs were included. The results section outlines the current IUD insertion pain-management options available and their limitations, alongside evidence of insufficient emphasis on pain education and its management in medical school and residency training. In conclusion, the study indicates that, although all pain-management approaches reduce perceived IUD-related pain, significant gaps in national guidelines, clinician–patient pain-perception non-alignment, and pain-education across UME and GME may be contributary to inconsistent clinical practices. A multi-pronged approach that includes strengthening pain-education throughout medical training could be one way to reduce these disparities by improving clinicians’ competence to manage pain effectively.

1. Introduction

Pain, despite its complex and multifactorial nature, remains one of the most common reasons patients seek medical care. Robust educational initiatives in undergraduate (UME) and graduate medical education (GME), covering pain pathophysiology, evidence-based treatment strategies, and empathic patient communication, are essential to prepare future physicians to manage pain competently and deliver high-quality patient care.
Hormonal and non-hormonal intrauterine devices (IUDs) are highly effective long-term contraceptive options [1,2] offering additional benefits, including reduced symptoms of menorrhagia, endometriosis, and adenomyosis, improvement of anemia, and decreased risk of endometrial cancer [3,4,5]. However, IUD insertion can be painful for many patients [6]. Despite this, approximately 14.3% people of reproductive age worldwide use IUDs for contraception, and U.S. utilization has increased from 5.6% (2006–2011) to 10.5% (2017–2019) [7].
Recent studies highlight substantial variation in pain-management practices for IUD insertion across healthcare settings. Reports highlight that clinicians minimize patients’ pain and provide insufficient patient counseling about available pain-management options [8]. These contribute to hesitancy among younger patients who consider IUDs [9,10]. National guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) were inconsistent and remained largely unchanged between 2017 and 2023. Only recently have both organizations updated their recommendations [11,12], prioritizing patient-centered communication and multimodal pain control to bridge the gap between clinicians’ expectations and patients’ reported pain experience. However, the recommendations differ in depth and emphasis, with ACOG providing more detailed, clinic-level operational guidance and CDC providing broader guidance, maintaining public health framing perspective.
This article examines the emphasis on pain education and physician-training for management of pain. Drawing on an extensive review of the existing literature, we have attempted to determine whether the identified gaps in pain medicine education are associated with clinicians’ ability to effectively manage patients’ pain, including IUD-related pain. We have also suggested recommendations to address these curricular deficiencies to reduce the existing disparities in clinical practice.

2. Materials and Methods

An exploratory search was conducted using PubMed, Google Scholar, Google Search, ScienceDirect, NIH, and CDC resources. The search, completed between April 2024 and March 2025, focused on two areas: (1) current approaches to managing IUD-associated pain, and (2) emphasis on pain education in UME and GME, including training in IUD insertion and related pain management.
For Section (1), the goal was to identify existing strategies for reducing pain during and after IUD insertion. Search terms included combinations of “intrauterine device,” “IUD,” “pain management,” “analgesia,” “insertion,” “procedure-related pain,” “strategies,” and “methods.” Eligible sources included peer-reviewed articles on pharmacological and non-pharmacological interventions, reviews, clinical guidelines, meta-analyses, controlled trials, national agency documents, and survey-based studies. After title and abstract screening, full-text reviews were performed. Exclusion criteria included studies unrelated to IUD-associated pain, non-human research, studies involving participants under 18, and non-English publications.
For Section (2), the aim was to assess how UME and GME curricula address pain education, IUD insertion/removal training, and instruction on managing associated pain. Search terms included “pain education,” “medical curriculum,” “undergraduate medical education,” “graduate medical education,” “IUD pain management training,” “IUD training,” and “medical student competencies.” Included materials consisted of reviews, research articles, and survey-based studies focused on pain-education practices, interdisciplinary approaches, IUD clinical training, and competency development. Screening followed the same process as Section (1). Notably, no studies were found that specifically addressed training in IUD-associated pain management within existing UME or GME curricula.
Given the limited literature specifically on the emphasis on pain education and management in the medical curriculum, we were compelled to accept all sources of information, including “grey literature,” which made a systematic review infeasible or inappropriate. Thus, we aimed to provide a comprehensive overview of the topic by summarizing and synthesizing all available evidence, without following the strict methodological procedures of systematic reviews. This ensured that sources could be represented accurately, that citations to relevant sources were included, even from “grey literature,” and that scholarly rigor could be preserved. Our narrative review of existing literature did not require primary data collection, which eliminated the requirement for ethical approval.

3. Results

To highlight the existing discrepancies in pain management options for IUD insertions and the lack of standardization in the process, Section 3 (results) lists the available options in the prevailing literature. It summarizes their efficacy, disadvantages, and their current use in clinical practice. Based on the premise that educational initiatives could play a pivotal and crucial role to ensure that physicians are equipped with the necessary knowledge, aptitude, and skill sets to mitigate patients’ pain in general and IUD-associated pain in specific. We have thus attempted to provide a status update on how general pain medicine education has historically been emphasized and incorporated into medical curricula globally. Furthermore, in this section, we have also provided a summary of the emphasis of UME and GME curricula on pain education, pain management, and training in IUD insertion and removal processes.

3.1. Current Management Options Available for IUD-Associated Pain

Misoprostol: Misoprostol is a synthetic prostaglandin E1 analog routinely used in the OB/GYN practice for medication abortion, medical management of miscarriage, induction of labor, and as a cervical ripening agent for hysteroscopic procedures like IUD insertion [13,14]. Routine utilization of the drug as a pain management option for IUD insertion by physicians is reflected in Table 1. However, due to its limited effectiveness [15], CDC does not recommend using misoprostol to reduce IUD insertion pain in their most recently updated guidelines [12].
Nonsteroidal anti-inflammatory drugs (NSAIDs): These drugs are the most commonly recommended by providers [16,17,18]. Although oral administration of NSAIDs like ibuprofen (800 mg), 30–45 min prior to IUD insertion, may have little to no effect on insertion pain [19,20], ibuprofen might help manage post-procedural pain [17]. The updated CDC and ACOG guidelines include the use of NSAIDs (such as ibuprofen or naproxen) as a recommended option for managing IUD insertion pain, often to be taken about an hour before the procedure [11,12].
Lidocaine: Recent guidance from both the CDC’s 2024 U.S. Selected Practice Recommendations and ACOG’s 2025 Clinical Consensus on Pain Management for in-office gynecologic procedures emphasizes that local anesthesia with lidocaine should be actively offered for the management of IUD-insertion pain. Both organizations note that a paracervical block with 1% lidocaine provides the most consistent reduction in insertion-related pain, particularly for nulliparous patients or those with anticipated high discomfort. They also acknowledge that topical lidocaine formulations, including lidocaine gel, spray, or cream applied to the cervix or cervical canal, can reduce tenaculum placement pain and decrease insertion pain, though with variable effects. CDC and ACOG frame lidocaine use as part of shared decision-making and a multimodal pain-management strategy, encouraging clinicians to offer topical lidocaine and/or a paracervical block rather than relying on NSAIDs alone.
Other lidocaine formulations with different efficacies used in the management of IUD-associated pain include 20 cc buffered 1% lidocaine paracervical block [21], 10% lidocaine spray [7,22], and 2% lidocaine gel used as a local anesthetic [23].
Combination drugs: Use of combination drugs, like oral administration of diclofenac potassium tablets one hour prior to the IUD insertion, followed by the application of 2% lidocaine gel on the anterior cervical lip and cervical canal, 3 min before insertion, is found to reduce IUD-associated pain efficiently [24]. Lidocaine-prilocaine cream (LP cream) is another effective combination drug that can reduce IUD insertion pain in subjects [25].
Sedation Options: Other less commonly used options for management of IUD-pain include conscious sedation (using nitrous oxide-based approaches) and moderate sedation/anesthesia (using midazolam and fentanyl) [26], which are preferred for patients with significant anxiety or who anticipate severe pain during IUD insertion. Full anesthesia is rarely used for IUD placement but may be considered in exceptional cases involving severe anxiety, prior trauma, or failed attempts [27].
Table 1. Summary of the results of two national surveys [17,28] highlighting the existing discrepancies in IUD-associated pain management in the US.
  • Percentage of use of the different pain management options by the current
Two U.S. provider surveys, a 2019 cross-sectional study of 1063 family planning clinicians [28], and a mixed-methods study of 33 routine IUD inserters [17], show wide variation in how clinicians use available options for managing IUD-related pain. As summarized in Table 1, their findings underscore substantial inconsistencies in pain-management practices across the country.

Identified Gaps in Pain Education in Medical School Curricula

International guidelines for pain education have existed for decades, including the International Association for the Study of Pain (IASP) curriculum, now in its third edition [29]. We also reviewed AAMC guidance on pain-education content in U.S. medical schools. Although “pain” and “pain management” appear among commonly included clerkship topics, AAMC data [30] (accessed 11 January 2026) do not provide robust information on the actual instructional hours devoted to pain medicine. This discrepancy highlights a persistent gap between national recommendations, curricular documentation, and the time allocated to pain-education content in U.S. medical schools. Our study, extrapolating from general literature related to emphasis on pain education in medical school curriculum (due to unavailability of literature on OBGYN pain or IUD pain management), identified three major areas for potential improvement in UME and GME curriculum.
  • Inconsistent Time Dedicated to Pain-Medicine Education
Studies from the early 21st century show substantial variation in pain-education hours across countries. North American medical schools offered limited and inconsistent instruction [31,32]. A 2009–2010 survey reported that although most U.S. (80%) and Canadian (92%) schools required at least one pain session, the content was “limited, variable, and fragmentary” [31,33]. A global review by Shipton et al. (2018) found the highest median instructional hours on pain were in Polish (39 h) and Finnish (30 h) medical schools, and the lowest in Romanian and Italian (4 h each) medical schools [34,35]. Canada, Australia, New Zealand, the UK, and Europe reported 12–20 h of pain education, while U.S. medical schools offered a median of only 11 h, with 20% providing fewer than 5 h [31,34]. More recent work [36] continues to criticize U.S. programs for insufficient pain-education time, particularly in GME. Collectively, these findings underscore the need for stronger, more consistent integration of pain-medicine education in medical education globally. Our review also revealed limited research comparing the emphasis on pain education between UME and GME.
2.
Lack of a Dedicated Pain-Focused Curriculum
Pain-education instruction is often fragmented across multiple courses rather than delivered through a unified curriculum. Studies describe pain-education content as “limited and variable” [31] and many IASP core topics remained unaddressed [33]. In most U.S, Canadian, and European medical programs, pain-related content is dispersed across pharmacology, anatomy, and physiology in UME, and oncology, anesthesiology, and emergency medicine in GME [32,34,37,38]. Australia and New Zealand commonly offer short elective pain-medicine courses, but these are not standardized [34]. These findings highlight the absence of comprehensive, standalone pain education curricula with defined objectives that cover pain physiology, assessment, management, and ethical considerations. Shipton et al. (2022) highlights the need to develop an innovative, interprofessional pain curriculum aligned with future healthcare needs and competency-based education in modern medical education [39].
3.
Insufficient Training in Advanced Contraceptive Methods, Including IUDs
Gaps in pain-medicine education mirror broader deficiencies in training on advanced contraceptive methods. Early work by Westhoff et al. (1993) showed that although OB/GYN residents felt comfortable with oral contraceptives and tubal ligations, 38% had never performed an IUD insertion [40]. Subsequent studies demonstrate that this limited exposure persist [41]. Steinauer et al. (2008) reported that only 76% of U.S. medical students received any IUD education, with curricula still centered on oral contraceptives [42]. More recent research [43,44] highlights the value of simulation-based IUD training in GME, particularly for non-OB/GYN specialties, while studies by Strasser et al. (2022) show that many residency programs continue to fall short in advanced reproductive health trainings [45], contributing to the low proportion of clinicians (40%) who provide IUD insertion to their patients. This lack of consistent, hands-on training may also limit physicians’ ability to anticipate, recognize, and effectively manage pain during IUD insertion, reinforcing variability in patient experience and procedural quality. Notably, very few studies have examined how GME or residency programs train clinicians specifically in IUD-related pain management, highlighting a persistent and understudied gap in the area.

4. Discussion

A persistent gap remains between patients’ and physicians’ perceptions of pain, its causes, and appropriate management strategies. Recent studies highlight that patients often report higher levels of pain than clinicians anticipate, particularly in procedures such as IUD insertion, where pain can vary widely across individuals [8,18,46]. This discrepancy between patients’ and physicians’ perceptions of pain can be partially attributed to the limited and fragmented nature of pain education in undergraduate medical education (UME) and to insufficient training in pain management during graduate medical education (GME) and residency. These findings align with longstanding evidence in the literature showing that medical graduates frequently feel underprepared to manage pain due to inadequate instruction in pain pathophysiology, treatment strategies, and communication skills [34,38,47]. Recent evidence also indicates that outdated pain management training methods, or the lack of them, continues to leave clinicians uncomfortable and underprepared [38,39]. This educational gap may also have direct implications for reproductive health procedures such as IUD insertion. While many patients experience pain similar to menstrual cramping during IUD insertion, nulliparous individuals and those with anxiety or dysmenorrhea often report significantly higher pain intensity [6,48]. The subjective nature of pain, shaped by psychological, experiential, and physiological factors, further complicates clinicians’ ability to anticipate patient needs. The complex sympathetic, parasympathetic, and sensory innervation of the female pelvis adds another layer of difficulty, making it challenging to target specific nociceptive pathways during IUD insertion [49]. The authors propose that these discrepancies, at least in part, may stem from the absence of a structured pain-education curriculum in medical school. We suggest that greater emphasis on foundational pain science during the preclinical UME years, followed by the integration of skills-based training in empathetic communication, pain assessment, and multimodal pain-management strategies within the GME curriculum may be useful in bridging the gap. Developing elective training programs focused on IUD-related pain management-grounded in competency-based education models and entrustable professional activities-is one potential solution. Additional structured approaches commonly used to evaluate curricular adequacy and clinical preparedness may also be incorporated to strengthen training [34,39]. This may help produce clinicians better equipped to manage pain in general and IUD-related pain in particular with both precision and empathy. However, the authors acknowledge that integrating new content into an already overloaded medical curriculum may pose significant time and resource constraints and should therefore be approached in stages.
The recent updates to national guidelines for IUD pain management represent a promising step toward standardizing patient-centered care. Between 2017 and 2023, major guidelines from the CDC and ACOG remained unchanged, a stagnation that may have contributed to inconsistent clinical practice. However, both organizations have now released updated recommendations—CDC in 2024 [12] and ACOG in 2025 [11]—which are largely aligned in their core messages. Both organizations acknowledge that the evidence base for many interventions remains limited or mixed, which underpins their cautious, flexible approach to pain-management strategies. Both CDC and ACOG acknowledge that IUD insertion can be painful, emphasize the importance of patient-centered counseling, and endorse offering local anesthetic—particularly lidocaine-based options—as evidence-supported strategies. Both recommendations also converge in advising against routine misoprostol use, limiting it to select situations such as prior failed insertion or cervical stenosis. However, the recommendations differ in depth and emphasis. ACOG provides more detailed, clinic-level operational guidance, including structured multimodal approaches (routine consideration of topical, intracervical, or paracervical lidocaine) and explicit attention to trauma-informed care, individualized and culturally competent counseling, and a stronger focus on equity and bias in pain assessment. In contrast, the CDC’s 2024 Selected Practice Recommendations provide broader guidance, maintaining a public-health framing with more general recommendations that emphasized lidocaine “might be useful” while reaffirming that misoprostol should not be used routinely due to minimal benefit as indicated in prior studies [50,51]. The clear emphasis of both organizations on the need for patient-centered communication may be considered an essential step toward narrowing the existing gap between clinician expectations and patient-reported pain.
Finally, enhanced procedural training in GME and residency is critical for improving IUD-specific pain management. The APGO Medical Student Educational Objectives (11th ed., 2019) include IUD insertion and removal under gynecologic procedures, underscoring the need for clerkship programs to emphasize procedural competence, risk–benefit counseling, and pain-management considerations [52]. Yet, as our findings indicate, consistent and comprehensive training in these areas remains incomplete across many programs [41,53]. Strengthening this component of training would help clinicians better navigate the individualized nature of IUD-associated pain and apply updated guidelines effectively.
Taken together, educational reforms based on competency-based education models and entrustable professional activities may offer a path to reduce patient discomfort, minimize skepticism, and strengthen patient–physician trust. By aligning medical training with contemporary evidence and patient-centered standards, the healthcare system can move closer to equitable, empathetic, and effective pain management across reproductive health and beyond.

5. Conclusions

This narrative review prioritized breadth over depth. The limited consistency in research on pain education and pain management training in medical education is a limitation of our study. As a result, our analysis is necessarily narrative in nature, drawing on heterogeneous sources to identify themes, highlight gaps, and propose directions for future curriculum development. Nonetheless, rising IUD use underscores the need to address persistent discrepancies in IUD-associated pain management. Our study concludes that all pain-management approaches identified reduce the perceived pain to some extent, yet pain management itself remains insufficiently addressed in medical education. The discrepancies observed in managing IUD-associated pain may stem from gaps in national recommendations, differences in pain perception between patients and practitioners, and limited pain-management training across UME and GME. The findings further suggest that expanding pain education efforts across all stages of medical training could help reduce these disparities by enhancing clinicians’ ability to manage pain effectively for the delivery of individualized, evidence-based pain management strategies consistent with updated CDC and ACOG guidelines [11,12], ultimately improving patient comfort and procedural experience. The authors acknowledge that adding new content to an already overloaded medical curriculum can pose significant time and resource challenges, and may address only part of the issue, given that gynecological pain remains widely normalized and stigmatized across cultures.

Author Contributions

Conceptualization: W.G., H.J.M., E.O., A.O., A.S. and J.P.; Methodology: W.G., H.J.M., E.O., A.O. and A.S.; Validation: A.S. and J.P.; Investigation: W.G., H.J.M., E.O. and A.O.; Visualization: A.S. and J.P.; Writing—original draft preparation: W.G., H.J.M., E.O. and A.O.; Writing—review and editing: A.S. and J.P.; Supervision: A.S.; Project administration: A.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data Availability Statement

The article describes entirely theoretical research. No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Acknowledgments

We thank the University of Illinois College of Medicine at Peoria (UICOMP) and AUC School of Medicine, Sint Maarten, for providing the support and resources needed to prepare this review. Special thanks to AJ Pool, research analyst at UICOMP, for helping with data analysis and feedback. We would also like to thank UICOMP faculty, Jenna Regan and Ayoola Awosika, for providing constructive feedback during the review development process. We sincerely thank Lawrence Brako for proofreading the different versions of the manuscript.

Conflicts of Interest

The authors report no competing interests.

Abbreviations

The following abbreviations are used in this manuscript:
IUDIntrauterine Device
UMEUndergraduate Medical Education
GMEGraduate Medical Education

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