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- [00:01]
Podcast Host
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- [00:33]
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- [01:06]
Art Shermanning
I didn't know about IUDs. I didn't know what they were or how they worked. And I assume the women here are already familiar. But I'm a man, so I'm going to explain it with more confidence and less accuracy. So what it is, it's this little T shaped rod wrapped in copper coils. It goes up into the uterus. I don't know how. I think it's like one of those ship in a bottle type mysteries. You're like, how does that fit in there? Like, I can't tell you. Trade secrets.
- [01:27]
Dr. Eva Jovic
You know, I like that. It's like the ship in a bottle mystery. So if you can't figure it out, in this episode we're going to talk about how to put the ship in the bottle. In other words, IUD insertion. And even though we've talked about this many times before, there is brand new data coming out in August of 2026 in the gray Journal that tackles this with some very special caveats that we have to here. But Nonetheless, the poor IUD or IUs depending on which flavor you like. Man, it takes a lot of heat, doesn't it? I mean, I recently covered a social media post by one physician who treats specifically infertile women who stated that in her anecdotal experience, which is obviously selection bias and observer bias, she's noted an increased likelihood of intrauterine adhesions with IUD use. Of course that freaked people out. And it all makes the point that the IUD just can't get any love or all right now. Larx specifically, whether it's the implant or intrauterine device or the intrauterine system. Highly, highly effective for contraception and the addition of an intrauterine system. In other words, something that's medicated versus something like the copper tea that's not medicated, also has the advantage, of course, of decreasing cramps and decreasing cycles. So, yeah, I mean, there's a lot of reasons why even virginal women may want an IUD if their period is driving them crazy. Okay. All to say IUD in the appropriate candidate can be a win. But people rightfully fear IUD insertion because the word on the street is, oh, my gosh, it's terrible. It's horrifying. It need not be right? Now, we've covered IUD pain control many times before, including our past protocol, which we did about 10 years ago, and people said, we're never gonna do that. And then, lo and behold, in 2024, CDC updated its guidance to formally recommend what we were doing years before that, which was just using local anesthesia. I mean, put some. Either lidocaine jelly, lidocaine spray and. Or paracervical block. Although I don't do the block. I do local gel topical application, and now that is in the formal guidance. All right, but that was 2024. All before that, it was, you know what? We don't really know. I mean, maybe take a Motrin, like, within an hour of IUD placement and see if that helps. The problem is there was a 2015 double blind randomized placebo controlled trial, and that showed that a single dose of 800 milligrams of Motrin, or, sorry, ibuprofen, within an hour before insertion actually did not relieve pain. Now, that may have been because these patients who took the 800mg ibuprofen took it within 30 minutes to 45 minutes. And we know that that probably was bad timing. Okay. Because it takes about an hour to an hour and a half for Motrin. Sorry, I keep saying Motrin. Not a sponsor, just ibuprofen to reach its steady state as a peak. And then before it drops down, it has a very quick half life, about two to three hours, but it doesn't work that fast. All right, The. The. The peak effect is about. At 60 minutes to 90, so about an hour to an hour and a half. So that may explain why the 2015 double blind randomized placebo controlled trial in their journal Contraception, and just didn't show a benefit. Okay. One dose, and it may have been taken too early. So there is an art to timing ibuprofen before IUD insertion. I have my patients take it with about an hour to an hour and a Half. So not within the hour. You want it an hour to an hour and a half so that it's kind of at its peak. And then right before it starts dropping down due to its half life again. Half life is about two, maximum three hours. And then it fades off pretty quickly at around four to six. That's why you can dose it every four to six to eight hours based on what initial dose you're using. Okay, so all to say, there is data that kind of pooh, poohed Motrin before IUD insertion, but people forgot that it may have been taken too soon, within 30 to 45 minutes when it probably needed more time. That brings us, guys, to this August 2026 publication that looked at preemptive, in other words, prophylactic multi dose ibuprofen regimen the day before the, the procedure to try to maintain a therapeutic blood level which can kind of keep steady state for about 10 hours after the last dose. That's different than a single dose. All right, you take a single dose, kind of reaches its peak at an hour, an hour and a half, and then about four hours, it's pretty much gone. Definitely gone by six hours if you don't repeat it. That's why you got to keep taking the medication. And there is this idea of drug accumulation and steady state, so that if you do multi dose treatment, the thought is maybe you can have a lasting effect that works a little bit better. So that's what these authors did. This was a triple blind, randomized trial. I'm gonna get into it in a minute here. And it was very well done. So just to be clear, this is looking at a single medication, ibuprofen, although it's multi dose as opposed to a single dose, even though there are ibuprofen and NSAID combinations over the counter, like ibuprofen and acetaminophen or naproxen and acetaminophen that just got approved by the FDA for over the counter use. This is not talking about that. We don't have data on the combination of an NSAID and something like acetaminophen for this kind of procedure. Most of these studies have used straight NSAIDs, ibuprofen or another type for IUD pre insertion medication. Just wanted to clarify that this is not a combination medication. This is just ibuprofen or an NSAID by itself. While there is a win in what they found in the results, there's some, some room for improvement here because the results are like, okay, they're better, but they weren't great. Even though they reached statistical significance based on what they considered a decrease of pain score on a 0 to 10 validation scale, they used a 2 point scale to consider that significant. And. And we'll get into it in a minute. That's what they saw. Although still the reduction was still at moderate pain. All to say. All to say, this was the only medication that these patients had at IUD insertion because the recruitment ended right before the CDC's 2024 update in the fall. Calling for local analgesia of some type for IUD procedural insert. Okay, so, so this is why there's some caveats here. And the first caveat is this does not mean not use some kind of local analgesia. That is the way to go. That is top notch. It definitely works. But as an adjuvant, rather than giving just one dose of Motrin like within the hour, maybe a multi dose regimen may work. And that's what we're going to talk about in this episode. I think I've set it up enough. We're going to talk about how to put the ship into the bottle pain free. Here we go. We're just trying to fulfill our life calling and our mission. This is Dr. Choppa's OBGYN no Spin podcast. Before we get into this data that is coming out August 2026 in the gray Journal, that intro that we did featuring comedian Matthew Broder and his mansplaining of the IUD placement as the ship in the bottle is too good to not do twice. Here we go. And you're welcome.
- [08:55]
Art Shermanning
Oh, I didn't know about IUDs. I didn't know what they were or how they worked. And I assume the women here are already familiar, but I'm a man, so I'm going to explain it with more confidence and less accuracy. So what it is, it's this little T shaped rod wrapped in copper coils. It goes up into the uterus. I don't know how. I think it's like one of those ship in a bottle type mysteries. You're like, how does that fit in there? Like, I can't tell you. Trade secrets, you know?
- [09:17]
Dr. Eva Jovic
Well, that's what we're talking about here. Trade secrets of how to make this pain free. Now let me preempt this by saying, as I already mentioned in the intro, this predated the CDC rule. So please, for God's sake, use some local. If you want to do paracervical block, fine. I think that's an extra level of pain because you got to stick around the cervix. I don't do that. I just do the lidocaine gel or spray. Typically, it's the gel and a warm compress and then appropriately timed single dose Motrin at 800mg given around an hour to an hour and a half before. Since we know that taking it less than an hour, According to the 2015 study in Contraception probably is not the best. Okay? Now, this study that's coming out in August is nothing new in concept because we've told patients, we've told women, we've told teenagers for years, for decades, hey, if you've got bad period cramps, if you start taking ibuprofen when you have your cramp, it's fine, but it's not gonna work as great as if you have Motrin. What? On board, Right? Have Motrin at a steady state. So try to take it on a regular schedule the day before you anticipate having your cycle. The problem is, of course, women's cycles aren't that, you know, precise. Some are, but not always. So it's kind of a guessing game. But at the start of that brownish discharge that's premenstrual, probably get on top of that. If you have dysmenorrhea that is affecting quality of life. That is actually also in the AAFP guidance, that's the American Academy of Family Physicians that says, quote, NSAIDS should be initiated 2. I'm sorry, one or two days before the onset of menses and continued in regular dosing intervals through the first two or three days of bleeding, end quote. There you go. I mean, we get that. Nothing new. It's even in ACOG's guidance as well, that NSAIDS for premenstrual pain issues or on the initiation of menstruation. Quote. Listen to what ACOG says it, because this is like a lot. Quote. Can be taken during the late luteal phase or as symptoms arise, end quote. Well, the late luteal phase, man, that's like one or two weeks. I mean, that's too long. But typically it states within around seven days before expected menses. I think that's way too many days of nsaid. It's going to mess up with your GI tract. But it's right there. I mean, it actually makes a statement that naproxen sodium, 550mg twice daily, started seven days before expected menses through day four of cycle significantly can reduce pain. That is in ACOG, clinical practice guideline number seven. All to say There is data about preloading and maintaining steady state, which is different than a single dose. Now, I do single dose. If you're going to do single dose, just time it appropriately and don't use it by itself, because that's what these authors did. It was just Motrin. That's it. It's Motrin and warm compress. Motrin and local anesthesia. Motrin and gentle technique. Hello. And above all, guys, here it is setting expectations, okay? Because unless they're under general anesthesia, they're gonna feel something. But it shouldn't feel any more, in my opinion, anything more than a 3 or a 4 on a 0 to 10 scale, which is one of my issues with this study. And we're gonna do this quickly. I'm not going through all the little minor details. I'm just gonna give you the. What the main findings are. But remember, in a 0 to 10 scale, just like we grade pain in labor and Delivery, typically under 4 is mild. You know, between 4 and 7 is typically moderate. Ish. And then greater than 7 or 7 and 10 is severe pain. So let me get into the study design, but let me just tell you briefly why that matters. Because in this study, which was, again, very well done, and it was blinded and triple blind and randomized, it was, it was well done. Out of Orlando va, out of the Veterans affairs in Orlando. For the women who wanted, who presented for an IUD insertion, this meant statistical significance. I mean, this thing worked in the sense that they call success what other people have called success, which is anything that reduces pain to points on that number scale. So if it goes to seven to a five, that's a win, y' all, with me. And ideally, it drops down a category. Well, that's exactly what this study showed. In other words, it went from a score of seven. Okay, so medium score of seven with placebo to a score of five. You're like, all right, great, we're moving down the number line. That's, that's great. We want that and that is a win. So these authors say, hey, this is a statistically and clinically meaningful difference. It is. No question. The issue is, is that a 5 is still considered moderate pain. So at least we went down from the severe, which is a score of seven, to down to a score of five in those that actually had the preloading multi dose ibuprofen regimen as a median score. But it's still. We went from severe to moderate. My goal is to move them off of moderate down into mild. And it is Possible. All right, so don't think it's not possible because it is. Because with good technique and gentle pass and a lot of local and a lot of coaching, our patients, many times, not always, but many times say, wow, that really wasn't bad at all. And on our informal scale, give me a zero. That's like no pain at all. Ten, which is like passing a kidney stone or a child without any, you know, labor analgesia. What's your number? And it's typically anywhere from around a three to a five. So it's on that lower end. So yes, using. Let me just show you right now what they found. Using three dosages of 800 milligrams of ibuprofen starting the day before resulted in a median score of a five compared to a seven. My beef with this is that it is still a five. Okay, but. But that's all that these patients got.
- [15:12]
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- [15:37]
Art Shermanning
I'm Art Shermanning. I'm Madison Skinner.
- [15:39]
Dr. Eva Jovic
I'm Eva Jovic. I'm Decoria Moore.
- [15:41]
Art Shermanning
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- [15:43]
Dr. Eva Jovic
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Dr. Eva Jovic
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Dr. Eva Jovic
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- [15:51]
Art Shermanning
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- [15:53]
Dr. Eva Jovic
Now let me just tell you what this actual regimen was. So if you want to know how to do this, I think it's fine to do this as an ancillary, but not as a standal. Remember, CDC and ACOG still say giving some kind of local really should be considered here. The dosages that were used here were that patients were instructed to take the medication, which was either true medication or a placebo starting at 12 noon the day before and then again at 8pm the day before and then 8am the day of insertion. So I think this is a little. It's fine, it's very practical. But it doesn't make a lot of sense because first dose is at 12, next dose is eight hours later. That's fine, that's on the tail end. But the next one is 12 hours later at 8am so you may have lost some of that steady state. And I get that these authors say even at 12 hours, there's still some medicine in there. Man, it's 12 hours. I mean, that's really pushing it. So that may explain why the number in the treatment group went down to five, which is good, but not lower. Okay. Because, I mean, it's begging for the last part of that medication because some of these patients had placement in the afternoon. All right, so once again, let me say it again. These patients had ibuprofen, 800 milligrams at 12 noon the day before the procedure, 8pm and then at 8am the day of the procedure. And some of these office visits were from 8am, which is perfect, to about 4pm so that's still lagging us, like eight hours later. Right from their 8am dose. If you take the last dose at 8am you go all through the morning, then you have it at 4pm that's eight hours later. You may be at the tail end there of that medication. So just throwing that out there. All right. Short of it is, yes, this is a win. I'm glad that this showed some kind of efficacy as opposed to single dosing. But my fear is that if we tell a patient, hey, I'm gonna do your iud, I'm giving you some local. No worries, a little heating pad, it's gonna be fine. But the day before, three times a day. Well, twice a day before, and then one in the morning of, you've gotta take this medication to prepare you for this. That may be freaking them out and sending some kind of weird, you know, some conscious, you know, pain perception that. Man, I gotta take Motrin three times a day for this. So that's the one kind of negative thing on this, where maybe it's setting up kind of a negative expectation. I don't know. I'm just throwing that out there all to say, this is an option, and I think it's valid. I have a simpler one, which is use local. Again, these patients did not get that. And then appropriately time the medication so that it has peak effect. Taking it 30 minutes before, not good enough. 45 minutes before, better, but still not at peak. It takes 60 to 90 minutes for this thing to work. And again, the dose used in this article was 800 milligrams over again, approximately 24 hours for three dosages. Let me give you the title of this because I kind of got ahead of myself and I went all over. I lost my location of my notes here. But let me just Give you the title of this again coming out August 2026 and then we're going to wrap this up quickly. Just to give you some practical implications here. The title is multi dose Ibuprofen prior to Intrauterine Device insertion. A triple blinded randomized controlled trial. If you're looking for some, you know, fancy little name for this. No, I mean they do call it mipi. That's M I P I mipi, which stands for multi dose ibuprofen prior to intrauterine insertion. M I P I mipi. Yeah, that's not a thing. I'm not going to use that. I'm just going to say multi dose ibuprofen. So it's an option if you want to. My point is, thankfully these things are getting attention. Thankfully giving patients something because historically there was like, yeah, you get nothing. It just, you know, kind of cough. Maybe when you, you know, place the IUD or at the tenectulum site. Because there's some weak data on as, mainly distraction, but nothing else. But that changed again in 2024. This CDC update is super important and I'm going to tell you why. And it's reflected right here in this publication. And then we're going to call it quits. All right, so here it is. Yes, it was a win.
- [20:02]
Podcast Host
Woo hoo.
- [20:02]
Dr. Eva Jovic
We went from seven to five. Yeah, but that's still moderate. But here's where we're at. When you step back and look at these patients who had this, whether it was a placebo or the ibuprofen and in MEPE fashion, multiple ibuprofen pre insertion protocol, the MEPE protocol. Here's the issue though, here's the reality. Remember, this predates that 2024 of August CDC wreck. Here it is, 81%, actually, 81.8 of these study participants of these patients still had moderate to severe pain by this protocol. That's unacceptable to me. So 81.8%, which was 54 of the 66 patients who participate in this, had moderate or severe pain. We can do better, guys. That's why I'm saying this is good info, but this predates what we're doing now. So please don't think that you're going to give a patient or you should give a patient, you know, three times a day Motrin the day before the iud, and that's it. They still need to have an expectation set. They still need ideally some kind of local analgesia. It doesn't have to be block. It can be local, topical or whatever your flavor is we actually, we mentioned in a previous episode where we gave intrauterine installation and that's been published as well. There's different things that can be done, including a heating pad and picking the appropriate patient. So if you have a patient who has very low pain tolerance and you know, has severe dysmenorrhea, then please do the maximum possible, including what these authors did, to try to get to that steady state functioning of nsaid. And then if you're going to give her a last dose at 8 in the morning, try not to place the IUD eight hours later. So I got two big issues with this and again, so very well done. And these authors did a phenomenal job on this. But the two things I have is, man, that's eight hours after the dose. It's like on fumes, so to speak, of the ibuprofen in the body. And that's all they got. So 81.8% in this study of these participants still reported moderate to severe pain. We can do better. Podcast family. Just a quick word about what's coming out. August 2026. This is again in the American Journal of OBGYN, the Gray Journal. It is multi dose ibuprofen prior to intrauterine device insertion and a triple blinded randomized control trial predated the 2024 CDC. Rex. All right, that's it. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, Michael, let's take it home. This is Dr. Chapma's OBGYN no Spin podcast. Sam.