Interventions for Pain with Intrauterine Device Insertion

A Cochrane review [Abstract] 1 included 33 studies with a total of 5 710 subjects. 400 mg of ibuprofen vs placebo at least 45 minutes prior to IUD insertion did not significantly reduce pain in 1 trial (mean difference in VAS -0.20, 95% CI -0.39to -0.01, n=2018). In another trial (n=55), ibuprofen 600 mg taken before IUD insertion did not show evidence of an effect on pain four to six hours after IUD insertion. Misoprostol for cervical ripening did not reduce pain with IUD insertion in nulliparous women. In one trial, naproxen as adjunctive treatment to paracervical block taken prior to IUD insertion was ineffective in reducing pain compared with placebo in the first two hours after IUD insertion in mostly nulliparous women. For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (2 trials) or on pain during IUD insertion (3 trials).

Another randomized, double-blind, placebo-controlled trial 3 (n=202) in USA evaluated if ibuprofen 800mg 30-45 min prior to IUD insertion reduces pain 2-6 weeks following first-trimester uterine aspiration.The median pain score with IUD insertion was 4.15 in the placebo group and 3.80 in the ibuprofen group. Mean and median pain scores did not differ between the groups when nulliparous and parous women were analyzed independently. Overall, median pain scores were 1.75 higher in nulliparous women than parous women (p = 0.004). Median pain scores did not differ by age, IUD-type, history of dysmenorrhea or time since aspiration.

A randomized, blinded trial 4 assessed pain control with intrauterine device insertion (levonorgestrel or copper intrauterine device) after patient-administered lidocaine gel (20 mL of 2% lidocaine gel) compared with placebo gel (n=220). Median (range) time from gel administration to speculum insertion was 21 and 20 minutes in the lidocaine and placebo groups, respectively (P = .13). The median pain scores were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (P = .09). Anticipated pain and menstrual pain were both predictors of pain with IUD insertion.

A randomized, double-blind, placebo-controlled trial 7 evaluated whether 550 mg oral naproxen sodium given 1 hour before IUD insertion is effective for pain relief as compared with placebo (n=118). There were no differences in median VAS pain scores for the IUD insertion between naproxen and placebo (69 mm vs. 66 mm, P=.89). However, median pain scores postprocedure were lower in the naproxen arm as compared with the placebo arm at 15 minutes postinsertion.

A multisite, single-blind, sham-controlled randomized trial 5 in adolescents and young women (n=95) assessed the effect of a 10 mL 1% lidocaine paracervical nerve block on pain during intrauterine device (13.5-mg levonorgestrel IUD) insertion compared with a sham block. The median visual analog scale score after IUD insertion was 30.0 (95% CI 20.0 to 58.0) in the lidocaine block group and 71.5 (95% CI 66.0 to 82.0) in the sham block (P<.001).

In another randomized, single-blind, placebo-controlled trial 6, women (n=64) were assigned to receive either a 20-mL buffered 1% lidocaine paracervical block or no block before IUD placement. Women who received the paracervical block reported less pain with IUD placement compared with women who received no block (median visual analog scale score of 33 mm vs 54 mm, P=.002).

In a randomized double-blind controlled trial 8 302 nulligravidas were block-randomized 3.6 mL 2%-lidocaine intracervical block, sham injection, or no intervention prior to 52-mg LNG-IUD insertion. Participants' pain was measured with a 10-cm visual analogue scale (VAS) and a 5-point Faces Pain Scale. The mean pain score reported was lower in the lidocaine group than in the other groups: intracervical block 4.3 (95% CI 3.8 to 4.9) vs sham 6.6 (95% CI 6.2 to 7.0), and intracervical block 4.3 (95% CI 3.8 to 4.9) vs no intervention 5.8 (95% CI 5.3 to 6.4).

An RCT 9 included 100 women. Women randomized to lidocaine intracervical block (6 mL 2%-lidocaine 5 minutes prior) presented lower mean pain score (VAS) at LNG-IUD insertion, when compared to women who received 550 naproxen 30 minutes prior (5.4 vs. 7.3, respectively; p < 0.001).

References

• Lopez LM, Bernholc A, Zeng Y et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2015;(7):CD007373. [PubMed]
• Conti JA, Lerma K, Schneyer RJ et al. Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial. Am J Obstet Gynecol 2019;220(2):177.e1-177.e7. [PubMed]
• Bednarek PH, Creinin MD, Reeves MF et al. Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial. Contraception 2014;Nov 25. pii: S0010-7824(14)00784-7. [PubMed]
• Akers AY, Steinway C, Sonalkar S et al. Reducing Pain During Intrauterine Device Insertion: A Randomized Controlled Trial in Adolescents and Young Women. Obstet Gynecol 2017;130(4):795-802. [PubMed]
• Mody SK, Farala JP, Jimenez B et al. Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial. Obstet Gynecol 2018;132(3):575-582. [PubMed]
• Ngo LL, Braaten KP, Eichen E et al. Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial. Obstet Gynecol 2016;128(6):1306-1313. [PubMed]
• De Nadai MN, Poli-Neto OB, Franceschini SA, et al. Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial. Am J Obstet Gynecol 2020;222(3):245.e1-245.e10 [PubMed]
• de Oliveira ECF, Baêta T, Brant APC, et al. Use of naproxen versus intracervical block for pain control during the 52-mg levonorgestrel-releasing intrauterine system insertion in young women: a multivariate analysis of a randomized controlled trial. BMC Womens Health 2021;21(1):377 [PubMed]