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 double-blind RCT 10assessing the effectiveness of topical 10% lidocaine spray (40mg) for pain control during IUD insertion included a total of 200 subjects. The pain experienced during the procedure was measured immediately after insertion by a standard 10 cm Visual Analogue Scale (VAS). The mean pain score was 1.01±1.20 in the lidocaine spray group and 3.23±1.60 in the placebo spray group (p<0.001).
Another RCT 11 comparing the effects of topical lidocaine spray, cream and injection on pain perception during IUD insertion included 200 women.Baseline pain assessment (VAS) was made immediately after the administration of analgesics, the second was performed immediately after use of the tenaculum, and the third after IUD insertion.Pain related to IUD insertion was lower in the lidocaine spray and injection groups (P < 0.001); however, lidocaine spray was superior to injection for the reduction of IUD insertion related pain (P = 0.001).
A third double-blind RCT 12 included 124 subjects. VAS was used to evaluate pain during several steps of the Cu-IUD insertion procedure.The 10% lidocaine spray group demonstrated significantly lower median VAS immediately after IUD insertion than the placebo group 2.95 (IQR1.00-5.63) vs 5.00 (IQR 3.35-7.00), respectively; p=0.002). Similarly, median VAS was significantly lower with lidocaine spray than with placebo during tenaculum use and uterine sounding. The proportion of women who reported VASHASH(0x2ed2410)4 was significantly lower in the lidocaine group than in the placebo group. Median change in VAS from baseline to IUD placement was 1.85 (IQR 0.08-4.03) in lidocain group vs 3.6 (IQR 2.40-5.80)in placebo group.
A meta-analysis 13 included 11 RCTs (n = 1458) reporting paracervical lidocaine block or uterine mucosa lidocaine application before IUD insertion. Paracervical lidocaine block significantly reduced pain, mean difference -1.66, 95% CI -3.74 to 0.41, 4 trials, n=310). In 2 trials (n=212) topical 5% lidocaine + prilocaine cream (EMLA) reduced pain during insertion compared with placebo (mean difference -3.50, 95% CI -4.27 to -2.73 and -1.92, 95% CI -2.06 to 0.01 in VAS). Lidocaine gel or cream did not reduce pain in 4 trials, although there was a trend towards lower pain compared with placebo.
A systematic review and network meta-analysis 14 included 38 RCTs (n=6314). Compared with placebo, at IUD insertion lidocaine-prilocaine cream (genital mucosal application) and paracervical lidocaine significantly reduced pain (mean difference -2.76, 95% CI -4.61 to -0.91 and -1.13, 95% CI -2.42 to 0.16, respectively). Lidocaine gel (genital mucosal application) only showed a trend towards reduced pain (mean difference -0.95, 95% CI -2.12 to 0.22) compared with placebo.
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