Management of pain associated with the insertion of intrauterine contraceptives

Abstract

BACKGROUNDMost intrauterine contraception (IUC) placements do not require pain relief. However, small proportions of nulliparous (∼17%) and parous (∼11%) women experience substantial pain that needs to be proactively managed. This review critically evaluates the evidence for pain management strategies, formulates evidence-based recommendations and identifies data gaps and areas for further research.METHODSA PubMed literature search was undertaken. Relevant articles on management of pain associated with IUC insertion, published in English between 1980 and November 2012, were identified using the following search terms: ‘intrauterine contraception’, ‘insertion’ and ‘pain’. RCTs were included; further relevant articles were also identified and included as appropriate.RESULTSSeventeen studies were identified and included: 12 RCTs and one non-randomized study of pre-insertion oral analgesia, cervical priming and local anaesthesia; one systematic review and one RCT on post-insertion analgesia and two non-randomized studies on non-pharmacological interventions. There was no conclusive evidence that any prophylactic pharmacological intervention reduces pain associated with IUC insertion. However, most of the regimens studied were adopted from hysteroscopy or abortion and effectiveness in specific subsets of women has not been studied adequately. A systematic review found non-steroidal anti-inflammatory agents (NSAID) to be effective in reactively treating post-insertion pain, but no benefit was found with prophylactic use.CONCLUSIONSNo prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUC insertion. Women's anxiety about the procedure may contribute to higher levels of perceived pain, which highlights the importance of counselling, and creating a trustworthy, unhurried and professional atmosphere in which the experience of the provider also has a major role; a situation frequently referred to as ‘verbal anaesthesia’.

Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives

“…The present authors have recently published a review of the evidence covering pain management strategies for IUC insertion 18. The review presents evidence-based recommendations and points out gaps in the data and areas for further research.…”

Long-Acting Reversible Contraception in the Pediatric Emergency Department

“…[46][47][48] Those with a cu-IUD may experience an increase in dysmenorrhea. 49 Two small studies in this review showed that counseling and reassurance to decrease anxiety about the procedure may decrease pain perception and recall.…”

Intrauterine levobupivacaine for pain control during intrauterine device insertion

“…pre-insertion counselling and the effect of an assistant providing reassurance and distraction during the procedure). 19 As these regimes are adapted from other surgical procedures, they are actually not IUD insertionspecific and there is no clear data about at which step of IUD application they block pain. The highest pain level was observed during the IUD application while the lowest one was during the tenaculum application in this study.…”