Topical anesthetics
Topical anesthetics offer promise of pain relief without the pain of injection and with the advantage of self-administration for some formulations.
Several RCTs evaluated whether lidocaine gel 2% applied to the cervix or injected via flexible catheter into the cervical os improved pain, but there were no substantial differences in pain perception between topical gel and placebo groups in the insertion of IUDs.9
Rapkin and colleagues15 studied whether self-administered intravaginal lidocaine gel 2% five minutes before insertion was helpful;15 they found that tenaculum placement was less painful, but IUD placement was not. Conti et al expanded upon the Rapkin study by extending the amount of time of exposure to self-administered intravaginal lidocaine gel 2% to 15 minutes; they found no difference in perception of pain during tenaculum placement, but they did see a substantial difference in discomfort during speculum placement.17 This finding may be helpful for patients with a history of sexual trauma or anxiety about gynecologic examinations. Based on surveys conducted during their study, they found that patients were willing to wait 15 minutes for this benefit.
In Gemzell-Danielsson and colleagues’ updated review, they identified that different lidocaine formulations, such as a controlled-release lidocaine and a lidocaine-prilocaine compound, resulted in slight reduction in pain scores at multiple points during the IUD insertion process compared with controls.8 Two RCTs demonstrated substantial reduction in pain with administration of lidocaine spray 10% during tenaculum placement, sounding, and immediately after IUD placement compared with a placebo group.18,19 This may be an appealing option for patients who do not want to undergo an injection for local anesthesia.
Nitrous oxide
Nitrous oxide is an odorless colorless gas with anxiolytic, analgesic, and amnestic effects. It has several advantages for outpatient administration including rapid onset, rapid recovery, high safety profile, and no residual incapacitation, enabling a patient to safely leave the office shortly after a procedure.20
Nitrous oxide was studied in an RCT of 74 young (12-20 years of age) nulliparous patients and found to be effective for decreasing pain during IUD insertion and increasing satisfaction with the procedure.20 However, another study of 80 nulliparous patients (aged 13-45 years) did not find any reduction in pain during the insertion procedure.21
Prostaglandin analogues
Misoprostol is a synthetic prostaglandin E1 analog that causes cervical softening, uterine contractions, and cervical dilation. Dinoprostone is a synthetic prostaglandin E2 analog that has similar effects on the cervix and uterus. These properties have made it a useful tool in minor gynecologic procedures, such as first trimester uterine aspiration and hysteroscopy. However, both have the disadvantage of causing adverse effects on gastric smooth muscle, leading to nausea, vomiting, diarrhea, and uncomfortable gastric cramping.
Several RCTs have examined the use of misoprostol administration approximately 2 to 4 hours before IUD placement. No studies found any improvement in pain during IUD insertion, but this likely is due to the discomfort caused by the use of misoprostol itself.9 A meta-analysis and systematic review of 14 studies found no effect on reducing the pain associated with IUD placement but did find that providers had an easier time with cervical dilation in patients who received it. The meta-analysis also demonstrated that patients receiving vaginal misoprostol were less likely to have gastric side effects.22 In another review of 5 RCTs using 400 µg to 600 µg of misoprostol for cervical preparation, Gemzell-Danielsson et al found reductions in mean pain scores with placement specifically among patients with previous cesarean delivery and/or nulliparous patients.8
In an RCT, Ashour and colleagues looked at the use of dinoprostone 3 mg compared with placebo in 160 patients and found that those in the dinoprostone group had less pain during and 15 minutes after the procedure, as well as ease of insertion and overall higher satisfaction with the IUD placement. Dinoprostone traditionally is used for labor induction in the United States and tends to be much more expensive than misoprostol, but it shows the most promise of the prostaglandins in making IUD placement more comfortable.
Conclusion: Integrating evidence and experience
Providers tend to underestimate the pain and anxiety experienced by their patients undergoing IUD insertion. Patients’ concerns about pain and anxiety increase their risk for experiencing pain during IUD insertion. Patient anxieties, and thus, pain may be allayed by offering support and education prior to placement, offering tailored pharmacologic strategies to mitigate pain, and offering supportive and distraction measures during the insertion process. ●
Key recommendations
- Patients should be counseled regarding the benefits and risks of the IUD, expectations for placement and removal, and offered the opportunity to ask questions and express their concerns.
- Providers should use this opportunity to assess for risk factors for increased pain during IUD placement.
- All patients should be offered premedication with naproxen 220 mg approximately 90 minutes prior to the procedure, as well as heat therapy and the opportunity to listen to music during the procedure.
- Patients with risk factors for pain should have pharmacologic strategies offered based on the available evidence, and providers should reassure patients that there are multiple strategies available that have been shown to reduce pain during IUD placement.
—Nulliparous patients and patients with a history of a cesarean delivery may be offered the option of cervical ripening with misoprostol 400 µg vaginally 2 to 4 hours prior to the procedure.
—Patients with a history of sexual trauma should be offered self-administered lidocaine 1% or lidocaine-prilocaine formulations to increase comfort during examinations and speculum placement.
—All other patients can be offered the option of a paracervical or intracervical block, with the caveat that administration of the block itself also may cause some pain during the procedure.
—For those patients who desire some sort of local anesthetic but do not want to undergo a lidocaine injection, patients should be offered the option of lidocaine spray 10%.
—Finally, for those patients who are undergoing a difficult IUD placement, ultrasound guidance should be readily available.