February 6, 2023
By Malory Gallagher, Drexel University College of Medicine
As a medical student on clinical rotations, I have witnessed many office gynecologic procedures such as pap smears, IUD insertions and even colposcopies and endometrial biopsies. With IUD insertion specifically, I am always surprised by the wide range of patient reactions to what the provider usually describes as “a small pinch.” Some people tolerate these procedures well while others are visibly tearful and in a lot of pain. IUDs are an extremely effective and reliable form of birth control, but it is possible the pain of insertion deters some from utilizing this method. Studies show nulliparous women can experience twice as much pain as parous women with IUD insertion. While we are taught that this procedure is tolerable with oral NSAIDs, my firsthand experiences make me wonder how effective this medication is in managing IUD insertion pain. Do oral NSAIDs help with the pain of IUD insertion? If not, what are other options for pain management during this procedure?
Forget the NSAIDs
While it is standard practice to advise women to take NSAIDs before IUD insertion, several studies show that this has little to no impact on the pain of IUD insertion. A 2015 randomized controlled trial looked at IUD insertion pain with administration of 800 mg ibuprofen or placebo 30-45 minutes before IUD insertion. The intervention dose of 800 mg was selected after a larger study conducted previously demonstrated no difference in pain with administration of 400 mg of ibuprofen. The study utilized a visual analog scale to measure both baseline pain after insertion of speculum and after insertion of IUD. The study found no statistical difference in pain between the ibuprofen group and placebo group. Other studies utilized other NSAIDs including ketorolac and naproxen and found that administration of NSAID only reduced cramping pain following insertion and had no impact on pain during the procedure itself. Since NSAIDs were shown to be relatively ineffective, I began looking at research for alternative methods of pain relief for IUD insertion.
What about misoprostol?
Misoprostol can be used to ripen the cervix and was used in several studies to see if it decreased IUD insertional pain. Studies show that neither buccal nor vaginal misoprostol decreased IUD insertion pain. Additionally, misoprostol caused many side effects, such as nausea, vomiting, diarrhea and fever, and is therefore not recommended. Providers also noted no difference in perceived ease of placement of the IUD after administering this medication.
Do topical anesthetics help?
A few different types of studies utilizing lidocaine gel were conducted to determine if it caused any reduction in pain. In one study, 2% topical lidocaine gel applied to the internal os with a cotton swab showed no effect on pain with IUD placement. In another study, 2% lidocaine gel was applied to the ectocervix at the site of tenaculum placement and placed into the endocervical canal. This study also showed no change in pain with tenaculum placement or IUD insertion. In another randomized controlled trial, self-application of vaginal 2% lidocaine gel showed a decrease in pain with tenaculum placement but no decrease in pain with IUD placement. While lidocaine gel might reduce the pain of tenaculum placement in some instances, it does not effectively control the pain of IUD placement and its use is not recommended by the American College of Obstetricians and Gynecologists (ACOG).
Do paracervical and intracervical blocks help?
I encountered some other research testing the pain relief of paracervical and intracervical blocks preceding IUD insertion. Paracervical block consisted of injection of 2 ml of lidocaine at the anterior lip of the cervix and 18 ml of lidocaine injected into the cervicovaginal junction at the 4 and 8 o’clock positions. Intracervical block consisted of 3.6 ml lidocaine spread out at the 3, 6, 9 and 12 o’clock positions prior to tenaculum placement. While women experienced some mild pain with injection, pain during IUD placement was lower in both the intracervical and paracervical groups than sham and no intervention groups. The study suggests that intracervical and paracervical lidocaine blocks could be used to reduce IUD insertional pain, especially in nulliparous women or patients with a prior failed placement.
What do the current guidelines recommend?
While some studies using cervical and paracervical lidocaine show promising results for reduction of pain with cervical block, other studies show more ambiguous data. ACOG maintains that no single effective strategy has been demonstrated to decrease discomfort during IUD insertion. ACOG advises against the use of misoprostol and topical lidocaine during IUD insertions since studies have shown these methods are ineffective. ACOG recommends shared decision-making when considering cervical block for IUD placement pain management. The benefits and harms of pain management available should be thoroughly discussed with the patient before coming to a decision. ACOG also states pain management should be more strongly considered in patients who are nulliparous, require cervical dilation or have had previous painful insertions in the past.
What next?
IUDs are an extremely effective and reliable form of contraception, but the pain associated with insertion might deter some for utilizing this method. To date, no clear solution has been found to mitigate this barrier. As more research is conducted and more data becomes available, it is possible a clear solution could be found. Additional research is required to determine whether paracervical or intracervical blocks should become the new gold standard of care. As for right now, most sources agree NSAIDs, topical lidocaine and misoprostol are not the answer.
Sources/Resources:
- Bednarek P, Creinin M, Reeves M, et. al. Prophylactic Ibuprofen Does Not Improve Pain with IUD Insertion: A Randomized Trial. Contraception. 2015;91:193-197
- Eisenberg D, Tyson N, Espey E. Clinical Challenges of Long-Acting Reversible Contraceptive Methods. American College of Obstetricians and Gynecology 2016;672:69-77
- Sandoval S, Neurice M, Pebley N, et. al. Alleviating Pain with IUD Placement: Recent Studies and Clinical Insight. Current Obstetrics and Gynecology Reports. 2022;11:12-20