The effect of nitroglycerin on the IUD insertion experience in nulliparous women: a pilot study

Pain Management During Intrauterine Device Insertion in Nulliparous Women: A Scoping Review

This study investigates the various methods of pain management during the insertion of intrauterine devices (IUDs) in nulliparous women. Currently, the only recommended method of pain management is 800 mg of ibuprofen taken one hour before insertion of the IUD. However, women continue to experience pain during the procedure. A scoping review was conducted using CINAHL, Medline, Web of Science, and Embase with inclusion criteria being English peer-reviewed articles from the last 10 years, involving nulliparous women of at least 18 years of age. The research reveals that management to minimize pain during IUD insertion can include oral analgesics, cervical blocks, and cervical softening and dilation with prostaglandins. The effect of pain management when using these techniques was further examined throughout the various steps of IUD placement, including cervical grasping, IUD insertion, and post IUD insertion. Ibuprofen is the current recommended analgesic; however, studies show that there was no significant reduction in pain found when ibuprofen is used. Alternatively, 500 mg of naproxen sodium taken prior to IUD insertion showed a significant reduction in post-IUD insertion pain (p=0.01) but did not show any significant reduction in pain during cervical grasping or during IUD insertion into the uterus. Cervical blocks using 1% lidocaine were shown to decrease pain during cervical gripping (p=0.002) and IUD insertion compared to the control group (p=0.005). The results of cervical blocks differed based on whether 1% lidocaine was injected or if a 2% lidocaine gel was used, but no significance was shown. Furthermore, cervical softening and dilation with dinoprostone 3 mg and misoprostol 3 mg demonstrated a reduction in pain during all stages of IUD insertion and after insertion (p<0.01). Pharmacological interventions with oral analgesics, lidocaine, and prostaglandins, such as dinoprostone and misoprostol, have all demonstrated some level of pain control during the IUD insertion procedure, but the use of prostaglandins and 2% lidocaine gel has been demonstrated to have the most clinically significant effect on pain control. Additionally, there has been some research examining the impact of verbal analgesics, which involves the provider using a calm, soothing voice and slow speech to put the patient at ease, and the role that anxiety about IUD insertion can influence pain, but further research is needed to determine its significance. This research provides valuable insight into enhancing the improvement of pain during and after the insertion of IUDs for nulliparous women.

A randomized double blinded clinical trial to explore the clinical outcomes of vaginal isonicotinic acid hydrazide (INH) administration six hours prior to T380A intrauterine device insertion in persons delivered only by cesarean delivery

OBJECTIVE

To compare insertion pain and ease of insertion in participants with a prior caesarean delivery having copper intrauterine device (IUD) after pretreatment with isonicotinic acid hydrazide (INH) 900 mg vaginally or placebo.

STUDY DESIGN

From September 2020 to September 2021, we conducted a randomized, double-blind, placebo-controlled experiment at Aswan University Hospital in Egypt with participants who were delivered solely by caesarean delivery and desired copper T380A IUD insertion. The participants were randomly assigned to either vaginal INH or placebo six hours before IUD insertion in a 1:1 ratio. The primary objective of the research was the individuals' self-reported pain during cervical tenaculum placement, sound insertion, IUD insertion, and 5 minutes after the placement, as measured by a 10-cm visual analogue scale (VAS). Our secondary outcomes were ease of insertion, satisfaction, the need for analgesics, and adverse effects. IUD insertion ease was graded from 0 to 10 on a 10-cm VAS scale, with 0 suggesting very easy insertion and 10 denoting extremely difficult insertion.

RESULTS

When compared to the placebo group, the INH group experienced considerably less pain during IUD insertion (2.9±0.85vs.5.11±0.82;p<0.01), lower median ease of insertion score (3(1-4)vs.5(3-6);p<0.01), and better satisfaction (8.17±0.69vs.5.57±0.75). The two groups had comparable side effects.

CONCLUSIONS

Vaginal INH administered before IUD insertion reduce the amount of discomfort participants feel throughout the process in individuals who had previously only been delivered via CD. It also has the potential to make insertion easier.

IMPLICATIONS

In participants who were delivered solely by CD before, vaginal INH given prior to IUD placement reduces the amount of discomfort participants experience throughout the procedure. Furthermore, it could increase the ease of insertion.

Benefits of Self-administered Vaginal Dinoprostone 12 Hours before Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Adolescents and Young Women: A Randomized Controlled Trial

STUDY OBJECTIVE

To assess safety and efficacy of self-administered vaginal dinoprostone 12 hours before a 52-mg levonorgestrel intrauterine device (LNG-IUD) insertion in adolescents and young nulliparous women.

DESIGN

Randomized controlled trial.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Nulliparous adolescents and young women aged 18-22 years.

INTERVENTIONS

Participants were randomly assigned into 2 groups; the dinoprostone group (n = 65) received dinoprostone 3 mg vaginally, and the placebo group (n = 65) received placebo tablets vaginally.

MAIN OUTCOME MEASURES

Primary outcome was pain scores during LNG-IUD insertion measured using a visual analogue scale. Secondary outcomes were pain scores during speculum insertion, tenaculum placement, uterine sounding, and 20 minutes postprocedure, ease of insertion, Women's satisfaction score, need for additional analgesics, and side effects.

RESULTS

The dinoprostone group had significantly lower pain scores during LNG-IUD insertion (2.83 ± 1.08 vs 3.95 ± 1.63), tenaculum placement (2.97 ± 1.41 vs 4.55 ± 1.53) and sounding of uterus (3.55 ± 1.71 vs 5.12 ± 1.37) compared with the placebo group (P < .001). No significant differences were found between both groups regarding anticipated pain scores (P = .85), pain during speculum insertion and 20 minutes postinsertion and insertion duration (P = .53). Women's satisfaction, provider reported ease of insertion, and need for additional analgesia were significantly better among dinoprostone users (P < .001, < .001, and .02, respectively). Side effects and procedure complications were similar for the 2 groups.

CONCLUSION

Self-administered dinoprostone 3 mg vaginally 12 hours before a 52-mg LNG-IUD insertion in nulliparous adolescent and young women effectively reduced pain during insertion and increased women's satisfaction and ease of insertion reported by clinicians.

Providing Long-acting Reversible Contraception to Adolescents: A Review

Unintended teen pregnancy continues to be a problem in the United States which has the highest rate of adolescent pregnancy among developed nations. Long-acting reversible contraception (LARC) has much higher continuation rates compared with moderately effective reversible contraception; however, moderately effective reversible contraception is more commonly used by adolescents. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend LARC as first-line contraception for adolescents. Clinicians providing contraception to adolescents should be knowledgeable of LARC indications, side effects, initiation guidelines, management of adverse reactions, and adolescent specific issues regarding LARC counseling, initiation, and continuation.

Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial

BACKGROUND

Fear of pain during the insertion of intrauterine contraceptives is a barrier to using these methods, especially for nulligravidas. An intracervical block may be easier and more reproducible than a paracervical block; however, this intervention has not been evaluated in nulligravid women to reduce pain with intrauterine contraceptive insertion.

OBJECTIVE

To evaluate whether a 3.6-mL 2% lidocaine intracervical block reduces pain at tenaculum placement and levonorgestrel-releasing intrauterine system insertion among nulligravidas; and, in addition, to assess whether the intracervical block has any effect on the ease of device insertion and on the overall experience with the procedure.

MATERIALS AND METHODS

In this randomized double-blind controlled trial, nulligravidas were block-randomized to 1 of 3 arms prior to 52-mg levonorgestrel-releasing intrauterine system insertion: 3.6-mL 2%-lidocaine intracervical block, sham injection (intracervical dry-needling), or no intervention. The primary outcome was pain at levonorgestrel-releasing intrauterine system insertion. Secondary outcomes were pain at tenaculum placement, ease of insertion (assessed by healthcare providers), and the overall experience with the procedure (pain with levonorgestrel-releasing intrauterine system insertion compared with expectations, discomfort level, wish to undergo another device insertion in the future, and recommendation of the procedure to others). Participants' pain was measured with a 10-cm visual analogue scale and a 5-point Faces Pain Scale. Pain was summarized into categories (none, mild, moderate, severe) and also analyzed as a continuous variable (mean and 95% confidence interval). Our sample size had 80% power (α = 0.05) to detect a 15% difference in pain score measured by visual analogue scale (mean [standard deviation] visual analogue scale score = 5.9 [2.0] cm) and an absolute difference of 20% in the proportion of women reporting severe pain at levonorgestrel-releasing intrauterine system insertion among groups. We used a χ² test and a mixed-effects linear regression model. We calculated the number needed to treat for the intracervical block to avert severe pain at tenaculum placement and levonorgestrel-releasing intrauterine system insertion.

RESULTS

A total of 302 women were randomized (99 to the intracervical block, 101 to the intracervical sham, and 102 to no intervention), and 300 had a successful device insertion. The intracervical block group had fewer women reporting severe pain than the other groups, both at tenaculum placement (intracervical block: 2% vs sham: 30.2% vs no intervention: 15.2%, P < .0001) and at levonorgestrel-releasing intrauterine system insertion (intracervical block: 26.5% vs sham: 59.4% vs no intervention: 50.5%, P < .0001). The mean (95% confidence interval) pain score reported at levonorgestrel-releasing intrauterine system insertion was lower in the intracervical block group than in the other groups (intracervical block: 4.3 [3.8-4.9] vs sham: 6.6 [6.2-7.0], P < .0001; intracervical block: 4.3 [3.8-4.9] vs no intervention: 5.8 [5.3-6.4], P < .0001). Women from the intracervical block group reported less pain than expected (P < .0001), rated the insertion as less uncomfortable (P < .0001), and were more willing to undergo another device insertion in the future (P < .01) than women in the other groups. The ease of insertion were similar among groups. The number needed to treat for the intracervical block to avert severe pain at tenaculum placement and levonorgestrel-releasing intrauterine system insertion was 2 and 4, respectively.

CONCLUSION

A 3.6-mL 2% lidocaine intracervical block decreased pain at tenaculum placement and levonorgestrel-releasing intrauterine system insertion among nulligravidas. It also provided a better overall experience during the procedure.

Effect of topical glyceryl trinitrate cream on pain perception during intrauterine device insertion in multiparous women: A randomized double-blinded placebo-controlled study

OBJECTIVE

Intrauterine contraceptive device (IUD) insertion-related pain presents a push beyond the decline of women to use IUD for family planning. We aimed to investigate the analgesic effect of glyceryl trinitrate cream (GTN) in reducing pain during IUD insertion.

MATERIALS AND METHODS

We conducted a randomized double-blinded placebo-controlled study (NCT02708251, clinicaltrials.gov) in a tertiary University hospital. Reproductive-aged women requesting Copper IUD for contraception were considered. Eligible women for IUD insertion were randomized (1:1) to glyceryl trinitrate cream (GTN arm) or Placebo. Three minutes before IUD insertion, 1 ml of GTN cream or placebo was applied to the cervical lip at the planned tenaculum site, followed by 1 ml placed in the cervical canal up to the level of the internal os using a Q-tip applicator. Our outcomes were the participant's self-rated pain perception utilizing a 10-cm Visual Analogue Scale (VAS) during cervical tenaculum placement, uterine sound and IUD insertion, then 15 min post-procedure.

RESULTS

100 women were enrolled and randomized to GTN arm (n = 50) or placebo (n = 50). Women in the GTN arm reported lower VAS scores during tenaculum placement, sound and IUD insertion (median: 2 vs. 4, p < 0.0001; 2.5 vs. 4.5, p < 0.001;3 vs. 5.5, p < 0.0001, respectively). Higher ease of insertion score was also determined among GTN arm (mean ± SD: 6.9 ± 1.15 vs. 4.7 ± 1.38, p < 0.0001). Additionally, women in the GTN arm were more satisfied by the end of the insertion (92% vs. 74%, p = 0.003).

CONCLUSION

Application of cervical GTN cream before IUD insertion seems to reduce the induced pain with subsequent easy insertion.

Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review

A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure‐related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement‐related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement‐related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.

Pain Perception during Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Women: A Systematic Review

STUDY OBJECTIVE

Intrauterine devices (IUDs) still remain underused in adolescents. Pain during insertion might prevent adolescents to opt for a levonorgestrel-releasing IUD. This study aimed to conduct a systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and critically appraise published data with respect to the efficacy of various substances (analgesics or not) in preventing pain during levonorgestrel-releasing IUD insertion in nulliparous women as a proxy for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A comprehensive computerized systematic literature search of all English language studies between 2006 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials), and Google Scholar. Relevant article reference lists were manually searched.

RESULTS

The computerized database search revealed 31 citations of relevance, 9 of which with a total of 355 treated women and 345 controls fulfilled the inclusion/exclusion criteria. In women treated with misoprostol (n = 150) vs placebo (n = 145), the median visual analogue scale (VAS) score ± SD were 5.7 ± 2.1 vs 5.1 ± 2.2, respectively. In the previously mentioned population, there was a nonsignificant change in VAS score (odds ratio, 1.44; 95% confidence interval, 0.86-2.40). In women treated with lidocaine (n = 140) vs placebo (n = 136), the median VAS score ± SD were 4.6 ± 2.1 vs 5.8 ± 2, respectively. In the aforementioned population, there was a significant decrease in VAS score (odds ratio, 0.12; 95% confidence interval, 0.02-0.91).

CONCLUSION

In nulliparous women, lidocaine treatment seems to be a reasonable choice. However, further studies are required to examine the different routes and modes of administration as well as optimal quantities.

Anticipated pain as a predictor of discomfort with intrauterine device placement

BACKGROUND

Intrauterine devices have been gaining popularity for the past 2 decades. Current data report that >10% of women who use contraception are using an intrauterine device. With <1% failure rates, the intrauterine device is one of the most effective forms of long-acting reversible contraception, yet evidence shows that fear of pain during intrauterine device placement deters women from choosing an intrauterine device as their contraceptive method.

OBJECTIVES

The objective of this analysis was to estimate the association between anticipated pain with intrauterine device placement and experienced pain. We also assessed other factors associated with increased discomfort during intrauterine device placement. We hypothesized that patients with higher levels of anticipated pain would report a higher level of discomfort during placement.

STUDY DESIGN

We performed a secondary analysis of the Contraceptive CHOICE Project. There were 9256 patients enrolled in Contraceptive CHOICE Project from the St. Louis region from 2007-2011; data for 1149 subjects who came for their first placement of either the original 52-mg levonorgestrel intrauterine system or the copper intrauterine device were analyzed in this study. Patients were asked to report their anticipated pain before intrauterine device placement and experienced pain during placement on a 10-point visual analog scale. We assessed the association of anticipated pain, patient demographics, reproductive characteristics, and intrauterine device type with experienced pain with intrauterine device placement.

RESULTS

The mean age of Contraceptive CHOICE Project participants in this subanalysis was 26 years. Of these 1149 study subjects, 44% were black, and 53% were of low socioeconomic status. The median expected pain score was 5 for both the levonorgestrel intrauterine system and the copper intrauterine device; the median experienced pain score was 5 for the levonorgestrel intrauterine system and 4 for the copper intrauterine device. After we controlled for parity, history of dysmenorrhea, and type of intrauterine device, higher anticipated pain was associated with increased experienced pain (adjusted relative risk for 1 unit increase in anticipated pain, 1.19; 95% confidence interval, 1.14-1.25). Nulliparity, history of dysmenorrhea, and the hormonal intrauterine device (compared with copper) also were associated with increased pain with intrauterine device placement.

CONCLUSION

High levels of anticipated pain correlated with high levels of experienced pain during intrauterine device placement. Nulliparity and a history of dysmenorrhea were also associated with greater discomfort during placement. This information may help guide and treat patients as they consider intrauterine device placement. Future research should focus on interventions to reduce preprocedural anxiety and anticipated pain to potentially decrease discomfort with intrauterine device placement.

Medications to ease intrauterine device insertion: a systematic review

BACKGROUND

Potential barriers to intrauterine device (IUD) use include provider concern about difficult insertion, particularly for nulliparous women.

OBJECTIVE

This study aims to evaluate the evidence on the effectiveness of medications to ease IUD insertion on provider outcomes (i.e., ease of insertion, need for adjunctive insertion measures, insertion success).

SEARCH STRATEGY

We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that examined medications to ease interval insertion of levonorgestrel-releasing IUDs and copper T IUDs.

RESULTS

From 1855 articles, we identified 15 RCTs that met our inclusion criteria. Most evidence suggested that misoprostol did not improve provider ease of insertion, reduce the need for adjunctive insertion measures or improve insertion success among general samples of women seeking an IUD (evidence Level I, good to fair). However, one RCT found significantly higher insertion success among women receiving misoprostol prior to a second IUD insertion attempt after failed attempt versus placebo (evidence Level I, good). Two RCTs on 2% intracervical lidocaine as a topical gel or injection suggested no positive effect on provider ease of insertion (evidence Level I, good to poor), and one RCT on diclofenac plus 2% intracervical lidocaine as a topical gel suggested no positive effect on provider ease of insertion (evidence Level I, good). Limited evidence from two RCTs on nitric oxide donors, specifically nitroprusside or nitroglycerin gel, suggested no positive effect on provider ease of insertion or need for adjunctive insertion measures (evidence Level I, fair).

CONCLUSIONS

Overall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls. Among women with a recent failed insertion who underwent a second insertion attempt, one RCT found improved insertion success among women using misoprostol versus placebo.

Interventions for pain with intrauterine device insertion

BACKGROUND

Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol.

OBJECTIVES

To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain

SEARCH METHODS

We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials.

SELECTION CRITERIA

We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours).

DATA COLLECTION AND ANALYSIS

Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD).

MAIN RESULTS

We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block.

AUTHORS' CONCLUSIONS

Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research.

Contraception for Adolescents: Focusing on Long-Acting Reversible Contraceptives (LARC) to Improve Reproductive Health Outcomes

Adolescent pregnancy rates in the U.S. have reached an all-time low from their peak in the 1980s and 1990s. However, the U.S. maintains the highest rate of teenage pregnancy among developed nations. Adolescents experience higher typical use failure rates for user-dependent contraceptives compared to their adult counterparts. Long-acting reversible contraception (LARC), IUDs and implants, have failure rates that are both very low and independent of user age. In settings where the most effective methods are prioritized and access barriers are removed, the majority of adolescents initiate LARC. Use of LARC by adolescents significantly reduces rates of overall and repeat teen pregnancy. All methods of contraception are safe for use in teens, including IUDs and DMPA. Dual use of LARC and barrier methods to reduce risk of sexually transmitted infection, is the optimal contraceptive strategy for most adolescents. Adolescent access to evidence-based and confidential contraceptive services, provided in a manner that respects autonomy, is a vital public health goal.

Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial

OBJECTIVE

To evaluate if ibuprofen 800mg reduces pain with intrauterine device (IUD) insertion among U.S. women.

STUDY DESIGN

We conducted a randomized, double-blind, placebo-controlled trial of women undergoing IUD insertion approximately 2-6weeks following first-trimester uterine aspiration. Subjects were randomized to receive ibuprofen 800mg or placebo 30-45min prior to IUD insertion. A 100-mm visual analog scale (VAS) was administered to measure pain after speculum insertion (baseline) and immediately following IUD insertion.

RESULTS

A total of 202 women were enrolled, with 101 randomized to each group (ibuprofen or placebo). Sociodemographic characteristics and baseline VAS scores were similar between groups. The median pain score with IUD insertion was 41.5mm in the placebo group and 38.0mm in the ibuprofen group (p=.50). Mean and median pain scores did not differ between placebo and ibuprofen when nulliparous and parous women were analyzed independently. Overall, median pain scores were 17.5mm higher in nulliparous women than parous women (p=.004). Median pain scores did not differ by age, IUD-type, history of dysmenorrhea or time since aspiration.

CONCLUSIONS

Administration of ibuprofen 800mg prior to IUD insertion does not reduce pain associated with the procedure for U.S. women. Overall, nulliparous women report more pain with IUD insertion than multiparous women.

Rationale and enrollment results for a partially randomized patient preference trial to compare continuation rates of short-acting and long-acting reversible contraception

OBJECTIVES

Most published contraceptive continuation rates have scientific limitations and cannot be compared; this is particularly true for dissimilar contraceptives. This study uses a new approach to determine if high continuation rates of long-acting reversible contraception (LARC) and protection from unintended pregnancy are observable in a population not self-selecting to use LARC.

STUDY DESIGN

We are conducting a partially randomized patient preference trial (PRPPT) to compare continuation rates of short-acting reversible contraception (SARC) and LARC. Only women seeking SARC were invited to participate. Participants chose to be in the preference cohort (self-selected method use) or opted to be randomized to SARC or LARC; only those in the randomized cohort received free product. We compared participant characteristics, reasons for not trying LARC previously and the contraceptive choices that were made.

RESULTS

We enrolled 917 eligible women; 57% chose to be in the preference cohort and 43% opted for the randomized trial. The preference and randomized cohorts were similar on most factors. However, the randomized cohort was more likely than the preference cohort to be uninsured (48% versus 36%, respectively) and to cite cost as a reason for not trying LARC previously (50% versus 10%) (p<.01 for both comparisons). In the preference cohort, fear of pain/injury/side effects/health risks were the predominant reasons (cited by over 25%) for not trying LARC previously (p<.01 in comparison to randomized cohort).

CONCLUSIONS

Enrollment was successful and the process created different cohorts to compare contraceptive continuation rates and unintended pregnancy in this ongoing trial. The choices participants made were associated with numerous factors; lack of insurance was associated with participation in the randomized trial.

IMPLICATIONS

This PRPPT will provide new estimates of contraceptive continuation rates, such that any benefits of LARC will be more easily attributable to the technology and not the user. Combined with measuring level of satisfaction with LARC, the results will help project the potential role and benefits of expanding voluntary use of LARC.