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

A Mystery Caller Study on Pain Management Options for Intrauterine Device Placement

OBJECTIVES

To understand whether clinics present pain management options for intrauterine device (IUD) placement over the phone and whether these options align with current evidence for effective pain control during placement STUDY DESIGN: We used a mystery shopper approach and a standardized call script to collect information from a diverse, purposive sample of 100 clinics listed on www.bedsider.org.

RESULTS

We reached responsive personnel at 90 of the 100 selected clinics, of whom 32 (36%) would not provide information about pain control for IUD placement by phone or to non-established patients. Of the 58 clinics that provided information, 4 (6.9%) reported that they did not provide any options for pain management, and 54 (93.1%) presented at least one pharmaceutical option. The most common was ibuprofen, which was mentioned by 49 clinics (84.5%). Lidocaine, misoprostol, and naproxen were mentioned by 16 (27.6%), 14 (24.1%), and 3 (5.2%) clinics, respectively.

CONCLUSIONS

More than one third of clinics were unable to present pain control options over the phone. Among the 58 clinics that presented options to simulated patients calling to request an IUD placement, evidence-based pain control methods, such as lidocaine blocks, 10% lidocaine spray, or naproxen, were not often presented.

IMPLICATIONS

Given the barriers that pain and pre-procedure anxiety pose to uptake of IUDs, it is important for clinic staff to understand current guidelines for pain management during IUD placement as well as the pain control options offered for IUD placements at their clinic.

Efficacy of NSAIDs in reducing pain during intrauterine device Insertion: A systematic review

BACKGROUND

Intrauterine devices (IUD) are highly effective, but insertion pain deters many. While no consensus exists on gold standard analgesia, practitioners commonly recommend over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). This systematic review evaluates NSAID efficacy for pain reduction during IUD insertion.

METHODS

We searched PubMed, Embase, Web of Science, Scopus and Cochrane Library using (intrauterine device* OR IUD*) AND (NSAIDs OR non-steroidal anti-inflammatory drugs). The primary outcome was patient-reported pain during IUD insertion. The authors evaluated each publication for bias using the Centre for Evidenced-Based Medine Critical Appraisal Tool for Randomised Control Trials (CEBM).

RESULTS

The search yielded 6,529 studies, retrieving 29 full texts, with 20 meeting inclusion criteria. This review found limited evidence that prophylactic NSAIDs provide clinically significant pain relief for most women. The review included various NSAID types and dosages. Six studies demonstrated a statistically significant reduction in pain (p < 0.05) compared to placebo.

CONCLUSION

Prophylactic NSAIDs show limited efficacy in reducing IUD insertion pain, with 70 % of studies reporting no significant benefit. These findings, suggesting lower overall effectiveness than previous research, underscore the need for standardized approaches and further research into meaningful pain relief. Heterogeneity in NSAID types, dosages, and pain assessment methods highlights the need for targeted research to improve patient-centered reproductive healthcare.

IUDs and pain control for adolescents and young adults

PURPOSE OF REVIEW

Intrauterine devices (IUDs) are safe and effective for most adolescents and young adults (AYA) for both contraception and menstrual management. However, multiple barriers exist to placement, including procedure-associated pain. There has been a recent call to action for healthcare providers to optimize pain management strategies for IUD insertion.

RECENT FINDINGS

Approach to pain management for IUD insertion varies significantly among providers, and there is no standardized approach to comfort optimization. Several methods of pain control for IUD insertion, both pharmacologic and nonpharmacologic, have been studied, though many have variable results.

SUMMARY

Approaching IUD insertion counseling through a lens of patient autonomy and reproductive justice will likely improve the patient experience and help providers to work toward enhancing comfort during the procedure. Further research is needed to determine optimal pain control strategies for IUD insertion.

Best practices for reducing pain associated with intrauterine device placement

Intrauterine devices are highly effective, long-acting, reversible forms of contraception. Despite their benefits, limited uptake persists, particularly among underserved populations, adolescents, and young adults. While most intrauterine device placement procedures are uncomplicated, pain is commonly reported, with more severe pain reported in certain groups. No current standard of care has been established specifically to manage pain with intrauterine device placement, resulting in wide variation in clinical practice. This article aims to provide practical, evidence-based, and expert-informed guidelines for managing pain during intrauterine device placement. The authors (a group of board-certified obstetrician-gynecologists, pediatricians, and a family physician) conducted a virtual expert meeting to develop consensus-based recommendations for pain management. The meeting covered environmental considerations, nonpharmacological, and pharmacological options. Key strategies include using a person-centered care model that focuses on patient values, needs, and preferences to promote shared decision-making around pain relief. Clinicians should assist patients in setting realistic expectations, including a discussion of the placement procedure, anticipated pain, and all options for pain relief, to allow for a comprehensive informed consent process. Nonpharmacological interventions, such as the use of therapeutic language and comforting environmental, complementary and integrative, and mind-body elements, are recommended to reduce patient anxiety and discomfort. In terms of pharmacological options, clinicians may offer pre-procedural-specific nonsteroidal antiinflammatory drugs (eg, naproxen and ketorolac) and anxiolytics to patients with significant anxiety, as well as intraprocedural application of topical anesthesia and paracervical or intracervical blocks. Finally, additional techniques, such as using appropriately sized instruments and ensuring gradual and gentle procedural steps, can also help enhance patient comfort during insertion. These expert guidelines emphasize the importance of personalized, trauma-informed, and evidence-based care, prioritizing patient autonomy and preferences to facilitate a safe and acceptable insertion experience. They are critical to reducing barriers to intrauterine device uptake and improving overall patient outcomes.

National assessment on the frequency of pain medication prescribed for intrauterine device insertion procedures within the Veterans Affairs Health Care System

BACKGROUND

The intrauterine device (IUD) is a highly effective form of long-acting reversible contraception, widely recognized for its convenience and efficacy. Despite its benefits, many patients report moderate to severe pain during and after their IUD insertion procedure. Furthermore, reports suggest significant variability in pain control medications, including no adequate pain medication. The aim of this evaluation was to assess the pharmaceutical pain medication types, proportions, and trends related to IUD insertion procedures within the Veterans Health Administration (VHA).

METHODS

IUD insertion procedures documented in the VA electronic health record were assessed from 1/1/2018 to 10/13/2023. Descriptive statistics described patient and facility characteristics while annual trends were assessed using linear regression.

RESULTS

Out of the 28,717 procedures captured, only 11.4% had any form of prescribed pain medication identified. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) were the most frequently prescribed pain medication category (8.3%), with ibuprofen being the most common pain medication overall (6.1%). Over the assessment period, there was an average annual increase of 0.52% (p = 0.038) of procedures with prescribed pain medication, increasing from 10.3% in 2018 to 13.3% in 2023.

CONCLUSIONS

Although IUD insertion procedures have been seeing an increase in prescribed pain medication, the overall proportion remains disproportionality low relative to the pain experienced. Additionally, when pain interventions were initiated, they disproportionally utilized medication that have been shown to be ineffective. The intent of the work is that the information will help guide data driven pain medication strategies for patients undergoing IUD insertion procedures within the VHA.

Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: A retrospective survey of HER Salt Lake participants

OBJECTIVES

In an established cohort of HER Salt Lake Contraceptive Initiative participants with a prior intrauterine device (IUD) placement, we sought to (1) define the proportion of participants who reported a negative Patient Acceptable Symptom State (PASS) response, (2) explore factors associated with an unacceptable PASS response, and (3) identify pain management preferences for IUD placement.

STUDY DESIGN

A retrospective survey was sent to 1440 HER Salt Lake IUD users. A PASS question queried IUD placement pain experience acceptability. We explored associations between an unacceptable PASS response and sociodemographic, reproductive and other individual characteristics using t-tests, chi-square tests, and multivariable logistic regression.

RESULTS

Of those surveyed, 620 responded (43%), and 41.6% reported an unacceptable PASS response. Those with an unacceptable PASS response reported a significantly higher experienced pain level (79.2 mm vs 51.8 mm; p < 0.01) than those with an acceptable response, were more likely to have an anxiety diagnosis (47.7% vs 37.1%; p < 0.01), and have a trauma history (33.7% vs 25.1%; p = 0.02). Most patients were not offered pain control options, but 29.4% used ibuprofen and 25.3% had a support person. Regardless of PASS response, if offered, 59.0% desired numbing medication, 56.8% ibuprofen, 51% heating pad, 33.2% support person, and 31.8% anti-anxiety medication, among others. In our multivariable logistic regression model, higher pain was associated with unacceptable PASS response (OR 1.07, 95% CI 1.05-1.08; p < 0.01).

CONCLUSIONS

The common finding of unacceptable pain experiences with IUD placement may cause negative perceptions of an otherwise desirable method. Incorporation of the PASS response into IUD pain management studies could expand our pain experience understanding.

IMPLICATIONS

IUD placement resulted in unacceptable pain experiences for 41.6% of respondents. Screening for anxiety and trauma history could identify at-risk patients to individualize pain management strategies. Incorporation of the PASS into future IUD pain management studies could result in a more comprehensive, patient-centered measure of patient experiences.

Provider Perspectives on Analgesic Use in Intrauterine Device Insertion Procedures: A Mixed Methods Analysis

CONTEXT

The intrauterine device (IUD) is one type of long-acting reversible contraceptive that is becoming increasingly popular among patients and healthcare providers alike, though many are deterred from using this option due to pain or fear of pain with IUD insertion. While the IUD insertion process itself is standardized, the use of pain medication is not. There is a lack of research regarding provider preference in analgesic use for IUD insertion procedures, which analgesics are being provided to patients, and under which circumstances. This study aims to explore which analgesics are being used routinely in clinical settings, which patient populations are more likely to receive or benefit from these treatments, and why. Secondarily, this study aims to evaluate the impacts of provider characteristics such as location of training and practice, length of practice, and type of training in analgesic administration.

METHODS

Various national organizations were contacted via email and asked to distribute the "IUD Pain Management" survey via discussion board or email newsletter. This survey was developed to gather demographic information on providers of IUD placement procedures and evaluate trends in analgesic methods used based on provider and patient characteristics. Additionally, the survey included an opportunity for participants to agree to participate in a brief interview to further elaborate on their responses via phone. Survey responses were collected and evaluated on the secure QuestionPro platform. Results from the interview were qualitatively assessed by coding recurrent themes between participant interviews.

RESULTS

Survey respondents represented physicians from family medicine and OB-GYN specialties, as well as nurse practitioners, registered nurses, physician assistants, and OB-GYN resident physicians. The average length of clinical practice is 6.7 years. The majority of respondents reported offering some sort of analgesic for IUD insertion procedures, with nonsteroidal anti-inflammatory drugs being the most commonly used. Participants also reported an increased likelihood of prescribing analgesics for adolescent and nulliparous patients. Participant interviews included themes such as patient perception of pain, provider training, barriers to access, and alternative analgesic options.

CONCLUSIONS

Our study has identified a significant amount of variation in practices regarding analgesic use for IUD insertion procedures and highlighted some underlying causes of these inconsistencies. Future studies should further investigate trends in analgesic administration in IUD insertion procedures with a larger sample size and delve into factors such as provider education and barriers to access.

Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review

Intrauterine devices (IUDs) are considered a reliable contraceptive option for women, but they can come with side effects. There is a disconnect in standard guidelines for IUD insertion within and without the U.S. The objective of this review was to address a gap in the literature regarding official procedures for pain management during IUD implantation. This scoping review was initiated using keywords to extract relevant articles from multiple databases: U.S. National Library of Medicine National Institutes of Health (PubMed), MEDLINE (Ovid), and Excerpta Medica dataBASE (EMBASE, Ovid). Initially, 457 articles were identified and after a rigorous screening and selection process, 37 articles were chosen to be further assessed to ascertain if they met the study's inclusion criteria. Those 37 articles were further evaluated fully to check for relevancy. From that process, 19 articles were chosen for the review, and all passed quality assessment evaluations using the JB Appraisal Tools. To best address the research question, the data from the 19 articles were divided into three categories: 1) circumstantial factors, 2) non-pharmacological methods, and 3) pharmacological methods. Circumstantially, women with previous vaginal deliveries experienced the lowest pain during the procedure, and nulligravid (never pregnant) women experienced the most pain. Lower pain scores were reported by lactating women compared to non-lactating. Black women experienced the most anticipated pain compared to other races. Regarding non-pharmacological methods, different insertion techniques, tools, and the use of a cold compress were found to not affect the level of pain during IUD insertion. Lastly, it was shown that pharmacological methods such as lidocaine gel, lidocaine paracervical block, and lidocaine combined with either diclofenac or prilocaine decreased pain scores at different time stamps of the procedure. Also, oral ketorolac and a vaginal combination of misoprostol and dinoprostone helped reduce pain. Findings from this scoping review revealed a lack of uniformity across practices when performing IUD insertions, possibly due to differences in procedures across circumstantial factors, non-pharmacological methods, and pharmacological methods. More research is needed to investigate the intricacies of pain with IUD insertion. Moving forward, especially following a potential increase in the use of IUDs after the reversal of Roe v. Wade, establishing this gap may lead to a more refined standardized protocol to mitigate pain with IUD insertions.

Does Ultrasound Guidance Provide Pain Relief During Intrauterine Contraceptive Device Insertion? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate ultrasound guidance effect in pain relief during intrauterine device (IUD) insertion.

METHODS

Four different databases were searched from inception till June 2022. We selected randomized controlled trials (RCTs) that compared transabdominal ultrasound guidance versus traditional non-guided IUD insertion among women undergoing IUD placement for contraception. We used Revman software during performing our meta-analysis. Our primary outcome was the pain score during IUD insertion as evaluated by the Visual Analog Scale (VAS). Our secondary outcomes were the procedure insertion time, satisfaction, and incidences of complications and misplaced IUDs.

RESULTS

Seven RCTs were retrieved with a total number of 1267 patients. There was a significant reduction in the VAS pain score during IUD insertion among the ultrasound-guided group (MD = -1.91, 95% CI [-3.08, -0.73], P = .001). The procedure insertion time was significantly shorter within the ultrasound guidance group compared with the control group (MD = -1.35, 95% CI [-1.81, -0.88], P < .001). Moreover, more women were significantly satisfied with the procedure among the ultrasound-guided group (P < .001). In addition, ultrasound-guided IUD insertion was linked to significant decline in incidences of complications and misplaced IUDs.

CONCLUSION

Ultrasound guidance can be used as a modified technique during IUD insertion as it decreases pain, procedure time, and rates of complications and misplaced IUDs with better patient satisfaction.

[Copper-containing intrauterine device (cIUD): Comparison of tolerance and efficacy in nulliparous and parous women over 6 months]

INTRODUCTION

The copper-containing intra-uterine device IUD (cIUD) is a non-hormonal, effective, long-acting method of contraception, which is not widely used in nulliparous patients in France. The objectives of the study are to compare the safety of the cIUD by the rate of continuation at 6 months between nulliparous and parous patients, and to assess the complications and side effects at insertion and during follow-up. Material and method This is a multicenter prospective epidemiological study with follow-up for 6 months. The adult patients were included in Nantes from February 2019 to October 2019 during the insertion of a IUD in different centers: the student health service (SUMPPS) (Nantes), the Clotilde de Vautier center in the Clinic Jules Verne (Nantes) and in the gynecological offices of the city of Nantes.

RESULTS

A total of 94 patients were included during the insertion of the cIUD. At 6 months, 77 patients answered the second questionnaire, 49 patients were nulliparous and 28 were parous. The pain on insertion was greater in nulliparous patients with a VAS of 6.5±2.4 (0-10) versus 3.9±2.2 (0-8) for multiparous patients (P<10^-4). The 6-month continuation rate for the cIUD was 92.8% for 83.4% for nulliparous patients, and parous patients with no significant difference (P=0.25). Expulsion was the only complication found with 12.2% in nulliparous and 3.5% in parous (P=0.40). Otherwise, 64% of the patients observed heavy bleeding than before without difference with the parity, and 72% of the nulliparous declared to have dysmenorrhea requiring the use of analgesics, against 47% of the parous (P=0.025). The nulliparous were very satisfied or satisfied for 89% in daily life and 96% of them in sex life, without difference compared to parous (97% and 100% respectively).

CONCLUSION

There is no difference in the rate of continuation at 6 months between nulliparous and parous. Nulliparous complained more often of dysmenorrhea in comparison to the period before the cIUD. The satisfaction rates were comparable.

Verbal analgesia is as good as oral tramadol prior to intrauterine device (IUD) insertion, among nulliparous women: A randomized controlled trial

OBJECTIVE

To compare two pain management strategies: oral tramadol or a verbal analgesia technique during insertion of an intrauterine device (IUD) among nulliparous women.

STUDY DESIGN

In this randomized, controlled trial, 54 nulliparous women undergoing insertion of a levonorgestrel-releasing intrauterine device (IUD), from December 2015 to December 2018 were randomized to receive oral tramadol for analgesia or verbal analgesia prior to IUD insertion. Demographic data, clinical symptoms, visual analogue scale (VAS) and complications were reviewed from patient records.

RESULTS

There was no difference between the two groups regarding gravidity, age, smoking or body mass index. No significant differences were detected between the groups regarding the procedure, including ease of insertion (p = .415), number of insertion attempts (p = .514) and complications during the insertion (p = .150). Mean pain level by VAS was 4.5 ± 1.6 (range 2-8) for the tramadol group and 4.8 ± 2.4 (0-10) for the verbal analgesia group (p = .610). There was no spontaneous ejection of the IUD in either group, and no endometritis or discomfort that resulted in IUD removal.

CONCLUSION

There was no benefit in using oral tramadol for analgesia prior to IUD insertion among nulliparous women. Verbal analgesia can be a suitable technique for this process and clinicians should become more familiar with its use.

Long-acting reversible contraception side effect management

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects.

RECENT FINDINGS

Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up.

SUMMARY

Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Predictors of severe pain during insertion of the levonorgestrel 52 mg intrauterine system among nulligravid women

OBJECTIVE

To identify sociodemographic and clinical variables associated with severe pain with levonorgestrel 52 mg intrauterine system (IUS) placement among nulligravid women.

STUDY DESIGN

We performed a secondary analysis of a randomized trial that evaluated intracervical anesthesia before IUS insertion. We assessed factors associated with severe pain (visual analog scale pain score ≥7) immediately after insertion using bivariate and multiple regression analyses.

RESULTS

Overall, 137/300 (45.7%) subjects reported severe pain. In multiple regression analysis, only intracervical anesthesia [RR 0.55, 95% CI 0.37-0.80] and a history of dysmenorrhea [RR 1.36, 95% CI 1.08-1.72)] were associated with severe pain.

CONCLUSIONS

Among nulligravid women, a history of dysmenorrhea increases, and intracervical block decreases severe pain during levonorgestrel IUS insertion.

IMPLICATIONS

Dysmenorrhea increases the risk of severe pain at levonorgestrel intrauterine system insertion, while receiving an intracervical lidocaine block decreases this risk. This information can be useful for counseling women prior to device placement and for selecting candidates who may particularly benefit from interventions to reduce pain.

Strategies to Mitigate Anxiety and Pain in Intrauterine Device Insertion: A Systematic Review

One barrier to the use of intrauterine devices (IUDs) as a contraceptive method is the experience of anxiety and pain during the insertion procedure. Previous reviews have focused on pharmacological methods used to relieve pain during IUD insertion; however, few similar reviews have examined non-pharmacological methods to relieve pain or strategies to reduce anxiety. The objectives of this study were to identify and categorize strategies for reducing anxiety and pain with respect to IUD insertion and the ways in which anxiety and pain were assessed. In particular, the study aimed to identify non-pharmacological interventions and studies that included anxiety as a research outcome. A literature search was conducted of all English-language studies between inception and the week of July 29, 2018 from the following online databases: Medline, Embase, Cochrane Library, and PubMed. The search revealed 426 studies after removal of duplicates, 35 of which fulfilled the inclusion criteria. A total of 29 studies were identified as assessing pharmacological interventions for the management of pain, and six studies assessed non-pharmacological interventions. Only one study included a measurement of patient anxiety during the procedure as an outcome measure. Research on non-pharmacological interventions for the management of anxiety and pain during IUD insertion is lacking. This review found that evidence for the studied pharmacological interventions is conflicting, and there is very little evidence on understanding the effectiveness of strategies to manage anxiety during the IUD insertion procedure. Further high-quality research on non-pharmacological pain and anxiety management strategies is warranted.

Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial

OBJECTIVE

To investigate whether a 20-mL buffered 1% lidocaine paracervical block decreases pain during intrauterine device (IUD) placement.

METHODS

In a randomized, single-blind, placebo-controlled trial, women were assigned to receive either a 20-mL buffered 1% lidocaine paracervical block or no block before IUD placement. The primary outcome was pain with IUD placement measured on a 100-mm visual analog scale. Our sample size had 80% power (α=0.05) to detect a 20-mm difference in visual analog scale scores with a SD of 28 mm. Secondary outcomes included pain with speculum placement, paracervical block administration, tenaculum placement, 5 minutes postprocedure, and overall pain perception.

RESULTS

From October 7, 2014, through October 26, 2017, 64 women were enrolled and analyzed (33 in the paracervical block arm, 31 in the no-block arm). There were no differences in baseline demographics between the groups. Women who received the paracervical block reported less pain with IUD placement compared with women who received no block (median visual analog scale score of 33 mm vs 54 mm, P=.002). Pain was significantly less in the intervention group for uterine sounding (30 mm vs 47 mm, P=.005), 5 minutes after placement (12 mm vs 27 mm, P=.005), and overall pain perception (30 mm vs 51 mm, P=.015). Participants who received the paracervical block experienced more pain with block administration compared with placebo (30 mm vs 8 mm, P=.003). There was no perceived pain difference for speculum insertion (10 mm vs 6 mm, P=.447) or tenaculum placement (15 mm vs 10 mm, P=.268).

CONCLUSION

A 20-mL buffered 1% lidocaine paracervical block decreases pain with IUD placement (primary outcome), uterine sounding (secondary outcome), and 5 minutes after placement (secondary outcome). Although paracervical block administration can be painful, perception of pain for overall IUD placement procedure is lower compared with no block.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02219308.

Intrauterine lidocaine and naproxen for analgesia during intrauterine device insertion: randomized controlled trial

Background

This study evaluates oral naproxen and intrauterine instillation of lidocaine for analgesia with intrauterine device (IUD) placement as compared to placebo.

Methods

This was a randomized, double-blind, placebo-controlled trial. Patients desiring levonorgestrel 52 mg IUD or Copper T380A IUD were randomized into treatment groups. Patients received either oral naproxen 375 mg or placebo approximately 1 h prior to procedure in conjunction with 5 mL of 2% lidocaine or 5 mL of intrauterine saline. The primary outcome was pain with IUD insertion measured on a visual analog scale immediately following the procedure. Prespecified secondary outcomes included physician pain assessment, post procedure analgesia, satisfaction with procedure, satisfaction with IUD, and pain assessment related to IUD type.

Results

From June 4, 2014 to October 28, 2016 a total of 160 women desiring Copper T380A or levonorgestrel 52 mg intrauterine device insertion and meeting study criteria were enrolled and randomized in the study. Of these, 157 (78 in the Copper T380A arm, 79 in the levonorgestrel 52 mg) received study treatment medication. There were 39 in naproxen/lidocaine arm, 39 in placebo/lidocaine arm, 40 in naproxen/placebo arm, and 39 in placebo/placebo arm. There were no differences in the mean pain scores for IUD placement between treatment groups (naproxen/lidocaine 3.38 ± 2.49; lidocaine only 2.87 ± 2.13; naproxen only 3.09 ± 2.18; placebo 3.62 ± 2.45). There was no difference in self-medication post procedure or in satisfaction with the procedure and IUD among women in the treatment arms or by type of IUD.

Conclusion

Naproxen with or without intrauterine lidocaine does not reduce pain with IUD placement.

Clinical trial registration

Clinicaltrials.gov, NCT02769247. Registered May 11, 2016, Retrospectively registered.

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.

Consensus of best practice in intrauterine contraception in France

Objective: Our aim was to provide a consensus of best practice in intrauterine contraception (IUC) for French practitioners. Methods: A meeting of 38 gynaecologists was held to establish a consensus of best practice in IUC, using the validated nominal group (NG) method to reach consensus. Seventy questions were posed covering insertion, monitoring and removal of IUC devices. Two working groups were formed and all proposals were voted on, discussed and approved by the NG. Results: Of the 70 questions asked, answers to only four failed to reach NG consensus. While, in general, the IUC practices of French gynaecologists are in line with international guidelines, some notable differences were identified: for example, when to use the levonorgestrel-releasing intrauterine system versus the copper intrauterine device; practice recommendations in the event of upper genital tract infections; and immediate postpartum insertion. Clinicians are encouraged to inform women about IUC, irrespective of their age or parity. In general, the wishes and characteristics of the woman must be the main criteria informing the choice of IUC, once all potential contraindications have been excluded and information about IUC shared. Conclusions: This consensus paper is intended to update and standardise knowledge about IUC for health care professionals, to address any reticence about use of this contraceptive method.

A prospective, randomized study evaluating the pain felt during intrauterine device insertion by the direct technique vs conventional technique

OBJECTIVE

To assess the value of the direct insertion technique compared to the conventional insertion technique in reducing the pain experienced during placement of an intrauterine device (IUD).

METHODS

A prospective, controlled, randomized, single-blind trial was conducted in women eligible for IUD insertion. Participants were randomized into two groups: "conventional placement" and "direct placement". The primary endpoint was the percentage of women reporting pain scored as ≥ 4 on the Numerical Verbal Rating Scale (NVRS) at IUD release. Secondary endpoints comprised the number of immediate incidents (insertion failure, vasovagal reaction, and IUD expulsion), the correct positioning of the IUD, checked by ultrasound, the occurrence of incidents within the week following IUD insertion, and the operators' evaluation of the procedure.

RESULTS

A total of 60 patients were enrolled. During IUD insertion, 27 women (45.8%) reported an NVRS score ≥ 4, 32.1% in the "direct placement" group and 58.1% in the "conventional placement" group (p = 0.07). The median NVRS pain scores in the "direct placement" and "classic placement" groups were 2 and 4, respectively (p = 0.01). No statistically significant between-group differences were found with regard to the secondary endpoints.

CONCLUSION

Use of the direct technique reduced the pain experienced during IUD placement. We observed a trend towards a decreased proportion of patients reporting an NVRS pain score ≥ 4 at IUD release with use of the direct technique and the median pain intensity scored on the NVRS was significantly lower in this group. The two techniques did not differ with respect to complications.

Helping patients select long-acting reversible contraceptives

To reduce the rate of unintended pregnancies, patients should select a contraceptive option that fits their needs and lifestyle. Long-acting reversible contraceptives (LARCs) are a relatively safe and effective option. This article outlines the characteristics of available LARCs and identifies the appropriate method for specific patient populations.

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.

Ultrasound-guided intrauterine device insertion: a step closer to painless insertion: a randomized control trial

AIM OF STUDY

To reduce the pain and duration of the intrauterine device (IUD) insertion procedure through minimizing instrumentation and using trans-abdominal sonography (TAS).

METHODS

This randomized control trial was conducted in a university hospital and included 102 eligible females, fulfilling the inclusion criteria. They were randomly assigned into two groups via 1:1 computer-based randomization program; the trans-abdominal guided IUD insertion group (n = 51), and the traditional IUD insertion group (n = 51). The main outcomes were the pain experienced during the procedure as scored by the visual analogue score and the duration of the procedure.

RESULTS

The trans-abdominal guided IUD insertion was found to be statistically superior to the traditional technique for IUD insertion regarding the pain scores (according to the Visual Analogue Scale, from 0 to 10) recorded by the candidates (2.4 ± 2.1 vs. 5.0 ± 1.7, p < .001) as well as the time (in seconds) taken for IUD insertion procedure (32.2 ± 14.8 vs. 77.7 ± 30.6, p < .001).

CONCLUSIONS

Due to the decrease in pain and time taken for IUD insertion, the trans-abdominal guided technique can be used as a modified technique for IUD insertion. ClinicalTrials.gov Identifier: NCT02582268.

Lidocaine gel vs lidocaine spray in reducing pain during insertion of the intrauterine contraceptive device

OBJECTIVES

The aim of this study was to compare the pain-relieving effect of intracervical lidocaine gel with that of lidocaine spray or no local anaesthesia in decreasing pain during insertion of the intrauterine contraceptive device (IUCD).

METHODS

In a prospective multicentre non-randomised comparative study design, 420 women were divided into three groups of 140 and fitted with the same type of IUCD. Group 1 received cervical lidocaine gel, group 2 received cervical lidocaine spray and group 3 received no topical anaesthesia. A visual analogue scale was used to measure the degree of pain experienced.

RESULTS

There were no significant differences between the three groups with regard to baseline characteristics such as age and number of deliveries. Significantly less pain was felt during cervical traction in women using a local anaesthetic. However, there were no significant differences in pain due to IUCD insertion.

CONCLUSIONS

Application of a local anaesthetic decreased the pain resulting from cervical traction but not that resulting from IUCD insertion.

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.

Providing Contraception to Adolescents

Adolescents have high rates of unintended pregnancy and face unique reproductive health challenges. Providing confidential contraceptive services to adolescents is important in reducing the rate of unintended pregnancy. Long-acting contraception such as the intrauterine device and contraceptive implant are recommended as first-line contraceptives for adolescents because they are highly effective with few side effects. The use of barrier methods to prevent sexually transmitted infections should be encouraged. Adolescents have limited knowledge of reproductive health and contraceptive options, and their sources of information are often unreliable. Access to contraception is available through a variety of resources that continue to expand.

Update on long-acting reversible methods

PURPOSE OF REVIEW

The last several years have seen a number of important clinical and academic advances in long-acting reversible contraceptive (LARC) methods, such that many professional medical organizations now recommend these methods as first-line contraception for all women.

RECENT FINDINGS

Recent data support the use of LARC in a variety of special circumstances including adolescents, nulliparous women and immediately postpartum and postabortion. Evidence also shows that traditional methods of pain control with intrauterine device (IUD) insertion and cervical preparation prior to insertion may not be warranted. Further, the extended use of IUDs is safer and more effective than previously realized.

SUMMARY

The rising uptake of LARC methods in the United States has the potential to dramatically decrease undesired pregnancies and abortion rates, and should be considered an effective option in the majority of women.

New developments in intrauterine device use: focus on the US

Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.

Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION:

SUMMARY STATEMENTS

1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Ketorolac for Pain Control With Intrauterine Device Placement: A Randomized Controlled Trial

OBJECTIVE

To evaluate intramuscular ketorolac compared with placebo saline injection for pain control with intrauterine device (IUD) placement.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial between July 2012 and March 2014. Patients received 30 mg ketorolac or placebo saline intramuscular injection 30 minutes before IUD placement. The primary outcome was pain with IUD placement on a 10-cm visual analog scale. Sample size was calculated to provide 80% power to show a 2.0-cm difference (α=0.05) in the primary outcome. Secondary outcomes included pain with study drug injection, speculum insertion, tenaculum placement, uterine sounding, and at 5 and 15 minutes after IUD placement.

RESULTS

A total of 67 women participated in the study, 33 in the ketorolac arm and 34 in the placebo arm. There were no differences in baseline demographics including age, body mass index, and race. There were no differences in median pain scores for IUD placement in the placebo compared with ketorolac groups (5.2 compared with 3.6 cm, P=.99). There was a decrease in median pain scores at 5 minutes (2.2 compared with 0.3 cm, P≤.001) and 15 minutes (1.6 compared with 0.1 cm, P≤.001) after IUD placement but no difference for all other time points. Nulliparous participants (n=16, eight per arm) had a decrease in pain scores with IUD placement (8.1 compared with 5.4 cm, P=.02). In this study, 22% of participants in the placebo group and 18% in the ketorolac group reported injection pain was as painful as IUD placement.

CONCLUSION

Ketorolac does not reduce pain with IUD placement but does reduce pain at 5 and 15 minutes after placement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; www.clinicaltrials.gov, NCT01664559.

LEVEL OF EVIDENCE

I.

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.