Lidocaine for pain control during intrauterine device insertion

Pain Management for In-Office Uterine and Cervical Procedures

SUMMARY

In-office gynecologic procedures, such as intrauterine device insertion, endometrial biopsy, hysteroscopy, intrauterine imaging, and cervical biopsy, among others, are common procedures experienced by many patients. There is an urgent need for health care professionals to have a better understanding of pain-management options and to not underestimate the pain experienced by patients and for patients to have more autonomy over pain-control options during in-office procedures. The way pain is understood and managed by health care professionals is also affected by systemic racism and bias of how pain is experienced. Specific populations, such as adolescents and those with a history of chronic pelvic pain, sexual violence or abuse, and other pain conditions, may also have increased or decreased tolerance of pain and resistance to pain medications. Several pain-management interventions being used have limited or conflicting evidence supporting their effectiveness at providing adequate pain control during in-office gynecologic procedures. Health care professionals therefore must be cautious when extrapolating data on what works for one procedure to another. Shared decision making with the patient should be practiced when discussing pain-management options because options that work for one patient may not work for another. Future research on pain and the management of pain must be more racially and ethnically diverse. Studies should include gender-diverse participants, focus on patient preferences and goals, and consider the needs of patients of various ages and those who have a history of trauma.

Differences in pain regimens among nulliparous patients undergoing intrauterine device placement within a single health system

BACKGROUND

Although offering pain management with intrauterine device placement is recommended, but no standardized protocol exists. Patients may experience disparities pain regimens offered with placement based on where they seek care.

OBJECTIVE

This study aimed to describe the pain medication regimens that clinicians use for intrauterine device placement and the patient and clinician factors and clinic settings associated with receiving medication before and during placement.

STUDY DESIGN

We performed a retrospective study of nulliparous individuals aged 15 to 50 years who had an intrauterine device placed from 2019 to 2021 (N=1153) across a large statewide health system in the Southeast. From the electronic health record, we abstracted exposure variables (ie, patient, clinician, and clinic characteristics) and outcomes (ie, medication regimens used before and during intrauterine device placement). We used bivariate analysis and multivariable logistic regression to examine associations between exposure variables and outcomes.

RESULTS

Less than half of the patients (41.7%) received medications before or during intrauterine device placement. Medication regimens used before and during intrauterine device placement varied by clinician specialty, clinician type, and clinic location. After multivariable regression, patients were more likely to receive preinsertion medications if they had a lower body mass index, received the Skyla intrauterine device, were treated by advanced practice providers or clinicians with a specialty in pediatrics or internal medicine, or were seen in >1 clinic visit for their intrauterine device placement (all P<.01). Patients were more likely to receive pain medications during intrauterine device placement if they were younger, treated by internal medicine clinicians, or had their intrauterine device placed on the same day they requested it, and they were less likely to receive medications during placement if seen by advanced practice providers or in a rural setting (all P<.01). There were no differences by patient race or insurance type.

CONCLUSION

We found that pain management with intrauterine device placement is associated with clinician specialty, clinician type, and practice setting, with few significant patient factors. Although no particular pain regimen is universally recommended, several options have been shown to be potentially beneficial for nulliparous patients. Therefore, improving clinician knowledge about effective pain regimens and expanding resources across all clinic settings may improve nulliparous patients' experiences and shared decision-making regarding medication use before and during intrauterine device placement.

Mepivacaine instillation for pain reduction during intrauterine device placement in nulliparous women: a double-blinded randomized trial

BACKGROUND

Fear of pain associated with intrauterine device (IUD) placement has been identified as a significant barrier to the adoption of long-acting reversible contraception, contributing to lower utilization of the most effective reversible contraceptive methods.

OBJECTIVE

To assess whether instillation of intrauterine mepivacaine before IUD placement alleviates pain more effectively than a placebo.

STUDY DESIGN

We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving nulliparous women undergoing IUD placement. An intrauterine instillation of 10 mL of 20 mg/mL mepivacaine or 0.9 mg/mL sodium chloride was administrated through a hydrosonography catheter 2 minutes prior to IUD placement. Pain scores were assessed using a 100 mm visual analog scale (VAS) at prespecified time points. Primary outcome measured the difference in VAS pain scores between the intervention group and the placebo group during IUD placement. Secondary outcomes included VAS pain scores at instillation and 10 minutes after placement, tolerability of the placement pain, as well as acceptability of the analgesia method.

RESULTS

We enrolled 151 participants, with 76 assigned to the mepivacaine group and 75 to the placebo group. The mean VAS pain score during IUD placement showed a difference of 13.3 mm (95% confidence interval (CI) 5.75-20.87; P<.001): the mepivacaine group had a mean of 53.9 mm (standard deviation [SD] 22.8), while the placebo group had a mean of 67.2 mm (SD 22.4). After adjusting for each individual provider's impact, the difference in mean pain scores remained statistically significant (12.2 mm 95% CI 4.85-19.62; P<.001). A greater proportion of women in the intervention group reported tolerable pain during placement with 70/75 participants (93.3%) compared to 53/66 participants (80.3%) in the placebo group (P=.021).

CONCLUSION

The intrauterine instillation of mepivacaine results in statistically significant reduction in pain score among nulliparous women during IUD placement. Although the precise clinical impact of this pain reduction method remains uncertain, the observed reduction in pain score result in a higher proportion of women reporting tolerable pain. This finding and the high acceptance as a pain reduction method thereby suggests clinical relevance. Intrauterine instillation of mepivacaine is a possible strategy to increase IUD utilization, particularly among nulliparous women who are at high risk of unintended pregnancy.

Anesthesia Usage and Pain Management in Colposcopy: A Scoping Review of Efficacy and Approaches

Colposcopies are diagnostic procedures conducted to detect precancerous and cancerous lesions on the cervix and are often done as a sequelae of histological abnormalities found on cervical screening exams, such as precancerous abnormalities, positive human papillomavirus (HPV) results, or a past medical history of cervical dysplasia. Colposcopies, while often necessary to ensure the health of the patient, can induce a lot of anxiety and distress in the time leading up to the procedure, often due to fear of the procedure itself, anticipation of pain, as well as fear regarding the results of the colposcopy. Experiencing physical pain and discomfort during gynecological procedures can negatively influence a woman's willingness to comply with future medical appointments, often exacerbating feelings of anxiety and distress. A systematic search was conducted to identify the relevant articles published within the last 10 years pertaining to pain management in colposcopy procedures. The search strategy aimed to identify studies involving the utilization of anesthesia or analgesics for pain management or prevention during colposcopy, with a focus on randomized controlled trials. This systematic review aims to review the existing literature on the use of anesthetics in colposcopy and its effect on patient outcomes, investigating the current strategies of anesthesia use in the setting of a colposcopy, as well as their efficacy in improving pain.

The Effect of Virtual Reality On Pain and Anxiety Management During Pelvic Examination: A Randomized Controlled Trial

INTRODUCTION

It is important for health care professionals to address women's pain and anxiety during pelvic examinations. This study aimed to evaluate the impact of virtual reality (VR) on pain and anxiety management during pelvic examinations.

METHODS

The study was a randomized controlled clinical trial reported in according to the Consolidated Standards of Reporting Trials 2010 Guidelines. The research was conducted with 128 women (64 intervention, 64 control) who received care at a tertiary hospital outpatient clinic between November 2021 and February 2022. The intervention group received VR application via virtual glasses during pelvic examination, while the control group received routine care. Anxiety was measured using the State-Trait Anxiety Inventory before and after the pelvic examination, and the Visual Analog Scale was used to assess pain after the pelvic examination. The study was registered at ClinicalTrials.gov (NCT05545488).

RESULTS

The mean anxiety scores of the women in the intervention and control groups were similar pretest (59.00 and 57.77). The mean anxiety score decreased after the pelvic examination to 36.53 in the intervention group and 47.55 in the control group. Results indicated a significant main effect for group assignment (F9.56; η2 = .071; P = .002), a significant main effect for time (F384.14; η2 = .753; P < .001), and a significant interaction between group and time (F53.95; η2 = .300; P < .001). Pain scores after the pelvic examination were lower in the intervention group (4.25) than in the control group (6.41; P < .001).

CONCLUSION

VR was effective in the management of pain and anxiety during pelvic examination. Future studies should compare the effectiveness of VR with other methods in reducing pain and anxiety during a pelvic examination.

Efficacy of Lidocaine Spray for Pain Reduction during Colposcopy-Directed Cervical Biopsies: A Randomized Controlled Trial

Objectives: The objective of this study was to evaluate the efficacy of lidocaine spray in reducing the pain during colposcopy-directed cervical biopsy (CDB). Methods: From December 2017 to February 2019, 312 women undergoing CDBs were enrolled. The participants were randomized to three groups: group 1 (lidocaine spray), in which lidocaine spray was applied thoroughly to the cervix; group 2 (placebo), in which normal saline was applied thoroughly to the cervix; and group 3 (control), in which no anesthetic agent was applied to the cervix. Each woman completed a 10 cm visual analog scale to classify the subjective pain experience at three time points: baseline, immediately after biopsy, and 10 min after the procedure. The primary outcome of this study was the biopsy pain score. Results: The 312 enrolled women were randomly assigned to the three groups, amounting to 104 women per group. The clinical and pathological characteristics of the participants in all groups were comparable. The baseline, the biopsy, and the post-procedure pain scores were comparable among the three groups. There was a significant increase in the pain score from baseline to biopsy and from baseline to post-procedure in each group. The pain-score changes from baseline to biopsy in the lidocaine spray group significantly decreased when compared with the normal saline group (<0.001), and tended to decrease, though not significantly (p = 0.06), when compared with the control group. No complication with the intervention was observed. Conclusions: The application of lidocaine spray to the cervix has the benefit of reducing the pain associated with CDBs by a small amount. However, the intervention is safe and may be considered in nulliparous and/or overly anxious women undergoing the procedure.

Comparative Study of the Effect of Lidocaine Spray and Ice Spray on the Pain Intensity During Intramuscular Injection: A Randomized Clinical Trial

BACKGROUND

Intramuscular injection is one of the most common, invasive, and painful ways to deliver medicine to the body.

AIM

Since one of the nurse's duties is to employ different methods to reduce pain caused by treatment procedures, this study was conducted to determine the effect of lidocaine spray and ice spray on pain intensity at the muscle injection site.

METHOD

A clinical trial was performed on 90 patients presenting to outpatient clinics of Neyshabur hospitals. The samples were selected using a computerized table of random numbers, and each participant was randomly assigned to one of the control, lidocaine spray, and ice spray groups. Pain severity was measured immediately after intramuscular injection using a numerical pain scale. Descriptive statistics along with statistical tests (chi-square, Fisher, etc.) were used to analyze the data in the R environment version 3.6.2. Ordinal logistic regression was used to compare pain intensity in the three groups by adjusting the effect of age variables and sensory disorders.

RESULTS

The mean pain intensity was 3.44 without intervention, 2.63 with lidocaine spray, and 2.27 with ice spray. Statistical tests indicated a significant difference in pain intensity of intramuscular injection between the ice group and the control group (p = .010). Although lidocaine spray reduced the pain intensity, its effect was insignificant compared with the control group.

CONCLUSIONS

Both ice and lidocaine spray can be effectively used to reduce the intensity of intramuscular injection pain; however, it seems that ice spray is a more effective, safe, and affordable method.

Effectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial

OBJECTIVE

Radial arterial puncture is a painful procedure. The aim of this study was to evaluate the effect of lidocaine spray (10%) on pain associated with radial artery blood withdrawal for arterial blood gas analysis.

METHODS

This randomized, controlled, double-blind study was performed between December 2018 and September 2019. Before radial arterial puncture, 10% lidocaine or placebo spray was applied to each patient by the attending physician, who was blinded with regard to random assignment. The spray was administered six times on the site from a distance of 5 cm. After waiting for 5 min, a radial arterial puncture was performed routinely. The pain levels of patients during radial arterial puncture and 5 min after puncture were evaluated with the visual analog scale (VAS). The Wilcoxon test was used to compare pain scores during puncture.

RESULTS

The research was performed with 67 patients (34 patients in the lidocaine group, 33 patients in the placebo group) who were admitted to the emergency department and required ABG analysis. Forty-three patients were men, and 24 were women. The ages of the patients ranged between 19 and 86 years, and the mean (± standard deviation) age was 56.3 ± 16.6 years. Pain levels, as measured by VAS, were significantly lower in the lidocaine group (24.00 mm IQR:[14.75-33.75]) compared with the placebo group (33.00 mm IQR:[22.00-61.50]) during radial arterial puncture (p = 0.011).

CONCLUSIONS

The level of pain perceived during radial arterial puncture was significantly lower in those who were administered lidocaine spray. Lidocaine spray application can be used in pain management related to radial arterial puncture.

10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Various medications have been investigated for their efficacy in pain reduction during intrauterine device (IUD) insertion, but there is currently no standard recommendation. This study aimed to investigate the efficacy of 10% lidocaine spray in reducing pain during copper-containing intrauterine device (Cu-IUD) insertion.

METHODS

This study was a randomised, double-blind, placebo-controlled trial. Reproductive-age women were randomised at a 1:1 ratio into 10% lidocaine spray or placebo spray group. A 10 cm visual analogue scale (VAS) was used to evaluate pain during several steps of the IUD insertion procedure, and after the procedure.

RESULTS

One hundred and twenty-four women were included and 62 women were randomised in each group. Baseline characteristics between groups were similar. The 10% lidocaine spray group demonstrated significantly lower median VAS immediately after IUD insertion than the placebo group (2.95 (IQR=1.00-5.63) vs 5.00 (IQR=3.35-7.00), respectively; p=0.002). Similarly, women receiving 10% lidocaine spray reported significantly lower median VAS than those receiving placebo during tenaculum use and uterine sounding. The maximum median VAS occurred immediately after Cu-IUD insertion. The proportion of women who reported VAS≥4 during uterine sounding and after IUD placement was significantly lower in the 10% lidocaine group than in the placebo group (p<0.05). Median change in VAS from baseline to IUD placement was significantly different between 10% lidocaine spray group and placebo group (1.85 (IQR=0.08-4.03) vs 3.6 (IQR=2.40-5.80), respectively; p=0.004).

CONCLUSION

10% lidocaine spray was found to be an effective local anaesthetic method for reducing pain during insertion of Cu-IUD.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT03870711.

Self-administrated vaginal 2% lidocaine in-situ gel for pain relief during copper intrauterine device insertion in women with previous caesarean delivery only: a randomised, double-blind placebo-controlled trial

OBJECTIVE

To evaluate the analgesic effect of self-administered vaginal 2% lidocaine in-situ gel in pain relief during copper intrauterine device (IUD) insertion in women with previous caesarean delivery only.

METHODS

A Randomised, double-blind, placebo-controlled trial (Clinicaltrials.gov: NCT03166111) included reproductive-aged women who previously delivered only by caesarean section (CS) requesting Copper IUD insertion. Eligible women were recruited and randomised (1:1) to lidocaine in-situ gel vs. placebo. Each woman was supplied by a syringe filled with five ml lidocaine or placebo in-situ gel to be self-administered vaginally ten minutes before insertion. The primary outcome was the difference in pain scores during IUD placement using a 10-cm Visual Analogue Scale (VAS).

RESULTS

The final analysis included 216 women (n = 108 in each arm). Women in the Lidocaine in situ gel group were more likely to report statistically significant lower pain scores during vulsellum application, uterine sound placement, and during IUD placement [Mean difference (95%CI) = 2.04 (1.66-2.42), 2.62 (2.20-3.04), and 2.57 (2.12-3.01), respectively, p = 0.0001]. A significantly lower IUD insertion score indicating easier insertion was reported in the lidocaine group (p = 0.004). Similarly, the duration of IUD insertion was significantly shorter in the lidocaine group (p = 0.008). There was a higher level of satisfaction in the lidocaine group (5.92 vs. 3.34) in the placebo group (p = 0.0001).

CONCLUSIONS

Self-administered vaginal lidocaine in-situ gel 10 min before copper IUD insertion is effective in pain reduction in women with previous caesarean delivery only.

A New Approach on the pain management of intramuscular injection: A Triple-Blind Randomized Clinical Trial

BACKGROUND

Pain management is an important part of care provided by nurses.

AIMS

The present study aimed to investigate the effect of an innovative method named the skin traction, pressure, and rapid muscle release (TPR) on reducing IM injection pain compared with the Z-track injection method DESIGN: This triple-blind clinical trial investigated 63 patients who required Methocarbamol injection.

METHODS

Two, 5-cc methocarbamol injections were given to each patient by the two techniques in two of his/her muscles. In the TPR technique, after applying skin traction and imposing deep pressure on the muscle, the needle was inserted at a 90° angle near the skin and the muscle was released rapidly towards the needle. Hence, the needle was embedded in the muscle. However, muscle release was not applied in the Z-track method. The visual analog scale (VAS) was used to measure pain intensity. For data analysis, T-independent and χ² tests were used.

RESULTS

The findings showed that the mean pain score in TPR and Z-track methods was 1.68 ± 1.20 and 3.76 ± 1.42, respectively. The difference was statistically significant.

CONCLUSION

The results of this study showed that the innovative method (TPR) can be used as a substitute for the Z-track method to reduce IM injection pain.

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.

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.

Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial

BACKGROUND

A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control.

OBJECTIVE(S)

The objective of the study was to assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared with placebo.

STUDY DESIGN

We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15 minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (0 being no pain and 100 being worst pain imaginable). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a postprocedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed because of the nonnormal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of intrauterine device insertion pain were assessed using a multiple linear regression.

RESULTS

In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (P = .13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (P = .09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 [0-81] mm vs 11 [0-80] mm, respectively; P = .046). Anticipated pain and menstrual pain were both predictors of pain with intrauterine device insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent of participants (n = 194) stated they would be willing to wait before intrauterine device placement for a potential analgesic effect.

CONCLUSION

Self-administered lidocaine gel at least 15 minutes before intrauterine device insertion does not appear to reduce pain compared with placebo but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.

The Efficacy of Lidocaine Spray in Pain Relief during Outpatient-Based Endometrial Sampling: A Randomized Placebo-Controlled Trial

Abnormal vaginal bleeding is one of the most frequent problems found in gynecology. Endometrial histopathology is needed for definite diagnosis. It was obtained either from endometrial tissue sampling or from standard uterine curettage. Office endometrial tissue sampling is an easy and low morbid procedure. It is usually associated with pain and discomfort. Topical anesthetic agent is needed for pain relieving. This study was conducted in outpatient gynecology clinic, Thammasat University Hospital, Thailand. It was a double blind randomized controlled trial. A total of 140 participants were enrolled in study and control group. Each group consisted of 70 cases. Study group received topical spray of 10% lidocaine (40 mg) before endometrial aspiration. Topical spray of 0.9% normal saline was performed in control group. Novak curettage was an application for endometrial tissue obtaining in this study. Visual analog scale (10cm-VAS) was used for pain evaluation. Demographic character of both groups showed no statistical difference. The percentage of participants who had severe pain (VAS≥7) during tenaculum application and Novak curettage insertion and during procedure were 28.5% (20/70) versus 12.9% (9/70), 55.7% (39/70) versus 38.5% (27/70), and 78.5% (55/70) versus 60% (42/70) in control and study group, respectively. Both groups had no significant differences of postoperative pain at 15 minutes and 2 hours. This study indicates that topical lidocaine spray can relieve pain during endometrial tissue sampling.

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.