ACOG: Providers Underestimate Pain Intensity During IUD Insertion

Providers underestimate the intensity of patients’ pain during IUD insertion, and often misidentify the moment at which maximum pain occurs, according to a randomized trial of 200 women. Midlevel providers are slightly better at estimating pain intensity.

The study, presented at the American Congress of Obstetricians and Gynecologists’ Annual Clinical Meeting, was a secondary analysis of a randomized, placebo-controlled trial that investigated the use of intracervical lidocane gel as an analgesic during IUD insertion (Cu T380A or LNG IUS). Women were between the ages of 18 and 45 with a mean average age of 27.6. None of the women had a recent pregnancy, and 30% were nulliparous.

Using a 100 mm visual analog scale (VAS), women marked the level of pain they felt at four points: tenaculum placement, uterine sounding, IUD insertion, and speculum removal. On an identical scale, providers marked the point during insertion that they perceived to be most painful, along with the perceived level of pain.

Participants mean maximum pain score was 63.8 (standard deviation [SD] 27) compared with the mean maximum pain score of 35.3 reported by the providers (SD 26), P<.001). Midlevel provider ratings were 6.6 points closer to the patient’s pain score than attending physicians (P=.04).

In both intensity of pain and the point of greatest pain, agreement between patient experience and provider perceptions showed “very poor agreement,” said lead author Karla Maguire, MD, MPH, of the Miller School of Medicine in Miami, Fla. (kappa 0.16, confidence interval [CI] 0.07, 0.25). While midlevel providers, including advanced practice nurses and physicians assistants, are slightly better at estimating patients’ pain, they were equivalent to primary providers in estimating the moment of greatest pain. Only 19% of all providers were within 10 mm of perceived pain rates indicated by patients.

Maguire said that while IUDs have low failure rates and high continuation rates, pain may be a barrier to IUD use. “Underestimations of pain [by providers] can lead to pain mismanagement,” said Maguire. She said it could also lead to lack of potentially beneficial research.