Pain Management During IUD Insertion

Topical or intracervical 2% lidocaine gel applied before intrauterine device (IUD) insertion does not decrease pain scores, concludes a double-blind, randomized controlled trial of women undergoing IUD insertion at Washington University in St. Louis, Missouri.¹

The study included 200 women who were randomized to receive either 2% lidocaine gel or placebo gel during the IUD insertion process. Using a 10-point visual analog scale, participants indicated current and anticipated pain levels before IUD placement, then indicated current pain levels immediately after tenaculum placement and immediately following insertion of the IUD. Between the placebo and lidocaine groups, there was no difference in scores for insertional pain, which is consistent with other studies that have shown that lidocaine gel does not effectively reduce pain during IUD insertion.^2,3

Nulliparous women reported significantly higher mean pain scores compared with parous women, but pain score for nulliparous women randomized to placebo or lidocaine were similar. In the placebo group, nulliparous women reported a mean pain score of 7, compared with a mean pain score of 5 reported by parous women. In the lidocaine group, the mean pain score was 6 for nulliparous women and 4 for parous women. Pain scores related to placement of the tenaculum and insertion of the device were similar between groups.

Attempts to provide pain relief during IUD insertion have been largely ineffective in studies, and fear of pain during the insertion process may be an important reason for why some women decide against IUDs despite the significant benefits associated with their use. Suggestions for pain control based on empirical evidence include the following practices:

- Recommend IUD insertion during the patient’s menses, because the cervix is slightly open during menstruation.
- Use a cervical block.
- Insert misoprostol into the vagina several hours before IUD insertion to help soften the cervix.
- Advise patients to take ibuprofen at least 30 minutes before the procedure.

Despite the discomfort that patients may feel during IUD insertion, the study authors urge providers to continue to emphasize the long-term outcomes and benefits of IUDs, which are one of the most effective forms of birth control currently available.

Pertinent Points:
- Intracervical placement of 2% lidocaine gel before insertion of an IUD does not reduce pain scores.
- Parity had no affect on the effectiveness of 2% lidocaine gel used for pain management during the IUD insertion process.

References:

1. NcNicholas CP, Madden T, Zhao Q, et al. Cervical lidocaine for IUD insertional pain: a randomized controlled trial. Am J Obstet Gynecol. 2012;207:e1-e6.
2. Maguire K, Davis A, Rosario-Tejeda L, Westhoff C. Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial. Contraception. 2012;86:214-219.
3. Mohammad-Alizadeh-Charandabi S, Seidi S, Kazemi F. Effect of lidocaine gel on pain from copper IUD insertion: a randomized double-blind controlled trial. Indian J Med Sci. 2010;64:349-355.