Takaisin Tulosta

Interventions for pain with intrauterine device insertion

Evidence summaries
Heidi Alenius
11.3.2016

Level of evidence: A

Ibuprofen (400 mg–800 mg) and intracervical lidocaine are not effective for pain relief during IUD insertion compared with placebo. There is insufficient evidence of the effectiveness of tramadol and naproxen.

A Cochrane review «»1 «Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien ...»1 included 33 studies with a total of 5 710 subjects. 400 mg of ibuprofen vs placebo at least 45 minutes prior to IUD insertion did not significantly reduce pain in 1 trial (mean difference in VAS -0.20, 95% CI -0.39to -0.01, n=2018). In another trial (n=55), ibuprofen 600 mg taken before IUD insertion did not show evidence of an effect on pain four to six hours after IUD insertion. Misoprostol for cervical ripening did not reduce pain with IUD insertion in nulliparous women. In one trial, naproxen as adjunctive treatment to paracervical block taken prior to IUD insertion was ineffective in reducing pain compared with placebo in the first two hours after IUD insertion in mostly nulliparous women. For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (2 trials) or on pain during IUC insertion (3 trials).

A double-blind RCT «McNicholas CP, Madden T, Zhao Q et al. Cervical li...»2 assessed the efficacy of intracervical 2% lidocaine gel for pain relief with IUD insertion. Participants (n=200) were randomly assigned to 2% lidocaine or placebo gel (3 ml) 3 minutes prior to insertion. Pain scores (10-point visual analog scale, VAS) among lidocaine and placebo arms were similar at tenaculum placement (lidocaine and placebo: median, 4; range, 0–10; p = 0.15) and with insertion (lidocaine: median, 5; range, 1–10; placebo: median, 6; range, 0–10; p = 0.16). These results did not differ by parity.

Another randomized, double-blind, placebo-controlled trial «Bednarek PH, Creinin MD, Reeves MF et al. Prophyla...»3 (n=202) in USA evaluated if ibuprofen 800mg 30–45 min prior to IUD insertion reduces pain 2–6 weeks following first-trimester uterine aspiration. Sociodemographic characteristics and baseline VAS scores were similar between groups. The median pain score with IUD insertion was 4.15 in the placebo group and 3.80 in the ibuprofen group. Mean and median pain scores did not differ between the groups when nulliparous and parous women were analyzed independently. Overall, median pain scores were 1.75 higher in nulliparous women than parous women (p = 0.004). Median pain scores did not differ by age, IUD-type, history of dysmenorrhea or time since aspiration.

A third double-blind RCT «Karabayirli S, Ayrim AA, Muslu B. Comparison of th...»4 in Turkey compared the analgesic efficacy of oral tramadol and naproxen sodium on pain during insertion of an intrauterine device (IUD). Patients (n=103) were randomly assigned to receive oral tramadol 50 mg (n = 35) or naproxen 550 mg (n = 34) or placebo (n = 34) 1 hour before insertion. Pain scores (VAS, 0–10) in the tramadol group were significantly lower than in the naproxen group (p = 0.003), and the scores in the naproxen group was significantly lower than in the control group (p = 0 .001). Patient satisfaction with the medication and preference for its future use were significantly lower in the control group than in the other 2 groups (p = 0.001).

In an open trial «Castro TV, Franceschini SA, Poli-Neto O et al. Eff...»5 in Brazil 100 women without previous vaginal delivery were randomized to 400 mg ibuprofen 1 h prior to LNG-IUS insertion or to 2% lidocaine intracervical injection 5 min prior to LNG-IUS insertion. The pain was evaluated immediately after LNG-IUS insertion and then 2 h and 6 h after insertion by VAS and the facial pain scale. The pain and discomfort associated with LNG-IUS insertion, and the ease of insertion of the LNG-IUS did not differ between the groups. Nulliparity was more associated with moderate/severe pain (adjusted odds ratio 3.1, 95% confidence interval 1.3 to 7.80). Injectable intracervical anesthesia reduced the risk of moderate/severe pain non-significantly.

References

  1. Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009 Jul 8;(3):CD007373 [Assessed as up-to-date: 23 June 2015]. «PMID: 19588429»PubMed
  2. McNicholas CP, Madden T, Zhao Q et al. Cervical lidocaine for IUD insertional pain: a randomized controlled trial. Am J Obstet Gynecol 2012;207(5):384.e1-6. «PMID: 23107081»PubMed
  3. Bednarek PH, Creinin MD, Reeves MF et al. Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial. Contraception 2014;Nov 25. pii: S0010-7824(14)00784-7. «PMID: 25487172»PubMed
  4. Karabayirli S, Ayrim AA, Muslu B. Comparison of the analgesic effects of oral tramadol and naproxen sodium on pain relief during IUD insertion. J Minim Invasive Gynecol 2012;19(5):581-4. «PMID: 22766124»PubMed
  5. Castro TV, Franceschini SA, Poli-Neto O et al. Effect of intracervical anesthesia on pain associated with the insertion of the levonorgestrel-releasing intrauterine system in women without previous vaginal delivery: a RCT. Hum Reprod 2014;29(11):2439-45. «PMID: 25240012»PubMed