Interventions for pain with intrauterine device insertion

Fear of pain during intrauterine device (IUD) insertion is a barrier to use of this contraceptive method. Interventions for pain during IUD insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol.

To review all randomized controlled trials that have evaluated a treatment for IUD insertion-related pain.

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, and EMBASE for relevant trials. We also examined reference lists of pertinent articles and wrote to known investigators for information about other published or unpublished trials.

We included all randomized controlled trials in any language that evaluated a treatment for IUD insertion-related pain. The intervention could be compared to a placebo or another active intervention.

Two authors independently abstracted data from relevant trials and data were entered into RevMan 5.0 for analysis. For dichotomous variables, the Peto odds ratios with 95% confidence intervals was calculated. For continuous variables, the mean differences with 95% confidence interval was computed.

Four trials met the inclusion criteria; the total number of participants was 2204. Nonsteroidal anti-inflammatory drugs of varying types and doses were not effective for reducing pain during IUD insertion. Misoprostol for cervical ripening did not reduce pain with IUD insertion in nulliparous women. Two trials evaluated pain that occurs after IUD insertion using nonsteroidal anti-inflammatory drugs. In one trial, naproxen taken prior to IUD insertion was effective in reducing pain compared with placebo in the first two hours after IUD insertion in mostly nulliparous women. However, this trial utilized the Dalkon Shield, an IUD with a wider diameter than modern IUDs. In another trial, ibuprofen 600 mg taken before IUD insertion did not show evidence of an effect on pain four to six hours after IUD insertion.

No interventions that have been properly evaluated reduce pain during or after IUD insertion. One poorly controlled trial suggested that topical lidocaine gel may reduce insertion-related pain and warrants further investigation.