Variability in pain management utilization during intrauterine device insertion: a retrospective review

There is increasing social media discourse on inadequate pain management during intrauterine device insertion. While a paracervical block has the most evidence for reducing intrauterine device insertion pain in the ambulatory setting, few studies have explored what factors contribute to paracervical block utilization at the level of the individual patient visit.

To estimate the utilization rate of pain management techniques, including paracervical block, during intrauterine device insertion and evaluate whether there are patient-based or provider-based factors associated with pain management methods.

We used billing data from January 2021 through December 2021 to identify patients who received contraceptive care in the Obstetrics and Gynecology ambulatory unit of a tertiary academic medical center. We then conducted a retrospective chart review of patients with billing codes indicating an intrauterine device insertion. We describe the prevalence of intrauterine device insertions and receipt of paracervical block according to patient characteristics, as well as other pain management options. The odds of receiving a paracervical block according to patient characteristics were assessed with a multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals of the effect based on parity, presence of gynecologic condition, race/ethnicity, and insurance.

Between January 2021 and December 2021, a total of 1464 unique patients accessed contraceptive care during the study period, and 464 patients underwent intrauterine device insertion. Notably, most patients had no documentation of any pain management method provided during intrauterine device insertion (N=339, 73.1%). A paracervical block was used for 12.5% of insertions (N=58). Common pain management options include oral nonsteroidal anti-inflammatory drugs (N=103, 22.2%) and acetaminophen (N=36, 7.8%). In our multivariable model, we observed statistically significant differences in the odds of receiving a paracervical block based on parity and presence of a gynecologic condition, controlling for patient race/ethnicity and insurance; nulliparous patients had over double the odds of receiving a paracervical block compared to multiparous patients (adjusted odds ratio, 2.61; 95% confidence interval, 1.11, 6.90), as did patients with a documented gynecologic condition (adjusted odds ratio, 2.23; 95% confidence interval, 1.15, 4.36). Among 34 clinicians inserting intrauterine devices, only 10 used a paracervical block. Three-quarters of paracervical blocks were performed by 2 providers.

Pain management options for intrauterine device insertion are broadly underused in an ambulatory tertiary care setting. Paracervical block utilization appears to be associated with specific providers rather than a patient-centered pain management approach. This highlights a need for increased attention to pain control and clinician education for intrauterine device insertion.