Pain control options for intrauterine device placement and endometrial biopsy

To review the effectiveness of pain control methods for outpatient intrauterine device (IUD) insertions and endometrial biopsy (EMB) procedures.

Several approaches to decreasing pain with ambulatory IUD placement and EMB have been evaluated in the literature. Paracervical blocks, cervical lidocaine spray, nonsteroidal anti-inflammatory drugs (NSAIDs), and anxiety reduction techniques have been shown to decrease pain reported by patients. For both IUD insertion and EMB, evidence regarding NSAIDs for intraprocedural pain is mixed, and they should be advised to decrease postprocedural cramping. A paracervical block with local anesthesia successfully targets pain but can cause discomfort with injection. Misoprostol may improve ease of IUD insertion and thus may be useful in select patients with difficult placements; however, routine use is not recommended because of increased side effects and risk of expulsion. Ultrasound-guided IUD insertion and nitrous oxide administration have also shown efficacy but are limited by cost and logistical barriers.

Pain during IUD placement and EMB is multifactorial and best addressed with use of an individualized, multimodal approach. Shared decision-making should guide clinician and patient discussion for offering strategies such as preprocedural NSAIDs, lidocaine spray, paracervical blocks, and anxiety management to all patients to optimize comfort and procedural experience.