Dr. Roberto Leon, MD, FRCSC (biography and disclosures)
Disclosures: Received an honorarium from Bayer for a speaking at CME events on IUDs. No conflict of interest. Mitigating potential bias: Only published trials are included.
Part I: http://thischangedmypractice.com/iud-part1/
What I did before
Up until recently, pain management with IUDs (intrauterine devices) insertion was not commonly performed, as most users were multiparous women and the insertion was reasonably straightforward. However, because the IUDs provide unsurpassed protection against a pregnancy along with many other advantages, its acceptance is dramatically increasing, especially in nulliparous women and adolescents (1).
A minimally painful IUD insertion is important because the fear of pain may still deter some women from getting it. Comments such as “that was the most painful experience ever”, or “the worse day of my life” are common, when the IUD is inserted without appropriate pain management, which is what I used to do before.
What changed my practice
After I caused excruciating pain to a young nulliparous woman, I made a conscious decision to take all the steps that I could to minimize the pain of insertion. A Cochrane review of the literature was not encouraging, stating that “no interventions that have been properly evaluated reduce pain during or after IUD insertion” (2).
In my own analysis of the possible sources of the pain, I came to the conclusion that it probably occurs at 3 levels:
- Central Nervous System level: anticipatory anxiety, apprehension and fear of pain,
- Cervical level: clamping the cervix with a tenaculum and dilating it during the passage of the IUD inserter,
- Uterine level: mild to intense cramping once the horizontal arms are opened in the fundus.
I decided to act upon each level, and to my surprise, the difference was remarkable. The reported description of pain went down to, on average, 1 or 2 out of 10, and many women did not experience any pain at all.
What I do now
To help deal with the CNS anxiety and anticipation of pain, I spend at least 20-30 minutes going through a PowerPoint presentation which explains the pros and cons of the different types of IUDs, how to minimize the insertion pain, and expected changes and side effects. I have a printout that reflects the PowerPoint presentation for patients to take home to read. I offer them 1-2 mg of sublingual lorazepam 30 min prior to insertion as long as they get a drive home. Naproxen or Ibuprofen is given 1-2 hours earlier for uterine cramps.
To reduce the cervical pain, a paracervical block is performed with10 cc of 1% Xylocaine 1%. A spinal needle with a control syringe is employed to minimize the risk of intravascular injection. Patients are informed all along what is happening, especially as the needle goes into the stroma of the cervix. Many women do not feel the needle at all, some feel a slight discomfort. After injecting 2 cc at 12 o’clock, a tenaculum is placed to lift the cervix and 4 cc are injected on each side at the 4-5 and 7-8 o’clock positions. The block may take 2-3 minutes to work. To confirm that it is effective, and to allow some further cervical dilatation, an os finder is introduced into the uterus.
Premedication with ibuprofen (600 mg) or naproxen (500 mg) 1-2 hours before is given to minimize the pain of the IUD deployment. Gentle manipulation is paramount. The inserter itself is used as a sound. Once the inserter has reached the fundus, it is retracted back about 1 cm. The horizontal arms are then opened, and after 10 seconds, the IUD is pushed to the fundus, and then released. At this stage, mild to intense uterine cramping is expected. If severe, it tends to last 1-2 minutes, and then it eases right off.
The patient is kept supine for another 5 minutes, while questions are addressed. Important topics such as what to take for the pain later on at home (NSAIDs and hot water bottle), what amount of pain and bleeding is normal, when can she resume full physical activity and sexual relations, and for how long do they have to use a back up method to avoid a pregnancy, are all reviewed, and time is given to ask questions.
A bedside transvaginal ultrasound is performed in selected cases, such as in women who have a higher risk than normal for uterine perforation (examples include previous C/Section, especially if they are still breastfeeding, or a markedly retroverted uterus). Perforations usually occur at the time of insertion. If a partial perforation is noted (IUD arms in the myometrium), then the IUD is removed immediately.
The patient is given an instruction sheet applicable to the IUD just inserted, and a channel of communication is firmly established, including access through email or telephone if they have questions or concerns.
A most recent Cochrane review in 2015 (3) states that “Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups”.
Most studies looking at pain management during insertion compared one intervention to none, showing limited benefits. In my experience, if we use all possible methods that help reduce the pain, a combination effect is achieved with a marked reduction of the discomfort, to the delight of our patients.
Patient Handouts
- Handout: After a COPPER IUD insertion http://med-fom-tcmp.sites.olt.ubc.ca/files/2016/01/TCMP-Dr.-Roberto-Leon-IUD-Handout-After-COPPER-IUD-insertion.pdf
- Handout: After a MIRENA or JAYDESS IUD insertion http://med-fom-tcmp.sites.olt.ubc.ca/files/2016/01/TCMP-Dr.-Roberto-Leon-IUD-Handout-After-MIRENA-JAYDESS-IUD-insertion.pdf
References
- Intrauterine Device Use in Adolescents. Journal of Adolescent Health; 57 (2015) 359e360. (View with CPSBC or UBC) DOI: 10.1016/j.jadohealth.2015.07.010
- Allen RH, Bartz D, Grimes DA, Hubacher D, O’Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009; CD007373. (Request with CPSBC or view UBC) DOI: 10.1002/14651858.CD007373.pub2
- Lopez LM, Bernholc A, Zeng Y, Allen RH, Bartz D, Hubacher D, O’Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2015; CD007373. (View CPSBC or UBC) DOI: 10.1002/14651858.CD007373.pub3
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I find too much instrumention and procedures are unnecessary and probably even increasing anxiety in a patient who is predisposed to anxiety states.
Can you share your powerpoint presentation?
Willa Henry MD
For uterine cramping consider premedicating with homeopathic magnesium phosporicum 200 C; this can then be repeated every 1-4 hours as needed. Since magnesium deficiency is so very common in Canada, especially among women, it might be helpful to encourage magnesium glycinate (dose b.i.d. to bowel tolerance, then reduce a bit) daily for a couple of weeks before and after insertion.
Use Gelsemium 200C for anticipatory anxiety — night before and q 4 h PRN.
I have been inserting IUD’s ‘old school’ for 20+ and have yet to cause anyone excruciating pain, or can only recall 1 nullip having moderate pain. So I never really feel motivated to make a change to my practice. I think the therapeutic alliance with my patients might be anxiolytic, since I don’t do them on a referral basis, or in a women’s health clinic. Usually I have had a few conversation with my patients about all forms of contraception, and what to expect, prior to the actual moment of insertion. I agree that knowing what to expect – according to what they want to know – is anxiolytic. Not all of my patients would be interested in seeing/hearing all about it. Some prefer only to know what they have to, and then want to listen to some music, and not even look at the insides of the package. I don’t think the ppt would be good for them. Last week, for the first time I gave a patient some lorazepam, because her previous MD gave it to her, and she felt she couldn’t try without it. I didn’t find it any different than any other IUD I had put in, so my n of 1 doesn’t convince me. Also, I find that putting on a tenaculum is equivalent to the pain of the injection in the cx prior to putting it on. I don’t see the benefit. I find once it is on, there is no further pain on the cervix. Maybe I have just been lucky? I go around this topic about once a year, and was very happy to see the resources and references. I am still mulling it over.
Can you share your powerpoint?
Thanks very much for this presentation. In the past, I also used to routinely do a cervical/paracervical block, however I’ve found that in about 80% of the patients, I can sound the uterus without a tenaculum by having them tilt their pelvis while applying downward suprapubic pressure with their hands. This serves 2 purposes – First it straightens out the anteverted uterus, and second, it gives them a sense of participating in the procedure. Years ago, working with fertility clinic patients doing intrauterine inseminations, we found that our pregnancy stats were higher when we were able to insert the IUI catheter without tenaculum, and certainly the patient experience was more positive – so I tried the same techniques here and it works well in nullips and multips. I agree wholeheartedly with your conclusion about the anxiety and anticipatory contributors to the pain experience, and really appreciate your comments about the importance of thoroughly preparing them. I find that most women aren’t interested in too much detail, but do want to have a general idea, so my pre-insertion consultation caters to as much info as they want, and I also show them how they can help with the procedure. I advise that sometimes we have to do a block and there can be some cramping, but I’ve found that each of these women leave after the insertion pleasantly surprised at having experienced little or no discomfort. I do have them take some ibuprofen pre-procedure. There are certainly some trickier ones where this minimal intervention approach doesn’t work and I need to do a block and be more aggressive, but as we hit that point, I remind her of what we discussed and talk her through it. Always glad to hear new ideas, and thanks for the resources and references. Much appreciated.
I provide lorazepam to my anxious patients and give ibuprofen immediately after inserting the iucd. I’ve never done a paracervical block for inserting an iucd. I may try it but so far all my patients have been quite happy with the procedure when I do it.