From a clinician’s perspective, inserting an intrauterine device (IUD) is a relatively quick procedure. However, during that short time, some patients may experience serious pain, notably when we pass the uterine sound and IUD inserter through the cervical os and up to the fundus. My patients are often worried about this pain and want to take something before their visit to make insertion more comfortable. Is there something we can recommend that actually works?
The appeal of premedication
Premedication has several advantages, especially if patients can take a medication orally prior to the appointment. Taking a medication in advance of the procedure allows it to take effect by the time the patient is in the exam room and prevents interruptions in clinic flow. In the context of IUD insertion, premedication would ideally help reduce the cramping that some patients experience after the procedure, allowing them to return to work, school or other responsibilities, and get themselves where they’re going next without a helper. Unfortunately, the evidence shows that several types of premedication are disappointing in terms of pain control.
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) widely used for post-procedural pain control. It is often recommended prior to IUD insertion, but there are now 4 randomized controlled trials demonstrating that it doesn’t reduce pain during insertion. These trials studied dosages varying from 400-800 mg. So it’s clear that ibuprofen should not be recommended as a premedication for reducing pain during IUD insertion. Unfortunately, most of these trials did not evaluate post-procedural pain control. The one trial that did found no reduction in pain, but they asked patients 4-6 hours after the procedure. By that point, any effect of the ibuprofen may have worn off. We’d need more research to know for sure whether ibuprofen should be recommended for post-procedural pain control.
What about other types of NSAIDs?
Naproxen sodium (e.g. Aleve®), another type of NSAID, has been shown to reduce pain during IUD insertion in patients who have previously given birth. One study found a clinically meaningful reduction in pain scores with a dose of 550 mg of naproxen sodium taken 1 hour prior to IUD insertion. An older trial demonstrated that when patients took 300 mg of naproxen sodium before IUD insertion, they had reported less pain 1-2 hours after the procedure, but no change in pain during IUD insertion. Another trial is underway looking at the effectiveness of 550 mg in patients who have not given birth, and will measure pain levels both during and after IUD insertion.
What if a patient is concerned about pain during IUD insertion but did not premedicate? In this case, another type of NSAID given as an intramuscular gluteal injection may be an option: ketorolac. A recent trial gave ketorolac to patients at least 30 minutes prior to IUD insertion. For women who had not given birth, there was a reduction in pain during IUD insertion. For women who had given birth, ketorolac had no effect on pain during the insertion. But all patients who received ketorolac reported lower pain scores starting at 5 minutes after the procedure when compared to a control group. One potential drawback of ketorolac is pain caused by the injection itself: about one-fifth of study participants felt the pain of the injection was just as bad as the IUD insertion.
It’s not an NSAID, but misoprostol has also been tested as a premedication for IUD insertion. Misoprostol is a prostaglandin E1 analogue often used to help soften the cervix in pregnant women, which led researchers to wonder if it would help soften the cervix for IUD insertion and make the procedure less painful. Unfortunately, misoprostol does not reduce pain with IUD insertion—and for some women it may actually worsen pain. It can also cause greater pre-procedure cramping and other unpleasant side effects. The drawbacks of misoprostol clearly outweigh any potential benefits—we should not be using it as a premedication for IUD insertion with the intent of reducing pain.
Local anesthetics given at the time of the procedure may be another route for pain control, though their effectiveness varies depending on type and potency of anesthetic, route of administration, and amount administered. Moreover, it would not help with post-procedural cramping. For more information on this and other anesthetic options, check out the most recent Cochrane Review from 2015 on interventions for pain with IUD insertion.
At the present time, oral naproxen sodium seems to be the best option for our patients who want to take something prior to their visit, though more data will be available in the coming year regarding this recommendation. Meanwhile, you can prescribe it or tell your patients how to purchase it over-the-counter.
There’s definitely room for improvement in our clinical options for reducing the discomfort of IUD insertion. Add a comment below if you have a brilliant idea to test!