
==== Front
CMAJ
CMAJ
9711805
CMAJ : Canadian Medical Association Journal
0820-3946
1488-2329
CMA Impact Inc.

39284599
10.1503/cmaj.240120
196e1045
Practice
Five Ways to Support …
Pain management in people receiving intrauterine device insertion
Arion Kristina MD
Booth Aryne BSc
McQuillan Sarah K. MD
Department of Obstetrics and Gynecology (Arion, McQuillan), University of Calgary, Calgary, Alta.; patient partner (Booth), Calgary, Alta.
Correspondence to: Kristina Arion, kristina.arion@ahs.ca
16 9 2024
16 9 2024
196 30 E1045E1045
© 2024 CMA Impact Inc. or its licensors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
==== Body
pmcTaking a trauma-informed history helps ensure people are appropriately counselled, prepared, and selected for an in-office intrauterine device (IUD) insertion

To empower patients and decrease fear and anxiety, providers should assess for a history of trauma, allow for time to answer questions, and offer educational resources. Providers should discuss that the procedure involves some pain, which can range in intensity; review analgesic options; and emphasize that patients will be able to stop the procedure at any time.

Adequate premedication is recommended to reduce pain

Acetaminophen with a nonsteroidal anti-inflammatory drug (e.g., ibuprofen, naproxen, or ketorolac) or tramadol taken 60 minutes before insertion has been shown to effectively reduce pain.1,2 Nonsteroidal anti-inflammatory drugs minimize release of cytokines and uterine contractility associated with IUD insertion. Misoprostol has not been shown to be effective for pain reduction.1,3

Anxiety can be associated with increased pain scores

Discussing the procedure before IUD insertion and offering a support person can minimize anticipatory anxiety. Cognitive engagement using distraction methods (e.g., music, games, or deep breathing) during insertion can reduce perceived intensity of pain.4

Procedural tactics and local anesthetic can reduce discomfort

Using the smallest speculum necessary can minimize trauma and discomfort at the initial insertion. Topical lidocaine (gel or spray) applied to the cervix or vagina 5 minutes before insertion can decrease pain.2,3 A trained provider may perform an intracervical or paracervical block, which has been shown to decrease pain during tenaculum placement and IUD insertion, and improves the patient’s overall experience.2,5,6

A variety of pain management options should be offered

Patients who anticipate needing analgesia in addition to premedication and local anesthetics may be offered other options for pain management, where available. The availability of procedural sedation or nitrous oxide inhalation may be discussed, which may require referral to a gynecologist who has access to hospital-based anesthesia services.

Competing interests: Sarah McQuillan is a member of the Society of Obstetricians and Gynaecologists of Canada Gynecology Committee. No other competing interests were declared.

This article has been peer reviewed.
==== Refs
References

1 Lopez LM Bernholc A Zeng Y . Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2015;(7 ):CD007373.26222246
2 Statement on intrauterine devices, counselling and pain management. Ottawa: Society of Obstetricians and Gynecologists of Canada; 2022.
3 Anthoulakis C Iordanidou E Vatopoulou A . Pain perception during levonorgestrel-releasing intrauterine device insertion in nulliparous women: a systematic review. J Pediatr Adolesc Gynecol 2018;31 :549–556.e4.29890206
4 Rischer KM González-Roldán AM Montoya P . Distraction from pain: the role of selective attention and pain catastrophizing. Eur J Pain 2020;24 :1880–91.32677265
5 De Nadai MN Poli-Neto OB Franceschini SA . Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial. Am J Obstet Gynecol 2020;222 :245.e1–10.
6 Akers AY Steinway C Sonalkar S . Reducing pain during intrauterine device insertion: a randomized controlled trial in adolescents and young women. Obstet Gynecol 2017; 130 : 795–802.28885425
