Pain Management for IUD Insertion: A Review of the Clinical Evidence on Pharmacologic and Nonpharmacologic Options

ABSTRACT Importance Intrauterine devices (IUDs) are a safe and highly effective contraceptive method, but pain poses a significant barrier to IUD uptake and satisfaction. Data on existing modalities for insertional pain management are limited, and there remains no consensus on standard of care. Objective To summarize the existing literature on pharmacologic and nonpharmacologic pain management options available for IUD insertion pain. Evidence Acquisition Articles published since 1995 were identified via literature search in PubMed and Ovid; relevant articles were reviewed. Results IUD insertion pain management interventions with the strongest evidence to date include cervical block, 10% lidocaine spray, and 5% lidocaine-prilocaine cream. Some low-risk interventions such as ultrasound guidance, music, and the “cough” method have less robust evidence but may be warranted for patients at risk for severe pain, including nulliparous patients, patients who have experienced dysmenorrhea or violence, and patients with high reported anticipated pain. More research is necessary to discern the effectiveness of certain nonsteroidal anti-inflammatory drugs, dinoprostone, transcutaneous electrical nerve stimulation, and acupuncture. Conclusions and Relevance Despite common practice to offer ibuprofen prior to IUD insertion, topical and injectable lidocaine formulations are more effective at reducing pain. Further research is necessary to strengthen recommendations, elucidate the efficacy of other adjunctive options, and optimize clinic workflow, but these findings suggest that lidocaine-based analgesics may represent the future of IUD insertion pain management. Providers can utilize this summary to offer individualized, evidence-based pain management options for patients seeking an IUD. Target Audience Obstetricians and gynecologists, family physicians, nurse practitioners, physician’s assistants. CME Learning Objectives After reading this article, the provider will be better able to describe the range of options that have been studied for IUD insertion pain management; discuss the strength of the current evidence available for each pain management modality; and identify the specific patient populations that may require special attention to pain relief.