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Hashem AT, Mahmoud M, Aly Islam B, Ibrahem Eid M, Ahmed N, Mohamed Mamdouh A, Elkomy R, Fouad Elgamel A, Hamada AAA, Khalil EM, Ashour ASA, Said Ali A, Taher A, Hasan Hussein A, Elzahaby I, Hafez Mohamed Younes M, Salah E, Mojahed EM, Talaat B, ElHodiby M, Kamal Osman N, Adel Nour D, Khamis Y, Aly Hamed Elsallamy A, Ahmed Gehad M, Kotb MMM, Gad Allah SH. Comparative efficacy of lidocaine-prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: A randomized controlled trial. Int J Gynaecol Obstet 2024; 165:634-643. [PMID: 35212402 DOI: 10.1002/ijgo.14157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/18/2021] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare efficacy of lidocaine-prilocaine (LP) cream versus misoprostol versus placebo before levonorgestrel-releasing intrauterine device (LNG-IUD) insertion. METHODS This randomized controlled trial (RCT) was conducted in a tertiary referral hospital from April 30, 2020 to March 1, 2021 on 210 parous women willing to receive LNG-IUD and delivered only by elective cesarean delivery (CD). Participants received 200 μg vaginal misoprostol or 5 ml of LP cream 5% or placebo 3 h before LNG-IUS insertion. Primary outcome was pain during LNG-IUD insertion, while secondary outcomes were pain 10 min post-procedure, ease of insertion, patient satisfaction, insertion time, and drug side effects. RESULTS Pain during LNG-IUS insertion was reduced in LP group and misoprostol group compared to placebo group (2.1 ± 1.0 vs 3.7 ± 1.6; p <0.001) and (2.3 ± 1.3 vs 3.7 ± 1.6; p <0.001), respectively. Ease of procedure and patient satisfaction were significantly higher in LP and misoprostol groups than placebo (P <0.001). Need for additional analgesia was significantly higher in placebo group than in the other two groups (P = 0.009). Adverse events were not significantly different between the three groups except vomiting and abdominal cramps, which were higher with misoprostol. CONCLUSION LP cream and 200 μg of vaginal misoprostol administration before LNG-IUD insertion in women delivered only by elective CD effectively reduced pain during insertion and 10 min post-procedure with easier insertions, high patient satisfaction, and tolerable side effects. Pain reduction with LP cream was clinically significant.
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Affiliation(s)
- Ahmed T Hashem
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mostafa Mahmoud
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Bassem Aly Islam
- Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Ibrahem Eid
- Department of Obstetrics & Gynecology, Faculty of Medicine, Mansoura University, Mansoura City, Egypt
| | - Nancy Ahmed
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ahmed Mohamed Mamdouh
- Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Elkomy
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amira Fouad Elgamel
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - A A Ali Hamada
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Eman M Khalil
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ahmed S A Ashour
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Ayman Taher
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hasan Hussein
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Iman Elzahaby
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Emad Salah
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman M Mojahed
- Department of Obstetrics &Gynecology, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Bassem Talaat
- Department of Obstetrics &Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed ElHodiby
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt
| | - Nada Kamal Osman
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dalia Adel Nour
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasser Khamis
- Department of Obstetrics &Gynecology, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ayman Aly Hamed Elsallamy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt
| | - Mahmoud Ahmed Gehad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha, Egypt
| | | | - Sherine H Gad Allah
- Department of Obstetrics &Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Rahman M, King C, Saikaly R, Sosa M, Sibaja K, Tran B, Tran S, Morello P, Yeon Seo S, Yeon Seo Y, Jacobs RJ. Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review. Cureus 2024; 16:e55785. [PMID: 38586685 PMCID: PMC10999118 DOI: 10.7759/cureus.55785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Intrauterine devices (IUDs) are considered a reliable contraceptive option for women, but they can come with side effects. There is a disconnect in standard guidelines for IUD insertion within and without the U.S. The objective of this review was to address a gap in the literature regarding official procedures for pain management during IUD implantation. This scoping review was initiated using keywords to extract relevant articles from multiple databases: U.S. National Library of Medicine National Institutes of Health (PubMed), MEDLINE (Ovid), and Excerpta Medica dataBASE (EMBASE, Ovid). Initially, 457 articles were identified and after a rigorous screening and selection process, 37 articles were chosen to be further assessed to ascertain if they met the study's inclusion criteria. Those 37 articles were further evaluated fully to check for relevancy. From that process, 19 articles were chosen for the review, and all passed quality assessment evaluations using the JB Appraisal Tools. To best address the research question, the data from the 19 articles were divided into three categories: 1) circumstantial factors, 2) non-pharmacological methods, and 3) pharmacological methods. Circumstantially, women with previous vaginal deliveries experienced the lowest pain during the procedure, and nulligravid (never pregnant) women experienced the most pain. Lower pain scores were reported by lactating women compared to non-lactating. Black women experienced the most anticipated pain compared to other races. Regarding non-pharmacological methods, different insertion techniques, tools, and the use of a cold compress were found to not affect the level of pain during IUD insertion. Lastly, it was shown that pharmacological methods such as lidocaine gel, lidocaine paracervical block, and lidocaine combined with either diclofenac or prilocaine decreased pain scores at different time stamps of the procedure. Also, oral ketorolac and a vaginal combination of misoprostol and dinoprostone helped reduce pain. Findings from this scoping review revealed a lack of uniformity across practices when performing IUD insertions, possibly due to differences in procedures across circumstantial factors, non-pharmacological methods, and pharmacological methods. More research is needed to investigate the intricacies of pain with IUD insertion. Moving forward, especially following a potential increase in the use of IUDs after the reversal of Roe v. Wade, establishing this gap may lead to a more refined standardized protocol to mitigate pain with IUD insertions.
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Affiliation(s)
- Mayisah Rahman
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Connor King
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Rosie Saikaly
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Maria Sosa
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Kristel Sibaja
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Brandon Tran
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Simon Tran
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Pamella Morello
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Se Yeon Seo
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Yi Yeon Seo
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Robin J Jacobs
- Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
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Abbas AM, Abd Ellah NH, Hosny MA, Abdellah MS, Ali MK. Self-administrated vaginal 2% lidocaine in-situ gel for pain relief during copper intrauterine device insertion in women with previous caesarean delivery only: a randomised, double-blind placebo-controlled trial. EUR J CONTRACEP REPR 2021; 26:132-138. [PMID: 33539256 DOI: 10.1080/13625187.2020.1868427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/11/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the analgesic effect of self-administered vaginal 2% lidocaine in-situ gel in pain relief during copper intrauterine device (IUD) insertion in women with previous caesarean delivery only. METHODS A Randomised, double-blind, placebo-controlled trial (Clinicaltrials.gov: NCT03166111) included reproductive-aged women who previously delivered only by caesarean section (CS) requesting Copper IUD insertion. Eligible women were recruited and randomised (1:1) to lidocaine in-situ gel vs. placebo. Each woman was supplied by a syringe filled with five ml lidocaine or placebo in-situ gel to be self-administered vaginally ten minutes before insertion. The primary outcome was the difference in pain scores during IUD placement using a 10-cm Visual Analogue Scale (VAS). RESULTS The final analysis included 216 women (n = 108 in each arm). Women in the Lidocaine in situ gel group were more likely to report statistically significant lower pain scores during vulsellum application, uterine sound placement, and during IUD placement [Mean difference (95%CI) = 2.04 (1.66-2.42), 2.62 (2.20-3.04), and 2.57 (2.12-3.01), respectively, p = 0.0001]. A significantly lower IUD insertion score indicating easier insertion was reported in the lidocaine group (p = 0.004). Similarly, the duration of IUD insertion was significantly shorter in the lidocaine group (p = 0.008). There was a higher level of satisfaction in the lidocaine group (5.92 vs. 3.34) in the placebo group (p = 0.0001). CONCLUSIONS Self-administered vaginal lidocaine in-situ gel 10 min before copper IUD insertion is effective in pain reduction in women with previous caesarean delivery only.
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Affiliation(s)
- Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Noura H Abd Ellah
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Maryt A Hosny
- Department of Obstetrics and Gynecology, Obstetrics, Gynecology and Pediatrics Hospital, Assiut, Egypt
| | - Mohamed S Abdellah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohammed K Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Abu-Zaid A, Alshahrani MS, Albezrah NA, Miski NT, Abuzaid M, Aboudi SA, Baredwan A, Almadhi N, Baradwan A, Alomar O, Salem H, A Al-Badawi I, Baradwan S. Vaginal dinoprostone versus placebo for pain relief during intrauterine device insertion: a systematic review and meta-analysis of randomised controlled trials. EUR J CONTRACEP REPR 2021; 26:357-366. [PMID: 33691549 DOI: 10.1080/13625187.2021.1891411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To systematically and meta-analytically investigate the efficacy and safety of vaginal dinoprostone versus placebo in pain relief during intrauterine device (IUD) insertion. METHODS PubMed, Scopus, Web of Science, and Cochrane Library were screened till 1 October 2020. Only randomised placebo-controlled studies were included and assessed for risk of bias. Main outcomes included IUD insertion related pain, patient satisfaction, provider ease of IUD insertion, and side effects. Pooled outcomes were summarised as standardised mean difference (SMD), weighted mean difference (WMD), or risk ratio (RR) with 95% confidence interval (95% CI). RESULTS Five studies were included, comprising 862 patients; equally 431 patients received vaginal dinoprostone and placebo. All studies showed an overall low risk of bias. When compared to placebo, dinoprostone significantly correlated with decreased pain at tenaculum placement (SMD = -0.79, 95% CI [-1.43, -0.16], p = 0.01), decreased pain at uterine sounding (SMD = -0.88, 95% CI [-1.54, -0.22], p = 0.009), decreased pain at IUD insertion (SMD = -1.18, 95% CI [-1.74, -0.61], p < 0.001), decreased need for additional analgesia (RR = 0.34, 95% CI [0.22, 0.53], p < 0.001), increased patient satisfaction (SMD = 1.41, 95% CI [0.62, 2.20], p < 0.001), and increased provider ease of IUD insertion (SMD = -1.17, 95% CI [-1.62, -0.73], p < 0.001). Fever was statistically significantly higher in dinoprostone versus placebo group (RR = 3.73, 95% CI [1.47, 9.44], p = 0.006). All other side effects-including nausea, vomiting, shivering, diarrhoea, abdominal cramps, vasovagal attack, uterine perforation, and postprocedural bleeding-did not substantially differ between both groups. CONCLUSIONS This first ever meta-analysis advocates that dinoprostone compared with placebo is safe, effective, and yields favourable analgesic outcomes during IUD insertion.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Majed S Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Nisreen A Albezrah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Taif University, Taif, Saudi Arabia
| | - Najlaa T Miski
- Department of Obstetrics and Gynecology, Faculty of Medicine in Rabigh, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Mohammed Abuzaid
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saud A Aboudi
- Department of Obstetrics and Gynecology, College of Medicine, Prince Sattam Bin Abdulaziz University, Saudi Arabia
| | - Ahlam Baredwan
- College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nada Almadhi
- Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Afnan Baradwan
- Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Osama Alomar
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hany Salem
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ismail A Al-Badawi
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Saeed Baradwan
- Department of Obstetrics and Gynecology, HealthPlus Fertility and Women's Health Center, Jeddah, Saudi Arabia
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Samy A, Abdelhakim AM, Latif D, Hamza M, Osman OM, Metwally AA. Benefits of vaginal dinoprostone administration prior to levonorgestrel-releasing intrauterine system insertion in women delivered only by elective cesarean section: a randomized double-blinded clinical trial. Arch Gynecol Obstet 2020; 301:1463-1471. [PMID: 32314015 DOI: 10.1007/s00404-020-05543-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 04/06/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed at investigating the efficacy and safety of dinoprostone 3 mg vaginally prior to levonorgestrel-releasing intrauterine system (LNG-IUS) insertion in women undergoing elective cesarean delivery (CD). METHODS We conducted a prospective, randomized, double-blinded, placebo-controlled trial at family planning clinic of Cairo University hospitals from August 2019 to January 2020. We included 200 women aged ≥ 18 years who previously delivered by elective CD willing to receive LNG-IUS. Women were randomly assigned with a 1:1 allocation ratio to receive 3 mg vaginal dinoprostone or placebo tablets two hours before LNG-IUS insertion. Our main outcomes were patient-reported pain during insertion and 30 min post-procedure, ease of insertion, satisfaction, duration of insertion, and different side effects. RESULTS Patient-perceived pain during LNG-IUS insertion was significantly reduced in dinoprostone compared to placebo (4.1 ± 1.7 vs 6.4 ± 1.3; p < 0.001). Dinoprostone reduced pain scores 30 min post-procedure compared to placebo, but the difference was not statistically significant (3.5 ± 1.1 vs 3.7 ± 1.6; p = 0.25). Satisfaction score was higher in dinoprostone compared to placebo (7.9 ± 1.0 vs 5.9 ± 0.8; p < 0.001). The insertion was significantly easier and shorter in dinoprostone than placebo (3.9 ± 1.1 vs 5.9 ± 1.1; p < 0.001) and (5.6 ± 0.9 vs 7.2 ± 0.8; p < 0.001), respectively. Adverse events were not significantly different between both groups. CONCLUSION Dinoprostone administration 2 h before LNG-IUS insertion in women delivered by elective CD effectively reduced pain during insertion and 30 min post-procedure. Women received dinoprostone had easier and shorter insertion and were more satisfied with tolerable side effects.
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Affiliation(s)
- Ahmed Samy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Dina Latif
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Hamza
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Omneya M Osman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed A Metwally
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Abbas AM, Samy A, El-Naser Abd El-Gaber Ali A, Khodry MM, Ahmed MA, El-Rasheedy MI, Abdallah KM, Mohammed AE, Abdelbaky WH, Raslan OK, Badawy MA, Elktatny HH. Medications for pain relief in outpatient endometrial sampling or biopsy: a systematic review and network meta-analysis. Fertil Steril 2019; 112:140-148.e12. [DOI: 10.1016/j.fertnstert.2019.03.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/28/2022]
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7
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Conti JA, Lerma K, Schneyer RJ, Hastings CV, Blumenthal PD, Shaw KA. Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial. Am J Obstet Gynecol 2019; 220:177.e1-177.e7. [PMID: 30444982 DOI: 10.1016/j.ajog.2018.11.1085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/02/2018] [Accepted: 11/07/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control. OBJECTIVE(S) The objective of the study was to assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared with placebo. STUDY DESIGN We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15 minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (0 being no pain and 100 being worst pain imaginable). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a postprocedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed because of the nonnormal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of intrauterine device insertion pain were assessed using a multiple linear regression. RESULTS In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (P = .13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (P = .09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 [0-81] mm vs 11 [0-80] mm, respectively; P = .046). Anticipated pain and menstrual pain were both predictors of pain with intrauterine device insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent of participants (n = 194) stated they would be willing to wait before intrauterine device placement for a potential analgesic effect. CONCLUSION Self-administered lidocaine gel at least 15 minutes before intrauterine device insertion does not appear to reduce pain compared with placebo but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.
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Affiliation(s)
- Jennifer A Conti
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA
| | - Klaira Lerma
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA.
| | - Rebecca J Schneyer
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA
| | - Charlotte V Hastings
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA
| | - Paul D Blumenthal
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA
| | - Kate A Shaw
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, CA
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Abdellah MS, Abbas AM, Hegazy AM, El-Nashar IM. Vaginal misoprostol prior to intrauterine device insertion in women delivered only by elective cesarean section: a randomized double-blind clinical trial. Contraception 2017; 95:538-543. [DOI: 10.1016/j.contraception.2017.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 01/02/2017] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
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9
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Fouda UM, Salah Eldin NM, Elsetohy KA, Tolba HA, Shaban MM, Sobh SM. Diclofenac plus lidocaine gel for pain relief during intrauterine device insertion. A randomized, double-blinded, placebo-controlled study. Contraception 2016; 93:513-8. [DOI: 10.1016/j.contraception.2016.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
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10
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Lopez LM, Bernholc A, Zeng Y, Allen RH, Bartz D, O'Brien PA, Hubacher D. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2015. [PMID: 26222246 PMCID: PMC9580985 DOI: 10.1002/14651858.cd007373.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fear of pain during insertion of intrauterine contraception (IUC) is a barrier to use of this method. IUC includes copper-containing intrauterine devices and levonorgestrel-releasing intrauterine systems. Interventions for pain control during IUC insertion include non-steroidal anti-inflammatory drugs (NSAIDs), local cervical anesthetics, and cervical ripening agents such as misoprostol. OBJECTIVES To review randomized controlled trials (RCTs) of interventions for reducing IUC insertion-related pain SEARCH METHODS We searched for trials in CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov, and ICTRP. The most recent search was 22 June 2015. We examined reference lists of pertinent articles. For the initial review, we wrote to investigators to find other published or unpublished trials. SELECTION CRITERIA We included RCTs that evaluated an intervention for preventing IUC insertion-related pain. The comparison could have been a placebo, no intervention, or another active intervention. The primary outcomes were self-reported pain at tenaculum placement, during IUC insertion, and after IUC insertion (up to six hours). DATA COLLECTION AND ANALYSIS Two authors extracted data from eligible trials. For dichotomous variables, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. In meta-analysis of trials with different measurement scales, we used the standardized mean difference (SMD). MAIN RESULTS We included 33 trials with 5710 participants total; 29 were published from 2010 to 2015. Studies examined lidocaine, misoprostol, NSAIDs, and other interventions. Here we synthesize results from trials with sufficient outcome data and moderate- or high-quality evidence.For lidocaine, meta-analysis showed topical 2% gel had no effect on pain at tenaculum placement (two trials) or on pain during IUC insertion (three trials). Other formulations were effective compared with placebo in individual trials. Mean score for IUC-insertion pain was lower with lidocaine and prilocaine cream (MD -1.96, 95% CI -3.00 to -0.92). Among nulliparous women, topical 4% formulation showed lower scores for IUC-insertion pain assessed within 10 minutes (MD -15.90, 95% CI -22.77 to -9.03) and at 30 minutes later (MD -11.10, 95% CI -19.05 to -3.15). Among parous women, IUC-insertion pain was lower with 10% spray (median 1.00 versus 3.00). Compared with no intervention, pain at tenaculum placement was lower with 1% paracervical block (median 12 versus 28).For misoprostol, meta-analysis showed a higher mean score for IUC insertion compared with placebo (SMD 0.27, 95% CI 0.07 to 0.46; four studies). In meta-analysis, cramping was more likely with misoprostol (OR 2.64, 95% CI 1.46 to 4.76; four studies). A trial with nulliparous women found a higher score for IUC-insertion pain with misoprostol (median 46 versus 34). Pain before leaving the clinic was higher for misoprostol in two trials with nulliparous women (MD 7.60, 95% CI 6.48 to 8.72; medians 35.5 versus 20.5). In one trial with nulliparous women, moderate or severe pain at IUC insertion was less likely with misoprostol (OR 0.30, 95% CI 0.16 to 0.55). In the same trial, the misoprostol group was more likely to rate the experience favorably. Within two trials of misoprostol plus diclofenac, shivering, headache, or abdominal pain were more likely with misoprostol. Participants had no vaginal delivery. One trial showed the misoprostol group less likely to choose or recommend the treatment.Among multiparous women, mean score for IUC-insertion pain was lower for tramadol 50 mg versus naproxen 550 mg (MD -0.63, 95% CI -0.94 to -0.32) and for naproxen versus placebo (MD -1.94, 95% CI -2.35 to -1.53). The naproxen group was less likely than the placebo group to report the insertion experience as unpleasant and not want the medication in the future. An older trial showed repeated doses of naproxen 300 mg led to lower pain scores at one hour (MD -1.04, 95% CI -1.67 to -0.41) and two hours (MD -0.98, 95% CI -1.64 to -0.32) after insertion. Most women were nulliparous and also had lidocaine paracervical block. AUTHORS' CONCLUSIONS Nearly all trials used modern IUC. Most effectiveness evidence was of moderate quality, having come from single trials. 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. The ineffective interventions do not need further research.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Alissa Bernholc
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Yanwu Zeng
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Rebecca H Allen
- Women and Infants HospitalDepartment of Obstetrics and Gynecology101 Dudley StreetProvidenceRhode IslandUSA02905
| | - Deborah Bartz
- Brigham and Women's HospitalDepartment of Obstetrics, Gynecology, and Reproductive BiologyBostonMassachusettsUSA
| | - Paul A O'Brien
- Central London Community HealthcareContraception and Sexual HealthRaymede Clinic, Exmoor StLondonUKW10 6DZ
| | - David Hubacher
- FHI 360Contraceptive Technology Innovation Dept359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
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