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Schneyer R, Lerma K, Conti J, Shaw K. Dysmenorrhoea as a risk factor for pain with intrauterine device insertion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e31-e37. [PMID: 33789955 DOI: 10.1136/bmjsrh-2020-200918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/21/2021] [Accepted: 03/07/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Understanding predictors of pain with gynaecological procedures may facilitate individualised counselling and pain management. We aimed to study the effect of dysmenorrhoea on intrauterine device (IUD) insertion pain. METHODS This was a planned secondary analysis of a randomised trial evaluating self-administered lidocaine gel versus placebo for IUD insertion pain. We included those participants who reported menses in the past 3 months. We assessed dysmenorrhoea (in the past 3 months) and procedural pain using a 100 mm visual analogue scale (VAS). We categorised dysmenorrhoea as none/mild (<40 mm), moderate (40-69 mm) or severe (≥70 mm). We assessed participant pain scores at speculum insertion, tenaculum placement, IUD insertion, and overall. We compared median procedural pain scores by dysmenorrhoea group with three-way and post hoc pairwise analyses. RESULTS We analysed 188 participants. Demographic characteristics were similar among the three dysmenorrhoea groups. Pairwise comparisons revealed higher median procedural pain scores in the severe dysmenorrhoea group compared with the none/mild dysmenorrhoea group at speculum insertion (25 mm vs 8 mm; p=0.007), tenaculum placement (51 mm vs 31 mm; p=0.04) and IUD insertion (74 mm vs 61 mm; p=0.04). Overall pain did not differ among the three groups (p=0.32). CONCLUSIONS Patients with severe dysmenorrhoea experienced increased pain with all aspects of IUD insertion, including speculum and tenaculum placement, compared with those with only mild or no dysmenorrhoea. Clinicians may consider this finding when providing individualised counselling and pain management for patients undergoing IUD insertion and other gynaecological procedures. Larger studies are needed to validate the effect of dysmenorrhoea severity on pain throughout IUD insertion.
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Affiliation(s)
- Rebecca Schneyer
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, California, USA
| | - Klaira Lerma
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer Conti
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, California, USA
| | - Kate Shaw
- Department of Obstetrics and Gynecology, Division of Family Planning Services and Research, Stanford University School of Medicine, Stanford, California, USA
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Cimsir MT, Yildiz MS. Could the Valsalva manoeuvre be an alternative to the tenaculum for intrauterine device insertion? EUR J CONTRACEP REPR 2021; 26:503-506. [PMID: 34114522 DOI: 10.1080/13625187.2021.1934442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study investigated whether the Valsalva manoeuvre (VM) could be an alternative to use of the tenaculum for intrauterine device (IUD) insertion. The aims were to establish whether VM could provide good patient comfort and enable the insertion to be performed successfully with adequate pain control in cases where the cervix could not be passed spontaneously. METHODS Women who attended the outpatient clinic of Alanya Education and Research Hospital between November 2017 and December 2020 for IUD insertion were randomly assigned to the VM (n = 52) or tenaculum (n = 55) group. Insertion in the latter group was carried out by grasping the cervix with a single-toothed tenaculum. In the VM group, no tenaculum was used to grasp the cervix; instead, the woman was asked to perform VM during insertion. RESULTS IUD insertion success rates were similar between the groups. Procedural anxiety scores were slightly higher in the tenaculum group. Pain scores measured during the procedure were significantly higher in the tenaculum group compared with the VM group. Severe pain was reported by 58.2% of women in the tenaculum group, whereas 57.7% of women in the VM group reported no pain. CONCLUSION In cases where an IUD cannot be passed through the cervical canal spontaneously, the procedure should be attempted using VM before using a tenaculum. The use of VM may lead to lower pain and anxiety levels as well as increased patient comfort.
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Affiliation(s)
- Meral Tugba Cimsir
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Alaaddin Keykubat University, Alanya, Turkey
| | - Muhammet Serhat Yildiz
- Department of Obstetrics and Gynaecology, Alanya Education and Research Hospital, Alanya, Turkey
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Lambert T, Truong T, Gray B. Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial. BMJ SEXUAL & REPRODUCTIVE HEALTH 2020; 46:126-131. [PMID: 31666302 DOI: 10.1136/bmjsrh-2019-200376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION 'Slow' and 'cough' techniques for tenaculum placement are commonly used. This trial sought to determine if one method of placement resulted in less pain for patients. METHODS This study was a randomised controlled trial of patients presenting for intrauterine device placement. Sixty-six participants were randomised to tenaculum placement via the 'slow' method (closure of tenaculum over a 5-s period) versus the 'cough' method (closure of tenaculum at the time of patient's cough). The primary outcome was pain at time of tenaculum placement measured on a 100 mm visual analogue scale. The study was powered to detect a 16 mm difference in pain. Secondary outcomes included pain with insertion and provider satisfaction with tenaculum grasp. Pain scores were analysed with Wilcoxon rank-sum test. RESULTS Sixty-six women were enrolled, 33 randomised to each group. Demographics were similar in each group. The primary outcome of pain with tenaculum placement showed a median pain score of 44 (IQR=21, 63) with slow placement and 32 (IQR=19, 54) with cough placement. There was no significant difference in pain scores between methods of tenaculum placement (p=0.16). There was no significant difference in overall pain scores (p=0.12). Provider satisfaction was not associated with one method of placement (p=1). Pre-procedure anxiety was significantly associated with pain at the time of tenaculum placement (p=0.01). CONCLUSIONS Neither the slow method nor cough method is superior for pain reduction or provider satisfaction. Pain with tenaculum use is significantly associated with anxiety. CLINICAL TRIAL REGISTRATION NCT02969421.
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Affiliation(s)
- Tashima Lambert
- Obstetrics and Gynecology, Unity Health Care, Washington, District of Columbia, USA
| | - Tracy Truong
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Beverly Gray
- Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina, USA
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Beckert V, Aqua K, Bechtel C, Cornago S, Kallner HK, Schulze A, Parashar P, Waddington A, Donders G. Insertion experience of women and health care professionals in the Kyleena ® Satisfaction Study. EUR J CONTRACEP REPR 2020; 25:182-189. [PMID: 32223466 DOI: 10.1080/13625187.2020.1736547] [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] [Indexed: 10/24/2022]
Abstract
Purpose: The Kyleena® Satisfaction Study (KYSS) is a prospective, observational study conducted to assess satisfaction with LNG-IUS 12 (Kyleena®) in clinical practice and aims to provide adequate information for counselling women on what to expect regarding insertion and satisfaction.Materials and methods: Women deciding to use LNG-IUS 12 during routine counselling were informed of the study and provided informed consent. A baseline analysis was conducted to evaluate demographics, ease of insertion assessed by investigators, pain at insertion rated by women, additional interventions for insertion, and adverse events.Results: 1,110 women (536 parous, 574 nulliparous) had an insertion attempt and were included. Insertion was rated as easy in 494 (92.2%) parous and 516 (89.9%) nulliparous women. Pain was assessed as none or mild by 475 (88.6%) parous and 387 (67.4%) nulliparous women. Additional interventions were not required for most insertions (705; 63.6%). Overall 111 (10.0%) women reported adverse events at the time of baseline analysis.Conclusions: This analysis demonstrates that LNG-IUS 12 insertion is easy and associated with no or mild pain in most women. Additional interventions for insertion are not required in most cases. After 3 months, the number of adverse events is low.Implications: The present baseline analysis of the Kyleena® Satisfaction Study (KYSS) demonstrates that most women rate insertion pain of LNG-IUS 12 as none or mild and clinicians consider insertion easy in the majority of cases.
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Affiliation(s)
| | - Keith Aqua
- Virtus Research Consultants, Wellington, Florida, USA
| | | | | | - Helena Kopp Kallner
- Dept of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Sweden
| | | | | | | | - Gilbert Donders
- Femicare VZW, Tienen, Belgium.,University Hospital Antwerp, Antwerp, Belgium
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Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr 2020; 174:186-194. [PMID: 31886837 DOI: 10.1001/jamapediatrics.2019.5040] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care. OBSERVATIONS The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders. CONCLUSIONS AND RELEVANCE Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.
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Affiliation(s)
- Claudia Borzutzky
- Keck School of Medicine of University of Southern California, Los Angeles.,Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Julie Jaffray
- Keck School of Medicine of University of Southern California, Los Angeles.,Children's Center for Cancer and Blood Diseases, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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6
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Improving information on intrauterine contraception: providing advice in primary care. Br J Gen Pract 2019; 69:98-99. [PMID: 30705022 DOI: 10.3399/bjgp19x701237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 10/08/2018] [Indexed: 10/31/2022] Open
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Effect of oral ketoprofen on pain perception during copper IUD insertion among parous women: A randomized double-blind controlled trial. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2018.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Turok DK, Simmons RG, Cappiello B, Gawron LM, Saviers-Steiger J, Sanders JN. Use of a novel suction cervical retractor for intrauterine device insertion: a pilot feasibility trial. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 45:bmjsrh-2017-200031. [PMID: 30396906 DOI: 10.1136/bmjsrh-2017-200031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The Bioceptive suction cervical retractor (SCR) is a novel device that can replace the standard single-tooth tenaculum to place traction on the cervix. A feasibility trial was conducted on the device for intrauterine device (IUD) placement. METHODS Our three-stage feasibility process began with Stage 1, where the device was tested on in-vitro and ex-vivo samples. In Stage 2, 10 women received their IUD using the device. In Stage 3, a feasibility trial, we randomly assigned 25 consenting women to receive their IUD using either the Bioceptive SCR or the standard single-tooth tenaculum. In Stages 2 and 3, we collected pain scores using an electronically adapted 100-point visual analogue scale (VAS) at eight timepoints during and after the insertion procedure, as well as satisfaction and acceptability measures. The primary outcome was the pain score after attaching the SCR or tenaculum (VAS 3). Wilcoxon rank sum tests compared pain scores between devices. RESULTS In Stage 2, pain scores with the SCR were lower than historical controls with the single-tooth tenaculum. In Stage 3, the median VAS 3 pain scores were 31 and 57 for the intervention and control groups, respectively. The differences in pain scores were not statistically significant but the trend was to lower pain scores with the intervention. Reported patient satisfaction with the SCR device was 80% in Stage 2% and 90% in Stage 3. CONCLUSIONS The Bioceptive SCR has potential as an atraumatic alternative to standard cervical retractor devices for gynaecological procedures. These findings can guide point estimates for future clinical studies. TRIAL REGISTRATION NCT02283463.
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Affiliation(s)
- David K Turok
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Rebecca G Simmons
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Benjamin Cappiello
- Bioceptive, Inc, New Orleans BioInnovation Center, New Orleans, Louisiana, USA
| | - Lori M Gawron
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jane Saviers-Steiger
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah Hospital, Salt Lake City, Utah, USA
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Foran T, Butcher BE, Kovacs G, Bateson D, O’Connor V. Safety of insertion of the copper IUD and LNG-IUS in nulliparous women: a systematic review. EUR J CONTRACEP REPR 2018; 23:379-386. [DOI: 10.1080/13625187.2018.1526898] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Therese Foran
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- Royal Hospital for Women, Sydney, NSW, Australia
| | - Belinda E. Butcher
- Biostatistics and Medical Writing, WriteSource Medical Pty Ltd, Sydney, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Gab Kovacs
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- Institute of Obstetrics and Gynaecology, Epworth HealthCare, Melbourne, VIC, Australia
| | - Deborah Bateson
- Family Planning NSW, Sydney, NSW, Australia
- Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW, Australia
| | - Vivienne O’Connor
- Mater Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Croan L, Craig A, Scott L, Cameron ST, Lakha F. Increasing access to contraceptive implants in the postnatal period via a home insertion service by community midwives. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:61-64. [PMID: 29117946 DOI: 10.1136/jfprhc-2017-101749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | - Alison Craig
- Department of Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
| | - Lesley Scott
- Craigmillar Medical Group, NHS Lothian, Edinburgh, UK
| | - Sharon T Cameron
- Department of Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
- Department of Obstetrics and Gynaecology, NHS Lothian Sexual and Reproductive Health, Edinburgh, UK
| | - Fatim Lakha
- NHS Lothian Directorate of Public Health and Health Policy, Edinburgh, UK
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Allen RH. Pain and pain relief with intrauterine device insertion. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2017; 42:239-240. [PMID: 29175840 DOI: 10.1136/jfprhc-2016-101572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/01/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Rebecca H Allen
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Duro Gómez J, Guisado López R, Partera Tejero I, Velasco Sánchez E, Arjona Berral J. ¿Es necesario el histerómetro y las pinzas de Pozzi para la inserción del dispositivo intrauterino? CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2017. [DOI: 10.1016/j.gine.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bahamondes L, Monteiro I. Comments on manuscript: vaginal misoprostol prior to intrauterine device insertion in women delivered only by elective cesarean section: a randomized double-blind clinical trial. Contraception 2017; 95:434-435. [PMID: 28189667 DOI: 10.1016/j.contraception.2017.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/21/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil.
| | - Ilza Monteiro
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
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McCarthy C. Intrauterine contraception insertion pain: nursing interventions to improve patient experience. J Clin Nurs 2017; 27:9-21. [PMID: 28177530 DOI: 10.1111/jocn.13751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 01/09/2023]
Abstract
AIMS AND OBJECTIVES To examine factors which contribute to the individual's experience of pain in relation to intrauterine contraception insertion and determine evidence-based nursing strategies to best assess and manage this pain. BACKGROUND Nurses are increasingly involved in consultations regarding intrauterine contraception. However, concerns regarding painful or difficult insertion may inhibit uptake and discourage nurses from promoting or inserting intrauterine contraception. DESIGN Integrative review. METHODS Database searches of CINAHL, PubMed, Wiley Online Library and the Cochrane Collaboration for relevant literature. Eight papers met the inclusion criteria and were analysed using an integrative review process. RESULTS Physical causes and pharmacological interventions for insertion pain have been thoroughly investigated. Absence of previous vaginal delivery and anxiety may increase the likelihood of procedural pain. The literature fails to conclusively determine any universally effective prophylactic analgesia. Cervical anaesthesia may be beneficial in some cases and oral analgesia may relieve postprocedural pain. Distraction in the form of conversation, music or television can be effective in reducing anxiety. CONCLUSIONS A combination of physical, psychological and environmental factors contribute to the individual's pain experience. Nurses have the potential to make a significant impact on pain outcomes by demonstrating clinical expertise and creating a trustful environment. Giving reliable information, acknowledging the significance of anxiety and providing reassurance and distraction are effective pain reducing strategies. Research into nonpharmacological approaches is warranted, especially those which reduce anxiety. RELEVANCE TO CLINICAL PRACTICE Increasing uptake of long-acting reversible contraception is a public health goal. Providing effective pain management strategies to improve patient experience may encourage more nurses to recommend, or enhance their scope of practice to include, intrauterine contraception insertion.
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Affiliation(s)
- Carmel McCarthy
- Cripps Health Centre, University of Nottingham Health Service, Nottingham, UK
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15
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Speedie JMM, Mansour D, Landy R, Clement KM. A randomised trial comparing pain and ease of use of two different stabilising forceps for insertion of intrauterine contraception. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2016; 42:241-246. [DOI: 10.1136/jfprhc-2016-101446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 06/27/2016] [Accepted: 07/05/2016] [Indexed: 11/04/2022]
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Badir S, Mazza E, Bajka M. Objective Assessment of Cervical Stiffness after Administration of Misoprostol for Intrauterine Contraceptive Insertion. Ultrasound Int Open 2016; 2:E63-7. [PMID: 27689173 PMCID: PMC5027756 DOI: 10.1055/s-0042-106393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/22/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The goal of this study was to objectively quantify cervical stiffness in misoprostol users prior to IUC insertion and at follow-up consultation to evaluate the feasibility of assessing cervical stiffness and to study the influence of misoprostol on cervical softening. MATERIALS AND METHODS This was a cross-sectional study that evaluated 40 women who wished to use the LNG IUS. These women were evaluated immediately before LNG IUS insertion and 6 weeks later at follow-up consultation. Participants received 200 μg of misoprostol combined with 75 mg of diclofenac in a single tablet orally (Arthrotec forte 75/200(®), Pfizer, USA) 6-12 h prior to insertion in "off label" use. On both occasions, cervical stiffness was determined using a novel medical device based on the aspiration technique. The Wilcoxon rank-sum and the Wilcoxon signed-rank test were applied to compare cervical stiffness assessments at insertion of the IUD and at follow-up. RESULTS For the first time, cervical stiffness was quantitatively assessed in misoprostol users prior to IUD insertion, proving that the aspiration technique enables detection of pharmacologically induced cervical changes, and also that misoprostol has a detectable softening effect on cervical tissue. CONCLUSION The clinical value of the detected cervical softening after misoprostol administration remains unclear. Aspiration measurements could be helpful in searching for the ideal candidate, the appropriate route, dosage and interval of misoprostol intake prior to IUC insertion.
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Affiliation(s)
- S. Badir
- Swiss Federal Institute of Technology Zurich, Institute of Mechanical Systems, Zurich, Switzerland
| | - E. Mazza
- Swiss Federal Institute of Technology Zurich, Institute of Mechanical Systems, Zurich, Switzerland
- EMPA, Swiss Federal Laboratories for Materials Testing and Research, Dübendorf, Switzerland
| | - M. Bajka
- University Hospital Zurich, OB/GYN, Zurich, Switzerland
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Akintomide H, Doshi J, Power J, Wilkinson C. Television: a way of distracting patients during sexual and reproductive healthcare procedures. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2016; 42:220-1. [PMID: 26817931 DOI: 10.1136/jfprhc-2015-101289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/30/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Hannat Akintomide
- Specialty Doctor, Department of Sexual and Reproductive Health, CNWL Camden Provider Services, Margaret Pyke Centre, London, UK
| | - Jagruti Doshi
- Specialty Doctor, Sexual and Reproductive Health, CNWL Camden Provider Services, Margaret Pyke Centre, London, UK
| | - Jo Power
- Consultant, Department of Sexual and Reproductive Health, CNWL Camden Provider Services, Margaret Pyke Centre, London, UK
| | - Chris Wilkinson
- Consultant, Sexual and Reproductive Health, CNWL Camden Provider Services, Margaret Pyke Centre, London, UK
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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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Bahamondes MV, Espejo-Arce X, Bahamondes L. Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion failure: a double blind RCT. Hum Reprod 2015; 30:1861-6. [PMID: 26040478 DOI: 10.1093/humrep/dev137] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/20/2015] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION Is pretreatment with misoprostol useful in insertion of intrauterine contraceptives (IUCs) after insertion failure at the first attempt? SUMMARY ANSWER Pretreatment with intravaginal administration of 200 mcg of misoprostol after IUC insertion failure 10 and 4 h before the second attempt of IUC placement was significantly better than placebo at facilitating the insertion of an IUC. WHAT IS KNOWN ALREADY One of the reasons for low use of IUCs is the concept that insertion is difficult. Misoprostol was used in several randomized clinical trials (RCT) before IUC insertion to facilitate the insertion. In general, the results showed no significant differences when compared with placebo. However, most previous studies have been carried out among unselected women whereas the present study is among women with previous insertion failure. STUDY DESIGN, SIZE, DURATION This was a double blind RCT conducted between February 2013 and October 2014. Participants were 104 women who requested an insertion of an IUC and the insertion failed at the first attempt. After insertion failure, the women received a sealed envelope with misoprostol or placebo. The randomization system (1: 1) in one block size was computer-generated. PARTICIPANTS/MATERIALS, SETTING, METHODS The study was conducted at a tertiary care centre. The women were instructed to insert vaginally one tablet of misoprostol 200 µg (Prostokos, Hebron, Cariacica, PE, Brazil) or placebo 10 and 4 h before the woman returned to the clinic for a new insertion attempt. The outcomes were successful IUC insertion and the use of a cervical dilator immediately prior to the insertion procedure. MAIN RESULTS AND THE ROLE OF CHANCE A total of 2639 women requested the insertion of an IUC during the study period. The IUC was inserted at the first attempt in 2535 women (96%) and 104 women in whom we were unable to insert the device were eligible to participate in the RCT. Four women declined and 100 women were randomized (55 for the misoprostol group and 45 for the placebo group). From the 100 participating women, the levonorgestrel-releasing intrauterine system (LNG-IUS) was chosen by 55 and 37 women and the TCu380A intrauterine device (Cu-IUD) was chosen by none and 8 women in the misoprostol and placebo group, respectively. Seven and three women allocated to misoprostol and placebo, respectively, never returned to the clinic after randomization. We placed the IUC in 42 (87.5%) out of the 48 women and in 26 (61.9%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.0066). Regarding the Evaluable Population the relative risk (RR) of successful insertions was 1.41 (95% confidence interval (CI) for absolute difference (8.2, 43.0), P = 0.0066); in the Intent-to-Treat Population the RR (95% CI) was 1.32 (0.3, 36.9). Multiple regression analysis showed that the significant variables associated with the insertion failure were the number of Caesarean section ≥1 (P = 0.020) and the use of placebo (P = 0.026). Dilators were used in 21 (43.7%) out of the 48 and 21 (50%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.804). LIMITATIONS, REASONS FOR CAUTION The limitations were that the majority of the women chose the LNG-IUS, and consequently the data for the Cu-IUD were limited, and there was a small number of nulligravidas. WIDER IMPLICATIONS OF THE FINDINGS The results show that IUC insertion difficulties and failures are not common. Pretreatment with intravaginal misoprostol facilitated IUC insertion after failure of insertion at the first attempt, and insertion failure was associated with number of Caesarean sections. STUDY FUNDING/COMPETING INTERESTS This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/10085-0, and from the National Research Council (CNPq), grant #573747/2008-3. All the TCu380A IUDs were donated by Injeflex, São Paulo, Brazil, and all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations were provided in the form of unrestricted grants. The authors declare that there are no conflicts of interest associated with this study. TRIAL REGISTRATION NUMBER ClinicalTrial.gov NCT01754649.
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Affiliation(s)
- M Valeria Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynaecology, School of Medical Sciences and National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Ximena Espejo-Arce
- Family Planning Clinic, Department of Obstetrics and Gynaecology, School of Medical Sciences and National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynaecology, School of Medical Sciences and National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
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Aksoy H, Aksoy Ü, Ozyurt S, Açmaz G, Babayigit M. Lidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: a double-blind randomised controlled trial. THE JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2015; 42:83-7. [PMID: 25759418 DOI: 10.1136/jfprhc-2014-100917] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 01/23/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Fear of pain during intrauterine device (IUD) insertion can be a barrier to widespread use of this safe and highly effective contraceptive method. Our objective was to determine the effectiveness of topical 10% lidocaine spray for pain control during IUD insertion. METHODS A total of 200 subjects with the request for IUD insertion were included in the study. The patients were randomly divided into two groups: lidocaine spray (n=100) and placebo (n=100). The pain experienced during the procedure was measured immediately after insertion by a standard Visual Analogue Scale (VAS) administered by a separate researcher with maintenance of allocation concealment. RESULTS The mean pain score during the procedure was 1.01±1.20 in the lidocaine spray group and 3.23±1.60 in the placebo spray group (p<0.001). Lidocaine spray treatment significantly lowered the overall procedural pain score compared with placebo. CONCLUSIONS Significant pain reduction during IUD insertion can be achieved by using 10% lidocaine spray alone. Lidocaine spray can be accepted as a non-invasive, easy to apply and more comfortable local anaesthetic method for IUD insertion. TRIAL REGISTRATION NUMBER NCT02020551.
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Affiliation(s)
- Hüseyin Aksoy
- Medical Doctor, Department of Obstetrics and Gynecology, Kayseri Military Hospital, Kayseri, Turkey
| | - Ülkü Aksoy
- Medical Doctor, Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Sezin Ozyurt
- Medical Doctor, Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Gökhan Açmaz
- Medical Doctor, Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Mustafa Babayigit
- Medical Doctor, Department of Public Health, Gulhane Military Medical Academy, Ankara, Turkey
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Wildemeersch D, Goldstuck N, Hasskamp T, Jandi S, Pett A. Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women? Open Access J Contracept 2015; 6:1-12. [PMID: 29386919 PMCID: PMC5683133 DOI: 10.2147/oajc.s72687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation. Objective This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD. Proposed problem solving The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best. Conclusion One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.
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Affiliation(s)
- Dirk Wildemeersch
- Gynecological Outpatient Clinic and IUD Training Center, Ghent, Belgium
| | - Norman Goldstuck
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Western Cape, South Africa
| | | | - Sohela Jandi
- Gynecological Outpatient Clinic, Berlin, Germany
| | - Ansgar Pett
- Gynecological Outpatient Clinic, Berlin, Germany
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Abstract
OBJECTIVE To assess the relationship of preinsertion vaginal ultrasound assessment and menstrual and gynecologic history as predictors of difficult or painful intrauterine device insertion in nulligravid women. METHODS Nulligravid women seeking contraception were invited to participate in this nonrandomized study and given the choice between the levonorgestrel-releasing intrauterine system or a copper-releasing intrauterine device. All 165 enrolled women were interviewed and a pelvic examination, including vaginal ultrasonography, was performed before insertion. Insertion difficulties and pain intensity were recorded and assessed against uterine measurements and background characteristics. RESULTS Most insertions were assessed as easy (n=144 [89.4%]) and only two (1.2%) failed. Most women had uterine measurements smaller than the studied devices. Odds for difficulties at insertion decreased with every increasing millimeter in total uterine length (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.78-0.96, P=.006) and cervical length (OR 0.85, 95% CI 0.74-0.97, P=.02) and similarly with every decreasing degree of (straighter) flexion angle (OR 0.96, 95% CI 0.94-0.99, P=.005). No absolute threshold measurements could be determined. Still, the majority of insertions in small and flexed uteri were uneventful. Severe insertion pain was common (n=94 [58.4%]). Severe dysmenorrhea was the only predictor of insertion pain (OR 8.16 95% CI 2.56-26.02, P<.001). CONCLUSION Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure. Although smaller uterine length measurements and steeper flexion angle more often predicted difficulties, the majority of insertions were uneventful in women with small measures. Dysmenorrhea was the only predictor of pain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT01685164. LEVEL OF EVIDENCE II.
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Difficult Placement of the Intrauterine Device: Practical Tips and Tricks. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2014.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Guillebaud J. Further comment on the avoidance of pain associated with intrauterine contraceptive insertion. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2014; 40:308-9. [PMID: 25240033 DOI: 10.1136/jfprhc-2014-101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- John Guillebaud
- Emeritus Professor of Family Planning and Reproductive Health, University College, London, UK,
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Bahamondes L, Mansour D, Fiala C, Kaunitz AM, Gemzell-Danielsson K. Comment on 'Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives': authors' response. ACTA ACUST UNITED AC 2014; 40:235. [PMID: 24939488 DOI: 10.1136/jfprhc-2014-100925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Luis Bahamondes
- Professor of Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil;
| | - Diana Mansour
- Consultant in Community Gynaecology and Reproductive Healthcare, Newcastle Hospitals, Community Health, New Croft Centre, Newcastle upon Tyne, UK;
| | - Christian Fiala
- Director, Gynmed Clinic, Vienna, Austria and Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden;
| | - Andrew M Kaunitz
- Professor and Associate Chair, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA;
| | - Kristina Gemzell-Danielsson
- Professor of Obstetrics and Gynecology and Department Chair, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden;
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Bahamondes L, Mansour D, Fiala C, Kaunitz AM, Gemzell-Danielsson K. Comment on 'practical advice for avoidance of pain associated with insertion of intrauterine contraceptives': authors' response. ACTA ACUST UNITED AC 2014; 40:152-3. [PMID: 24648536 DOI: 10.1136/jfprhc-2014-100874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Luis Bahamondes
- Professor of Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil;
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Guillebaud J. Comment on 'practical advice for avoidance of pain associated with insertion of intrauterine contraceptives'. ACTA ACUST UNITED AC 2014; 40:150-1. [PMID: 24648534 DOI: 10.1136/jfprhc-2014-100904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- John Guillebaud
- Emeritus Professor of Family Planning and Reproductive Health, University College London, London, UK;
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