title: Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section.
abstract: BACKGROUND
  Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group.
  
  
  METHODS
  Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain.
  
  
  RESULTS
  Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section.
  
  
  CONCLUSIONS
  Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.
authors.affiliation: Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil.
authors.forename: Ana Raquel Gouvea
authors.initials: AR
authors.lastname: Santos
authors.forename: M Valeria
authors.initials: MV
authors.lastname: Bahamondes
authors.forename: M Margarete
authors.initials: MM
authors.lastname: Hidalgo
authors.forename: Ana
authors.initials: A
authors.lastname: Atti
authors.forename: Luis
authors.initials: L
authors.lastname: Bahamondes
authors.forename: Ilza
authors.initials: I
authors.lastname: Monteiro
mesh_terms: D000328:Adult; D001938:Brazil; D002585:Cesarean Section / Q000009:adverse effects; D003271:Contraceptive Agents, Female / Q000008:administration & dosage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007436:Intrauterine Devices, Medicated / Q000009:adverse effects*; D016912:Levonorgestrel / Q000008:administration & dosage; D008422:Materials Testing; D010147:Pain Measurement; D010298:Parity; D010342:Patient Acceptance of Health Care; D017060:Patient Satisfaction; D011247:Pregnancy; D011446:Prospective Studies; D055815:Young Adult
chemical_list: D003271:Contraceptive Agents, Female; D016912:Levonorgestrel