title: Management of pain associated with the insertion of intrauterine contraceptives.
abstract: BACKGROUND
  Most intrauterine contraception (IUC) placements do not require pain relief. However, small proportions of nulliparous (∼17%) and parous (∼11%) women experience substantial pain that needs to be proactively managed. This review critically evaluates the evidence for pain management strategies, formulates evidence-based recommendations and identifies data gaps and areas for further research.
  
  
  METHODS
  A PubMed literature search was undertaken. Relevant articles on management of pain associated with IUC insertion, published in English between 1980 and November 2012, were identified using the following search terms: 'intrauterine contraception', 'insertion' and 'pain'. RCTs were included; further relevant articles were also identified and included as appropriate.
  
  
  RESULTS
  Seventeen studies were identified and included: 12 RCTs and one non-randomized study of pre-insertion oral analgesia, cervical priming and local anaesthesia; one systematic review and one RCT on post-insertion analgesia and two non-randomized studies on non-pharmacological interventions. There was no conclusive evidence that any prophylactic pharmacological intervention reduces pain associated with IUC insertion. However, most of the regimens studied were adopted from hysteroscopy or abortion and effectiveness in specific subsets of women has not been studied adequately. A systematic review found non-steroidal anti-inflammatory agents (NSAID) to be effective in reactively treating post-insertion pain, but no benefit was found with prophylactic use.
  
  
  CONCLUSIONS
  No prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUC insertion. Women's anxiety about the procedure may contribute to higher levels of perceived pain, which highlights the importance of counselling, and creating a trustworthy, unhurried and professional atmosphere in which the experience of the provider also has a major role; a situation frequently referred to as 'verbal anaesthesia'.
authors.affiliation: Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, SE-17176 Stockholm, Sweden. kristina.gemzell@ki.se
authors.forename: K
authors.initials: K
authors.lastname: Gemzell-Danielsson
authors.forename: D
authors.initials: D
authors.lastname: Mansour
authors.forename: C
authors.initials: C
authors.lastname: Fiala
authors.forename: A M
authors.initials: AM
authors.lastname: Kaunitz
authors.forename: L
authors.initials: L
authors.lastname: Bahamondes
mesh_terms: D000028:Abortion, Induced; D000700:Analgesics / Q000627:therapeutic use; D000772:Anesthesia, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D005260:Female; D006801:Humans; D015907:Hysteroscopy; D007434:Intrauterine Devices / Q000009:adverse effects*; D059408:Pain Management; D017699:Pelvic Pain / Q000188:drug therapy / Q000209:etiology* / Q000517:prevention & control*
chemical_list: D000700:Analgesics; D000894:Anti-Inflammatory Agents, Non-Steroidal
keywords: analgesia; cervical priming; intrauterine contraception; local anaesthesia; pain