Intrauterine devices (IUDs), also known as coils, are safe and effective contraceptive methods, reports Medscape, however, many women still oppose this method because of concerns regarding pain.
Two studies recently published in JAMA examined pain and pain relief associated with IUD use, with the researchers suggesting that counselling on analgesia options should precede insertion.
A US study examined the number of women who opted for pain medication, while Swedish researchers investigated the effectiveness of intrauterine instillation of mepivacaine as an option to ease the discomfort.
Cornelia Hösemann, MD, gynaecologist in private practice in Großpösna and board member of the Professional Association of Gynaecologists in Munich, told Medscape’s German edition that the potential for pain and the available options for pain relief should be discussed during the gynaecological consultation before IUD insertion.
“However, that pain perception varies considerably among patients and cannot be reliably predicted in an individual case,” she noted.
Germany’s 2024 S2k Guideline on Non-Hormonal Contraception specifically addresses pain during IUD insertion and outlines pain relief options. Its consensus statement advises that pain relievers like naproxen and tramadol, as well as local application of an anaesthetic in the form of a gel or cream, at higher doses, have analgesic effect during IUD insertion.
But studies have not shown that misoprostol administered before insertion generally facilitates the procedure. According to consensus-based recommendations, pain relievers may be used to alleviate pain during and after IUD insertion.
After a previous unsuccessful insertion, another attempt may be made after the administration of misoprostol.
Intravenous sedation (IVS)
In the US study, Armide Storey, MD, clinical fellow in complex family planning in the Department of Obstetrics and Gynaecology at Brigham and Women’s Hospital in Boston and colleagues, examined how often patients offered IVS for IUD insertion chose to receive IVS.
They studied 1 324 patients who underwent IUD insertion at family planning clinics in Massachusetts between 1 April 2024, and 30 March 2025.
Patients were routinely offered non-steroidal anti-inflammatory drugs and a paracervical block with lidocaine for pain management. IVS with fentanyl and midazolam was also promoted online and offered to all patients when they scheduled their appointments.
Overall, 269 of the 1 324 patients (20.3%) received IVS.
Patients who received IVS were more likely to have never given birth (93.7% vs 84.9%; P < .001) and to have diagnoses of pelvic pain (5.9% vs 2.0%; P < .001) and depression or anxiety (64.7% vs 45.5%; P < .001). They were also more likely to identify as white (64.7% vs 53.1%) and non-cisgender (10.0% vs 5.5%).
“In this sample, one fifth of patients received IUD placement with IVS when universally offered, indicating meaningful demand for this option in routine contraceptive care,” the authors concluded.
On the basis of the observed prevalence, the researchers suggested that the actual demand for IVS may be under-estimated.
Mepivacaine findings
In the second study, Swedish researchers examined whether intrauterine instillation of mepivacaine could reduce pain during IUD insertion in nulliparous individuals. Mepivacaine is a local anaesthetic of the aminoamide class that acts by blocking sodium channels in nerve cell membranes.
The multi-centre, double-blind, randomised, placebo-controlled study included 370 nulliparous women aged 18-31, and was conducted at 11 outpatient clinics in Sweden. Participants were randomly assigned in a 1:1 ratio to receive 10 mL of mepivacaine or saline (9 mg/mL) through a hydrosonography catheter two minutes before IUD insertion.
The primary endpoint was the difference in pain scores.
The mean pain score during IUD insertion was 43.8 mm (SD, 24.7) in the mepivacaine group and 58.6 mm (SD, 21.5) in the placebo group, corresponding to a mean difference of 14.8 mm (P < .001).
The authors concluded that intrauterine instillation of 10 mL of mepivacaine significantly reduced pain and improved tolerability during IUD insertion compared with the instillation of the placebo (saline).
In 2024,, the team, Karin Elgemark, MD, PhD, researcher in the Department of Clinical Sciences, Danderyd Hospital at Karolinska Institutet in Stockholm, Sweden, and colleagues, had already reported evidence supporting the effectiveness of intrauterine mepivacaine during IUD insertion in a smaller study involving 151 patients.
Bettina Böttcher, MD, PD, senior physician in the Department of Gynaecological Endocrinology and Reproductive Medicine at the Medical University of Innsbruck in Austria, and co-ordinator of the S2k Guideline, said that sufficient data on mepivacaine were not available when the guideline recommendations were developed.
“The guideline is scheduled for revision in 2027, so all studies published in the meantime will be considered and, provided they meet the quality criteria, incorporated into the recommendations,” Böttcher said.
Medscape article – IUD Insertion: New Studies Highlight Ways to Ease Pain (Open access)
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