Barbara Boughton

May 24, 2012

May 24, 2012 (San Diego California) — Providers underestimate the pain experienced by women undergoing intrauterine device (IUD) insertion, and they have a poor understanding of when pain is the worst during the procedure, according to researchers.

Karla Maguire, MD, MPH, from the University of Miami, Miller School of Medicine in Florida, presented a secondary analysis of a randomized placebo-controlled trial here at the American Congress of Obstetricians and Gynecologists 60th Annual Clinical Meeting.

"Patients in our analysis rated their pain as much higher than providers. Patients experienced a maximum pain score that was on average 28.5 points higher [on a 100-point scale] than assessments by providers," said Dr. Maguire.

Results showed that intracervical 2% lidocaine gel was no better than placebo at relieving pain during IUD insertion.

When asked to rank their pain during the procedure on a 100-point visual analogue scale, patients rated their maximum pain as 63.8, whereas providers estimated it to be 35.3 (P < .001).

The patients and providers also rated the pain that occurred at 4 time points during the procedure: tenaculum placement, uterine sounding, IUD insertion, and speculum removal. There was only 41% patient and provider agreement about the time point of maximum pain, Dr. Maguire explained (kappa, 0.16; 95% confidence interval, 0.07 to 0.25).

Providers who performed the procedures included attending physicians, midlevel providers, and residents, Dr. Maguire noted. Midlevel providers did the best at rating patients' pain accurately; their ratings were 6.6 points closer to the patient's perceived pain score than those of attending physicians (P = .04). All providers had poor agreement with their patients when asked to assess the point of maximum pain, Dr. Maguire said.

Does this lack of understanding about patients' pain during IUD insertion really matter?

"Pain may be a barrier during IUD insertion, and underestimation may lead to less research to find therapies that ease pain," Dr. Maguire noted.

Other clinicians have a different perspective. "The findings of this study are really not that surprising," said Susan Richman, MD, MPH, associate clinical professor in the Department of Obstetrics and Gynecology at the Yale School of Medicine in New Haven, Connecticut.

"The provider is looking through the women's legs, and unless the patient says 'I'm in pain' or you notice a change in facial expression or rate of breathing, you may not have a good handle on the patient's pain," Dr. Richman said.

She noted that even though women vary in their tolerance for pain during IUD insertion, she advises all her patients that the procedure will be uncomfortable. "It's easier to assume that it will hurt, and have everyone protected by using pain protection, such as taking 800 mg [ibuprofen] beforehand," she said.

Dr. Maguire and Dr. Richman have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 60th Annual Clinical Meeting. Presented May 7, 2012.

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