Most IUD Insertions Uneventful in Nulligravid Women

Veronica Hackethal, MD

July 10, 2014

Nine of 10 intrauterine device (IUD) insertions in women who have not borne children were uneventful, according to a study by researchers in Finland, published online July 7 in Obstetrics & Gynecology.

"Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure," Janina Kaislasuo, MD, from the Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Central Hospital, Finland, and colleagues write. "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."

IUD size and shape, as well as uterine size, may all influence successful IUD insertion, the authors write. Women who have not borne children usually have smaller intrauterine spaces. Fear of insertion pain and difficulty may discourage women from using IUDs, as well as physicians from recommending them.

From January 1, 2011, to July 3, 2012, researchers enrolled 165 women at a family planning clinic in Helsinki, Finland. Women who had never borne children and who were requesting their first IUD were offered either a levonorgestrel-releasing IUD or a copper-releasing IUD. The researchers obtained menstrual and gynecologic histories through interviews and performed pelvic exams with vaginal ultrasound. All women received standard pain medication before IUD insertion. A single experienced physician inserted all IUDs. Both the patient and physician rated insertion pain immediately after the procedure, and the physician rated ease of insertion.

Most insertions (n = 144 [89.4%]) were "easy." Insertion difficulty decreased for each millimeter increase in 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). Ease of insertion also increased with a straighter uterine flexion angle (OR, 0.96; 95% CI, 0.94 - 0.99; P = .005). No significant differences regarding ease of insertion were found between the 2 types of IUDs.

All women reported insertion pain, with more than half describing it as "severe" (n = 94 [58.4%]). Severe dysmenorrhea was the only predictor of insertion pain (OR, 8.16; 95% CI, 2.56 - 26.02; P < .001). The physician "commonly" rated pain 1 step milder than the woman (P < .001).

The authors mention past studies suggesting that pain assessed immediately after insertion is significantly greater than at 3 minutes. Dysmenorrhea, they add, is linked to increased uterine contractility and changes in blood flow. Altered central nervous system pain responses, immune factors, and steroid hormones could also play roles. Reversing vasoconstriction with prostaglandins, they mention, could help decrease the pain.

"[I]dentifying means of sufficient analgesia for these women is important," the authors conclude. "Equally important is counseling women coming to IUD insertion and proper insertion technique, including clinical evaluation by palpation and sound measure. However, ultrasound evaluation before insertion does not give additional information and must not limit access to IUD use."

"A smaller uterine length and steeper flexion angle will more often predict difficulties with IUD insertion than ultrasound," William Schweizer, MD, clinical associate professor in the Department of Obstetrics and Gynecology at New York University Langone Medical Center, New York City, told Medscape Medical News.

Another take-home point, according to Dr. Schweizer, is that all women in this study noted pain, and women with severe dysmenorrhea noted significantly more pain.

In his clinical experience, Dr. Schweizer said, IUD placement is usually described by women as "crampy, painful," and generally unpleasant.

Patient counseling remains important and should include information about discomfort during the pelvic exam, pain associated with IUD insertion, and the benefits and risks of IUD use. Benefits, according to Dr. Schweizer, include insertion of a reliable, reversible form of contraception that is "nonnegotiable." Risks include infection, bleeding, and rarely, uterine perforation.

"Physicians routinely suggest Motrin or Tylenol prior to IUD insertion," Dr. Schweizer stated. "Women need to understand that IUD insertion is associated with short-lived pain."

Dr. Suhonen reports receiving lecture fess from Bayer and MSD Finland and being on the advisory board for Contraception MSD Finland. One coauthor reported occasionally serving on the advisory board and designing educational events for Bayer Healthcare, Gedeon Richter, and MSD/Merck. The other authors and Dr. Schweizer have disclosed no relevant financial relationships.

Obstet Gynecol. Published online July 7, 2014. Abstract

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