Addressing procedural pain: A barrier to IUD use in Pakistan

Abstract

Madam,

I am writing to highlight an important but often overlooked issue in women’s reproductive health: the pain associated with intrauterine device (IUD) insertion. Although IUDs are among the most effective methods of contraception, with a typical-use success rate of over 99%, many women experience significant pain during and after insertion, which affects both patient satisfaction and long-term continuation (1).

IUDs, including copper and levonorgestrel-releasing types, work primarily by preventing fertilisation through the creation of a local inflammatory environment. However, the insertion process is often painful, especially for nulliparous women or those with a history of caesarean delivery. In a cross-sectional study assessing pain using the Visual Analog Scale (VAS), 49.7% of women reported intense pain, 31.3% reported moderate pain, and only 2.5% reported no pain (1). Factors such as uterine position, patient age, and a prolonged interval since last delivery also contribute to greater procedural discomfort.

In one study, cramping was the most common reason for IUD removal within six months, with 28% of levonorgestrel IUD users and 35% of copper IUD users discontinuing due to pain or cramping (2). These figures highlight the urgent need for more effective pain management, not just for insertion, but to ensure continued use of this highly effective contraceptive.

Commonly used pain management strategies, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and misoprostol, have shown limited and inconsistent benefit. While misoprostol can facilitate cervical dilation, it is also associated with increased side-effects, including cramping. In contrast, a randomised controlled trial demonstrated that a 20 cc buffered 1% lidocaine paracervical block significantly reduced pain during uterine sounding, device insertion, and in the immediate post-insertion period (3).

The recently published American College of Obstetricians and Gynaecologists (ACOG) guidelines reinforce these findings, emphasising that pain during in-office procedures, including IUD insertion, has historically been under-managed. ACOG recommends that all patients be offered multimodal, evidence-based pain relief and that clinicians engage in shared decision-making to determine the most appropriate approach for each individual. Local anaesthetics, including paracervical blocks, have been identified as effective options (4).

In Pakistan, where approximately 7.5% of contraceptive users rely on IUDs (5), the standard practice often involves the use of mefenamic acid and vaginal misoprostol. Given the current evidence, this protocol should be re-evaluated and updated to incorporate more effective analgesic strategies, such as paracervical blocks.

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