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Wednesday, July 9, 2014

Improving the Difficult Intrauterine Contraception Insertion: A Challenging Task
Matthew L. Zerden, MD, MPH
Fellow, Division of Family Planning
Department of Obstetrics and Gynecology
School of Medicine
University of North Carolina
As clinicians in the field of contraceptive care, we are consistently attempting to find ways to promote the most effective forms of contraception, which includes intrauterine contraception (IUC). We now have excellent evidence to support the use of IUC in almost all patients at risk of unintended pregnancy; however, concerns regarding painful pelvic exams and insertions have deterred some nulligravid patients from choosing IUC. We also know that social networks (ie, family and friends) in younger populations are very influential in contraceptive decision-making.1,2 Because women who have a negative, painful experience are likely to influence others, we need to make the insertion as painless as possible, focusing on nulligravid women.
Efforts to improve IUC insertion in this population have taken many different avenues, including developing more narrow and smaller IUC (Skyla); pharmacologic interventions for all nulligravidas such as pre-procedural misoprostol3 and intrauterine lidocaine4; informational campaigns (; and even novel approaches such as self-administered vaginal lidocaine.5
In their innovative attempt to risk stratify patients who will have a difficult or painful insertion published in the August 2014 issue of Obstetrics & Gynecology, Kaislasuo and colleagues performed a pre-insertion transvaginal ultrasound to evaluate if uterine parameters could predict a challenging insertion.6 Their results confirmed clinical suspicions: women with smaller uteri, smaller cervices, and more flexion had more difficult insertions. Unfortunately, a cut-off value of uterine length could not be determined and, not surprisingly, women with a history of dysmenorrhea had increased pain on insertion.
Consistent with the previous attempts and strategies to decrease pain with IUC insertion cited above, Kaislasuo and colleagues were unable to demonstrate that their intervention should be adopted into routine clinical practice. Because the intervention involves an additional, intrusive test, transvaginal ultrasounds should be reserved for clinically indicated scenarios, such as a women with a prior failed insertion.
Perhaps what is most useful from this study is that providers should continue to rely on their gestalt, and consider other relevant clinical information that confers a higher likelihood of pain with IUC insertion. Conditions such as a history of dysmenorrhea, pelvic pain, or vulvodynia are more likely to predict a challenging insertion and require more thoughtful care. When providers encounter a woman who has these characteristics, the provider and patient can consider peri-procedural strategies that may ameliorate the pain experienced by the patient, even if these interventions have not been shown to be effective for the average woman. Explaining the potential benefit of misoprostol, non-traditional uses of lidocaine, or a pre-insertion ultrasound may provide the reassurance that will facilitate successful insertion. Anecdotally, having patient buy-in for challenging insertions can be a key step to achieving IUC insertion when others have failed. Specialists who attempt difficult IUC insertions will continue to benefit from research such as the present study by Kaislasuo, and we should continue to search for the elusive intervention that will significantly decrease IUC pain at insertion.
  1. Weston MR, Martins SL, Neustadt AB, Gilliam ML. Factors influencing uptake of intrauterine devices among postpartum adolescents: a qualitative study. Am J Obstet Gynecol 2012;206:40-e1.
  2. Gilliam ML, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus-group approach. Contraception 2004;70:299-305.
  3. Swenson C, Turok DK, Ward K, Jacobson JC, Dermish A. Self-administered misoprostol or placebo before intrauterine device insertion in nulliparous women: a randomized controlled trial. Obstet Gynecol 2012;120:341-7.
  4. Mercier RJ, Zerden ML. Intrauterine anesthesia for gynecologic procedures: a systematic review. Obstet Gynecol 2012;120: 669-77.
  5. Rapkin RB, Achilles SL, Boraas C, Cremer M, Schwarz EB, Chen BA. Self-administered lidocaine gel for intrauterine device insertion in nulliparous women: a randomized controlled trial. Obstet Gynecol 2014;123:110S.
  6. Kaislasuo J, Heikinheimo O, Lähteenmäki P, Suhonen S. Predicting painful or difficult intrauterine device insertion in nulligravid women. Obstet Gynecol 2014;124(2).