Intrauterine devices (IUDs) are safe and highly effective birth control.1 Despite this, they were utilized by only 7.2% of reproductive-aged women in the United States from 2011 to 2013.2 One barrier to using IUDs may be the perception of pain involved with placement.3–6
The American College of Obstetricians and Gynecologists recommends taking over-the-counter pain medication before IUD placement; however, no specific medication is recommended.7 Methods that have been studied include nonsteroidal antiinflammatory drugs (NSAIDs), misoprostol, and local anesthetics. Despite the use of these medications in practice, few studies have shown benefit.8–12 Nonsteroidal antiinflammatory drugs, however, may help reduce pain. Oral naproxen sodium taken 1 hour before IUD placement may decrease pain with placement.13,14 However, waiting 1 hour may not be possible in a busy clinic.
Intramuscular ketorolac has an onset of analgesia at approximately 30 minutes. It is a potent acetic acid NSAID. It is indicated for short-term moderate acute pain and is often used in the postoperative setting.15 The maximal effect is at 1–2 hours with a 4- to 6-hour duration of analgesia.16 In studies of suction curettage, use of ketorolac demonstrated a decrease in acetaminophen requirement postoperatively but no difference in pain control between ketorolac and ibuprofen.17,18
Ketorolac may be useful in the clinic setting given its quicker onset of action compared with oral medications. This study was designed to assess whether administering intramuscular ketorolac 30 minutes before IUD placement would result in a reduction in pain scores compared with placebo injection.
MATERIALS AND METHODS
This was a randomized, double-blind, placebo-controlled trial. It was approved by the University of California San Diego institutional review board. Recruitment took place at the University of California San Diego Women's Health Clinics, which is part of an urban academic institution. Clinicians included obstetrics and gynecology first-, second-, third-, and fourth-year residents as well as attending physicians.
Women who were eligible for the study included those ages 18–50 years, nulliparous or multiparous, English- or Spanish-speaking, and those presenting for either levonorgestrel or TCu 380A IUD. Women were excluded if they were pregnant, had any diagnosed chronic pain issues (including fibromyalgia, endometriosis, dysmenorrhea, irritable bowel syndrome, interstitial cystitis), had taken any pain medications within 6 hours of enrollment, had misoprostol within 24 hours of enrollment, had a history of prior intrauterine device insertion, had a known allergy or contraindication to NSAIDs, or had any known contraindications to IUD placement.
Participants underwent informed consent by trained registered nurses or by the first author. They signed a written consent approved by the University of California San Diego institutional review board, which was available in English and Spanish. A recruitment log-tracked patients who were approached and declined participation or were ineligible for participation.
Patients were randomized to receive either ketorolac 30 mg (1-mL volume) or placebo injection of normal saline (1-mL volume). Injection was into the upper outer quadrant of the gluteus muscle. A timer was used to monitor when 30 minutes was completed. The clinicians started the IUD placement procedure immediately after the timer alarmed. Time between study medication administration and IUD placement was not recorded.
Randomization was stratified by parity, nulliparous compared with multiparous, with a block size of four and a one-to-one allocation ratio. The randomization allocation sequence was computer-generated with a random number generator by a statistician not otherwise involved in the study. Group assignment was concealed in sealed, numbered, and opaque envelopes opened only by the clinic nurse administering the study drug. Clinicians and participants were blinded to group allocation. When available, a blinded clinic staff member administered study forms during the course of the procedure. However, given research and clinic staff limitations, the majority of participants were administered study forms by the unblinded nurse.
The primary outcome of interest was pain level measured on a visual analog scale from 0 cm (no pain) to 10 cm (worst pain possible) for IUD placement. Secondary outcomes were pain levels measured at six other time points: 1) study drug administration, 2) speculum placement, 3) tenaculum placement, 4) uterine sounding, 5) 5 minutes after IUD placement, and 6) 15 minutes after IUD placement. We also measured anticipated pain before study drug administration. Participants marked their pain scores immediately after each procedure step. Of note, participants did not receive any anesthetic agent for tenaculum placement.
A postprocedural questionnaire was completed by each health care provider and participant. The health care provider questionnaire collected information including level of training, the type of IUD placed, the purpose of the IUD placement, uterine position, and any complications. Each patient received a questionnaire at the 15-minute postprocedure time point, which assessed for possible adverse effects from the study drug (including nausea, vomiting, heartburn, dizziness or drowsiness, and injection site pain), pain from the injection compared with pain with the procedure, overall satisfaction with the procedure, and desire for any additional pain medication. Study participants were offered acetaminophen at the 15-minute postprocedure time point (after all visual analog scale pain scores were assessed) as additional pain medication and as another marker of pain control. We chose acetaminophen because it was readily available in our clinic, would not impair the participant's ability to drive, and was safe to take with ketorolac. At the conclusion of the study, participants were compensated with a gift card. Charts were reviewed at a later date to determine if participants called the clinic within 24 hours of enrollment to request stronger pain medications.
The power calculation was based on previous studies assessing pain control with IUD placement using a 10-cm (100 mm) visual analog scale.12,19 A clinically significant difference in visual analog scale pain score has been defined as 1.3–2.0 cm.20,21 Using a standard deviation of 2.7 cm and a clinically significant pain difference of 2.0 cm, to obtain 80% power with a 5% α error rate, 57 participants were needed.20 To allow room for missing data and participants who may discontinue, we planned to recruit approximately 66 participants with 33 per arm. All data entry was performed twice to ensure accuracy.
The data were analyzed based on an intention-to-treat analysis. For our statistical analysis, we tested the pain scores (continuous variables) for normality and they were found to have a nonnormal distribution. Therefore, pain scores were compared using the Wilcoxon rank-sum test. We also performed a subgroup analysis by parity, which was decided on a priori. For demographics and questionnaires, the χ2 test was used to compare categorical variables and the t test or Wilcoxon rank-sum test was used to compare continuous variables. Statistical analyses were performed using PASW Statistics 18 and SAS 9.4 software.
Participants were enrolled from July 2012 until March 2014. A total of 110 patients were approached for eligibility. Thirty-four of the patients approached to participate were excluded because they did not meet inclusion criteria (the majority had a prior IUD or had taken pain medications before the visit). Nine patients declined to participate for reasons including not wanting to wait and fear of injections. A total of 67 participants were randomized with 33 participants allocated to the ketorolac arm and 34 participants allocated to the placebo arm (Fig. 1). All patients randomized received the assigned study drug, underwent successful IUD placement, and completed the study.
There were no differences in baseline demographics including age, body mass index, gravidity, parity, race, education, current breastfeeding, and prior history of cone biopsy or a loop electrosurgical excisional procedure of the cervix. The majority of patients in both groups were either Caucasian or Hispanic. Almost all patients had attended high school (Table 1).
Median pain scores for all participants were compared between placebo and ketorolac groups for the primary and secondary outcomes of pain scores. There was no difference in anticipated pain between the two groups (4.4 compared with 3.5 cm, P=.31) or for pain with study drug injection (1.0 compared with 0.6 cm, P=.33). Uterine sounding (5.0 compared with 4.3 cm, P=.64) and IUD placement (5.2 compared with 3.6 cm, P=.99) had the highest pain scores without a difference between the two groups. There was also no difference for speculum or tenaculum placement. There was a decrease in pain scores at 5 minutes after IUD placement (2.2 compared with 0.3 cm, P≤.001) as well as at 15 minutes after IUD placement (1.6 compared with 0.1 cm, P≤.001). Results for all patients are outlined in Table 2 and Figure 2.
In our subgroup analysis, nulliparous patients (n=16, with eight in each arm) had a decrease in median pain scores with uterine sounding (8.4 compared with 6.0 cm, P=.04) and IUD placement (8.1 compared with 5.4 cm, P=.02). There was no difference in pain scores at 5 minutes after placement (3.7 compared with 2.7 cm, P=.32) but there was a decrease at 15 minutes after placement (4.8 compared with 1.8 cm, P=.02). For multiparous patients, there was a decrease in pain scores at 5 minutes (1.3 compared with 0.1 cm, P≤.001) and 15 minutes (1.3 compared with 0.0 cm, P≤.001). Of note, median pains scores for IUD placement were higher in the nulliparous subgroup compared with the multiparous subgroup (8.1 compared with 3.7 cm in the placebo arm and 5.4 compared with 2.5 cm in the ketorolac arm) (Table 2).
The postprocedure participant questionnaire revealed few minor adverse effects from study drug administration and no difference between the two groups. The majority of patients felt that the pain from the injection was “not as bad” as pain from IUD placement (71% compared with 81%). However, 22% in the placebo group and 18% in the ketorolac group reported the pain was just as bad as the IUD placement procedure. The majority of patients were very satisfied or satisfied with their procedure (90% compared with 93%) and would recommend IUD placement to a friend (85% compared with 91%). There were no statistically significant differences in these findings, although the study was not powered to evaluate these outcomes (Table 3).
The postprocedure health care provider questionnaire revealed that at 15 minutes after IUD placement, significantly more participants in the placebo group received acetaminophen compared with the ketorolac group (52% compared with 21%, P=.02). No major adverse events from IUD placement were reported by clinicians. There were no differences for type of IUD placed (levonorgestrel-releasing or TCu 380A), purpose of IUD placement (contraception or menorrhagia), uterine position (anteverted, midpositioned, or retroverted), need for cervical dilation (two patients per group), and level of health care provider performing the procedure (Table 4). On review of electronic medical records, no participants called to request stronger pain medications within 24 hours of enrollment. Of note, the study was not powered to detect a difference for any of these categories.
In our overall analysis we did not find a decrease in pain scores for IUD placement. However, this study was not powered to detect a difference less than 2.0 cm. The study does support intramuscular ketorolac for decreasing pain after IUD placement. This was demonstrated with lower pain scores and less acetaminophen requirement at 15 minutes after placement.
Nulliparous participants showed a decrease in pain for uterine sounding and IUD placement. However, these results must be interpreted with caution. The study was not powered for subgroup analysis by parity or other subgroups such as IUD type. A P value adjustment may lead to a nonsignificant result for uterine sounding and a borderline significant result for IUD placement. In addition, given the small sample size of 16 participants, the results may be the result of chance and may not be generalizable. A trial powered for subgroup analysis may clarify the effects of ketorolac.
Although ketorolac has a maximal effect at 1–2 hours, we chose to study it at the time of onset, 30 minutes. This was a more realistic wait time for our busy clinic. This may have contributed to pain reduction noted only after the IUD procedure was completed. We did not follow participants past 15 minutes to minimize clinic flow interruptions. Although this is a study limitation, compared with other NSAID trials, we did demonstrate a postprocedural benefit.
Many of the oral NSAID trials are limited by short time to IUD placement and lack of follow-up pain scores. Ibuprofen was administered up to 45 minutes before placement in three of four trials, so there may not have been sufficient time for analgesic effect. Pain after placement was not evaluated in these trials. Jensen et al did not observe a difference during or after placement with ibuprofen 1–4 hours before placement. However, postprocedural pain was evaluated 4–6 hours after placement, when the ibuprofen may not have been therapeutic.19,22–24 Naproxen sodium at 550 mg reduces pain with Multiload Cu 375 IUD placement, although follow-up pain scores were not evaluated. Of note, this trial was published after the start of the present trial.13 A trial of 300 mg naproxen sodium with the Dalkon Shield IUD did not reduce pain with placement, but did reduce pain medication requirement postprocedure.14 Naproxen sodium may have demonstrated efficacy because sufficient time was given for onset of analgesia. Trials directly comparing efficacy of naproxen, ibuprofen, and ketorolac in a procedural setting are not available, so it is unclear if there is a physiologic basis for the differences observed.
The strength of this study is that it is a double-blind, randomized, placebo-controlled trial. Ketorolac is a relatively inexpensive medication, costing approximately $1 per dose. It can be stocked in clinics. It has a wait time of 30 minutes compared with 1 hour for oral NSAIDs with analgesia lasting 4–6 hours. Injection pain scores were objectively low compared with IUD placement pain. However, 20% of patients reported their injection site pain after 15 minutes was just as bad as their IUD placement.
There are limitations to this study. Staff administering study forms were unblinded to treatment allocation because of limited research personnel. This may have resulted in a bias toward a beneficial effect. However, participants marked their own pain score with study staff only holding up the visual analog scale forms. This helped to limit potential bias. Another limitation is that ketorolac may not be available in all clinics. When it is given, a health care provider must be available to administer the injection.
Patient satisfaction was high regardless of treatment allocation, likely because IUD placement is a short procedure and all participants had successful placement. Pain scores were higher at 15 minutes compared with 5 minutes for the nulliparous control group, the reason for which is unclear but may be the result of increased endometrial irritation from the IUD absent an NSAID effect. We did not perform ultrasound assessment to confirm IUD placement, although it may have been helpful to identify a small number of IUD embedment cases.
The demonstrated efficacy of ketorolac in this study is encouraging. However, it is limited by the need for a potentially painful intramuscular injection and an in-clinic 30-minute wait time. An oral medication such as naproxen sodium taken before clinic arrival may be more practical. Additional studies on the efficacy of naproxen sodium during and after IUD placement would be helpful. Ultimately, we hope decreasing pain associated with IUD placement can help increase utilization of this highly effective contraceptive method.
1. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404.
2. Branum A, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15–44. NCHS Data Brief 2015:1–8.
3. Bracken J, Graham CA. Young women's attitudes towards, and experiences of, long-acting reversible contraceptives. Eur J Contracept Reprod Health Care 2014;19:276–84.
4. Michie L, Cameron ST, Glasier A, Wellings K, Loudon J. Myths and misconceptions about intrauterine contraception among women seeking termination of pregnancy. J Fam Plann Reprod Health Care 2014;40:36–40.
5. 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.e1–7.
6. Asker C, Stokes-Lampard H, Beavan J, Wilson S. What is it about intrauterine devices that women find unacceptable? Factors that make women non-users: a qualitative study. J Fam Plann Reprod Health Care 2006;32:89–94.
8. Nelson AL, Fong JK. Intrauterine infusion of lidocaine does not reduce pain scores during IUD insertion. Contraception 2013;88:37–40.
9. Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien P. Interventions for pain with intrauterine device insertion. The Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007373. DOI: 10.1002/14651858.CD007373.pub2.
10. Edelman AB, Schaefer E, Olson A, Van Houten L, Bednarek P, Jensen JT, et al.. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women. Contraception 2011;84:234–9.
11. Maguire K, Davis A, Rosario Tejeda L, Westhoff C. Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial. Contraception 2012;86:214–9.
12. Mody SK, Kiley J, Rademaker A, Gawron L, Stika C, Hammond C. Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block. Contraception 2012;86:704–9.
13. Karabayirli S, Ayrim AA, Muslu B. Comparison of the analgesic effects of oral tramadol and naproxen sodium on pain relief during IUD insertion. J Minim Invasive Gynecol 2012;19:581–4.
14. Massey SE, Varady JC, Henzl MR. Pain relief with naproxen following insertion of an intrauterine device. J Reprod Med 1974;13:226–31.
15. Fiedler MA. Clinical implications of ketorolac for postoperative analgesia. J Perianesth Nurs 1997;12:426–33.
16. Ketorolac. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics, Inc: Greenwood Village, CO. Available at: http://www.micromedexsolutions.com
. Retrieved January 8, 2012.
17. Braaten KP, Hurwitz S, Fortin J, Goldberg AB. Intramuscular ketorolac versus oral ibuprofen for pain relief in first-trimester surgical abortion: a randomized clinical trial. Contraception 2014;89:116–21.
18. Roche NE, Li D, James D, Fechner A, Tilak V. The effect of perioperative ketorolac on pain control in pregnancy termination. Contraception 2012;85:299–303.
19. Chor J, Bregand-White J, Golobof A, Harwood B, Cowett A. Ibuprofen prophylaxis for levonorgestrel-releasing intrauterine system insertion: a randomized controlled trial. Contraception 2012;85:558–62.
20. Rowbotham MC. What is a ‘clinically meaningful’ reduction in pain? Pain 2001;94:131–2.
21. Todd KH, Funk KG, Funk JP, Bonacci R. Clinical significance of reported changes in pain severity. Ann Emerg Med 1996;27:485–9.
22. Hubacher D, Reyes V, Lillo S, Zepeda A, Chen PL, Croxatto H. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol 2006;195:1272–7.
23. Jensen HH, Blaabjerg J, Lyndrup J. Prophylactic use of prostaglandin synthesis inhibitors in connection with IUD insertion [in Danish]. Ugeskr Laeger 1998;160:6958–61.
© 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
24. Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT, et al.. Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial. Contraception 2015;91:193–7.