Conference Coverage

Physicians Underestimate Patient Pain from IUD Insertion



SAN DIEGO – Medical providers – especially physicians – underestimate how much pain a woman feels when an IUD is inserted, an analysis of data on 200 patients and their providers suggests.

The data came from a double-blind, randomized, placebo-controlled trial of intracervical lidocaine gel, compared with placebo, for relieving pain during IUD insertion; it found no advantage to lidocaine gel. This secondary analysis looked at patient and provider ratings for patient pain on a 100-mm visual analogue scale (VAS), with no pain at 0 mm and worst pain possible at 100 mm.

Dr. Karla E. Maguire

The point of maximum pain during the IUD insertion procedure rated a mean score of 64 from patients, compared with a mean rating of 35 from providers. That 29-mm difference was statistically significant, Dr. Karla E. Maguire and her associates reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Nineteen percent of providers rated patient pain within 10 mm of patients’ ratings. Twenty-three percent of providers gave ratings that were 50 mm or farther apart from patients’ pain ratings, said Dr. Maguire, an ob.gyn. at the University of Miami.

The results will be published in the journal Contraception, she said.

Patients rated pain at four points during the procedure: tenaculum placement; uterine sounding; IUD insertion; and speculum removal. Patients and providers agreed about the timing of maximum pain 41% of the time – a very poor level of agreement, she said.

Uterine sounding was rated the most painful point by 40% of patients and 45% of providers. IUD insertion was rated the most painful point by 36% of patients and 15% of providers. Tenaculum placement was rated the most painful point by 14% of patients and 25% of providers. Speculum removal was rated the most painful point by 10% of patients and 5% of providers. No patients and 8% of providers said patients felt no pain. Three percent of providers (and no patients) wrote in some other point of maximum pain for the procedure instead of answering the multiple-choice question.

Ratings by the midlevel providers were slightly but significantly closer to patient ratings, compared with physician ratings – 7 points closer, on average, Dr. Maguire said. The midlevel providers were no better than were attending physicians, however, in estimating the point of maximum patient pain during the procedure.

The mean age of the patients was 27 years. The cohort was 77% Latina/Hispanic, 13% white, and 10% other races/ethnicities. Thirty percent were nulliparous. Their mean pain score for past episodes of dysmenorrhea was 35. They anticipated a pain rating of 57 for the IUD insertion procedure.

Among the providers, 91 (46%) were physicians, 91 (46%) were nurse practitioners, certified nurse-midwives, or physician assistants, and 18 (9%) were residents. Most (52%) had 11-20 years of experience in IUD insertion, while 26% had 5-10 years of experience, and 22% had less than 5 years of experience.

The IUD insertion procedures were done in public clinics in 80% of cases and in private clinics in 20%.

The pain that accompanies IUD insertion may be a barrier to wider use of IUDs, she said. Previous studies suggest that pain is more likely in nulliparous women, those whose last pregnancy is remote from the time of IUD insertion, in women with dysmenorrhea, when pain is highly anticipated, or with the levonorgestrel IUD.

Previous studies have shown that medical providers underestimate patient pain in emergency departments, family medicine clinics, during cystoscopy, and in patients with coronary artery disease. Other studies suggest that differences in pain ratings by patients and physicians are predictive of inadequate pain management. Underestimating pain could result in less research on new methods of pain relief.

The current study’s large sample size and variety of providers were strengths, but it was a secondary analysis and may not be generalizable to other settings, Dr. Maguire said.

"More research needs to be done to provide patients with better anesthesia for IUD insertion," she said.

Approximately 6% of U.S. women who use contraceptives choose IUDs, she said. Both the copper IUD and levonorgestrel IUD have low failure rates (0.8% and 0.2% per year with typical use, respectively) and high percentages of users who choose to continue using the device (78% and 80%, respectively).

Dr. Maguire reported having no relevant financial disclosures.

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