P-089 - Evaluating the Efficacy of Prophylactic NSAIDs in Reducing Pain During Intrauterine Device Placement: A Systematic Review

Abstract Title: Evaluating the Efficacy of Prophylactic NSAIDs in Reducing Pain During Intrauterine Device Placement: A Systematic Review

Background: Intrauterine devices (IUD) have a one-year failure rate of less than 1% making it one of the most effective birth control options on the market. Despite the devices having been utilized for many years, a barrier to access remains fear of pain during insertion. Oligoanalgesia for women’s pain has been well-documented. Studies have shown that women presenting to the emergency department are less likely to receive appropriate pain medication treatment and are more likely to be diagnosed with a mental health condition when presenting with a chronic pain concern. Disparities in pain management extend to outpatient procedures like IUD insertion. Like all forms of pain, the severity varies from person-to-person ranging from moderate discomfort to extreme. Various forms of analgesia have been studied to reduce IUD insertion pain including paracervical block, topical analgesics, misoprostol and NSAIDs. No method has produced consistently effective results both in the literature and in clinical practice. Due to lack of clear evidence and guidelines, providers in the community resort to using NSAIDs. Other systematic reviews in the past have analyzed pain reduction methods at insertion. However, no review has focused on NSAIDs alone, which is the most commonly recommended analgesic for pain reduction.

Purpose/Objectives: The present study's purpose was to incorporate updated research on the efficacy of prophylactic NSAIDs at reducing pain during IUD insertion. By adding to the body of literature on this topic, a more thorough and updated clinical decision can be made by healthcare providers, medical associations and patients.

Methods: Pubmed, Embase and Web of Science databases were searched using appropriate key terms to identify all articles associated with IUD insertion and pain including “intrauterine devices”, “NSAID” and associated Mesh headings. The initial search retrieved 5,178 studies. 1,288 were duplicate articles. 3,868 studies were excluded yielding 22 full-text studies that were retrieved. Inclusion criteria included: 1) Studies that compare different methods of pain control during IUD insertion 2) Studies that measure pain outcomes using validated scales 3) Studies that include women of reproductive age who are eligible for IUD insertion, regardless of parity, previous experience, or geographic location and 4) Studies that have been published in peer-reviewed journals, in English language, since the year 2000. For each study, primary and secondary outcome measures, VAS pain scores for the treatment and placebo groups, the pharmacologic intervention used with corresponding dosage and method of delivery, and the number of participants in the treatment and control groups were analyzed.

Results: 14 studies were included. Pharmacologic interventions included: 375 mg oral naproxen, 550 mg oral naproxen (2 studies), 550 mg oral naproxen sodium, 150 mg oral ketoprofen, 20 mg oral ketorolac, 30 mg intramuscular ketorolac, 800mg oral ibuprofen (2 studies), 400 mg oral ibuprofen (3 studies), 120 mg etoricoxib oral, and 100 mg oral diclofenac. In 11 out of 14 of the included studies (78.6%), prophylactic NSAID usage was not clinically significant for pain control during IUD insertion. Mean VAS scores with prophylactic NSAIDs ranged from 1.8 to 7.3 with the average being 4.25. The largest pain reduction found amongst the included studies was 39.75%, while the least reduction in pain was 0%. Amongst the three studies that found a significant pain control following prophylactic NSAIDs, two studies found that NSAIDs were effective at all steps of the procedure except for tenaculum placement. Another study tested the efficacy of three different treatment groups: tramadol, NSAIDs and a placebo. While they found a statistical difference with NSAIDs, the authors reported a larger clinical significance with tramadol.

Conclusions/Implications for future research and/or clinical care: We conducted a systematic review of randomized-control trials. Our findings suggest the use of prophylactic NSAIDs for pain reduction during IUD insertion is not clinically significant for the majority of women undergoing the procedure. An IUD is a long term, effective form of birth control; The lack of clinical trials demonstrating a significant reduction in IUD pain insertion through the use of prophylactic NSAIDs emphasizes the importance of increased research dedicated to finding an appropriate pain management option. This importance is further corroborated by the public outcry for the improvement of women’s reproductive health services, with women sharing their stories and signing petitions for better pain relief for both IUD insertions and removals. It is the author’s opinion that clinical guidelines should be updated appropriately.

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