FPIN's Help Desk Answers

Pain Medications Before IUD Placement


Am Fam Physician. 2020 Jan 15;101(2):119-120.

Clinical Question

Do preprocedure medications affect the pain of intrauterine device (IUD) insertion?

Evidence-Based Answer

Topical lidocaine preparations including gels, creams, and sprays may modestly decrease pain with tenaculum placement but not during IUD insertion. (Strength of Recommendation [SOR]: A, based on a meta-analysis of randomized controlled trials [RCTs].) The use of a paracervical block with unbuffered lidocaine does not decrease pain with either step. (SOR: A, based on a meta-analysis of RCTs.) However, a paracervical block using buffered lidocaine may decrease pain with uterine sounding and IUD placement, as well as overall pain. (SOR: B, based on an RCT.) Tramadol and naproxen decrease pain with IUD placement. (SOR: A, based on a meta-analysis of RCTs.)


A 2018 meta-analysis of 11 RCTs (N = 1,458) evaluated the effects of a paracervical lidocaine block or application of lidocaine to the genital mucosa before IUD insertion in nulliparous and parous women.1 Copper IUDs and the levonorgestrel-releasing intrauterine system (Mirena) were used. Pain was assessed using a 0- to 10-point visual analog scale, with higher numbers indicating more pain. A lidocaine preparation of 2.5% gel (three trials) or 2.5% cream (one trial), or a combination of 2.5% lidocaine and 2.5% prilocaine cream (two trials) was applied to the ectocervix, in the cervical canal, or both. Lidocaine 10% spray (two trials) was applied as four pumps (40 mg) to the ectocervix, and paracervical blocks (four trials) were performed as unbuffered 1% lidocaine injections on either side of the cervix and at the tenaculum site. Control interventions were placebo or no intervention. As a group, genital mucosa lidocaine applications reduced pain with tenaculum placement (six trials; n = 764; mean difference [MD] = −1.0; 95% CI, −1.9 to−0.09) compared with placebo or no intervention, but there was no significant difference with IUD insertion (seven trials; n = 828; MD = −1.0; 95% CI, −2.0 to 0.01). There was

Author disclosure: No relevant financial affiliations.

Copyright © Family Physicians Inquiries Network. Used with permission.

Address correspondence to Kyaw Naing, MD, PhD, at knaing@siumed.edu. Reprints are not available from the authors.


1. Perez-Lopez FR, Martinez-Dominguez SJ, Perez-Roncero GR, et al. Uterine or paracervical lidocaine application for pain control during intrauterine contraceptive device insertion: a meta-analysis of randomized controlled trials. Eur J Contracept Reprod Health Care. 2018;23(3):207–217.

2. Mody SK, Farala JP, Jimenez B, et al. Paracervical block for intrauterine device placement among nulliparous women. Obstet Gynecol. 2018;132(3):575–582.

3. Lopez LM, Bernholc A, Zeng Y, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2015;(7):CD007373.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN's Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.



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