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Am Fam Physician. 2017;96(11):online

Author disclosure: No relevant financial affiliations.

Clinical Question

Is there a benefit to using local anesthesia for intrauterine device (IUD) insertion or endo-metrial biopsy?

Evidence-Based Answer

Topical application of lidocaine/prilocaine cream to the cervix reduces mean pain scores during IUD insertion. Intrauterine instillation of liquid anesthesia reduces median pain scores during endometrial biopsy. (Strength of Recommendation: B, based on a single randomized controlled trial.)

Evidence Summary

A 2015 randomized, controlled, triple-blinded study of 46 Iranian women examined the effectiveness of lidocaine/prilocaine 5% cream (25 mg of lidocaine and 25 mg of prilocaine per g) applied to the cervix in reducing pain from copper IUD insertion or removal.1 Pain severity was assessed using a validated 10-cm visual analog scale after applying 5 g of cream to the cervix and external os with a cotton swab, then waiting seven minutes for anesthesia onset. Scores of 1 to 3, 4 to 6, 7 to 9, or 10 indicated mild, moderate, severe, and extremely severe pain, respectively. Pain severity during the first stage (tenaculum application) was significantly lower with lidocaine/prilocaine cream compared with placebo (mean pain scores of 1.5 vs. 4.3; P < .001). During the second stage (insertion of uterine sound), the mean pain score was also lower with lidocaine/prilocaine cream vs. placebo (3.1 vs. 5.2; P < .001). Similarly, the mean pain score during the last stage (insertion or removal of the IUD) was significantly lower with lidocaine/prilocaine cream vs. placebo (2.6 vs. 4.6; P < .001).

A randomized, double-blind, placebo-controlled trial in pre- and postmenopausal women compared pain levels during endometrial biopsy using local intrauter-ine anesthesia and placebo.2 Trial medications (0.9% saline for the control group vs. 0.5% levobupivacaine [no longer available in the United States] or 2% lidocaine for the experimental group) were identical in appearance and consistency. Technical variation was minimized by using a similar technique to instill 5 mL of unlabeled solution into the uterine cavity before endometrial biopsy using an 18-gauge angiocatheter. Endometrial biopsy was performed using the same technique by the same small group of resident physicians. Time between instillation and biopsy was 15 minutes to allow for anesthesia onset. Median pain scores during biopsy in the lidocaine and levobupivacaine groups were significantly lower than those in the control group (1 vs. 3; P < .001). Of note, insufficient biopsy material was obtained only in the control group (pathologists also blinded).

Copyright Family Physicians Inquiries Network. Used with permission.

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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