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#405 Taking the “ouch” out of IUD insertion: Can topical lidocaine help?


CLINICAL QUESTION
QUESTION CLINIQUE
 Does topical lidocaine decrease pain during tenaculum placement and intra-uterine device (IUD) insertion?

BOTTOM LINE
RÉSULTAT FINAL
 Topical lidocaine-prilocaine 2.5% cream reduces pain with tenaculum placement and copper/levonorgesterel IUD insertion by about 2-3 points more than placebo on a 10-point scale. Lidocaine spray reduces the proportion of women experiencing moderate/severe pain to 6% versus 41% on placebo, but ~55% experience vaginal irritation.  Topical lidocaine 2% is likely ineffective.


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EVIDENCE
DONNÉES PROBANTES
  • Results statistically different unless indicated. Scores reported on 10-point scale (lower=better). Mostly multiparous women.
  • Topical lidocaine-prilocaine (example: EMLA® 5% cream 2mL applied with cotton swab 5 minutes before procedure) versus placebo:
    • Systematic review [2 randomized, controlled trials (RCTs), 212 women]:1-2
      • Pain (tenaculum placement), mean difference: 2.3-2.8 points better than placebo.
      • Pain (copper-IUD insertion), mean difference: 2-2.8 points better than placebo.
    • Additional RCT, 140 women:3
      • Mean pain (tenaculum placement): 3 versus 4.5 (placebo).
      • Mean pain (levonorgestrel-IUD insertion): 2.1 versus 3.7 (placebo).
      • Patient satisfaction (10-point scale, higher=better): 8.4 versus 6.5 (placebo).
      • Vaginal irritation not reported.
  • Lidocaine 10% spray (example: 4 puffs to cervix 3 minutes prior to procedure) versus placebo:
    • RCT, 200 women:4
      • Median pain during “procedure” (copper-IUD): 1 versus 3 (placebo).
      • Proportion of women with pain score≥4: 6% versus 41% (placebo), Number Needed to Treat (NNT)=3.
    • RCT, 124 women:5
      • Mean pain (tenaculum placement): 0.8 versus 2.4 (placebo).
      • Mean pain (copper-IUD insertion): 3 versus 5 (placebo).
      • Proportion of women with pain score≥4 (IUD insertion): 39% versus 61% (placebo), NNT=5.
      • Vaginal irritation: 55% versus 1.6%.
  • Topical lidocaine 2% (various methods/sites, example: cotton swab, angiocatheter) versus placebo:
    • Systematic review (2-3 RCTs, 345-409 women),2 additional RCTs (59-220 women):6-9 tenaculum placement/IUD insertion pain: no difference. Exception: pain during tenaculum placement 3.2 versus 5.6 (placebo) in 1 RCT (59 women).9
      • Adverse events: No difference. Vaginal irritation: Not reported.
 
CONTEXT
CONTEXTE
  • NSAIDs, misoprostol, inhaled nitric oxide, topical nitroprusside or topical nitroglycerin: inconsistent to no effect.1,2 Paracervical block: Mixed results, injection itself painful.6 Methoxyflurane: Not studied for IUDs.10
  • Guidelines support topical lidocaine-prilocaine, but do not mention lidocaine spray.11
  • Minimum clinically important difference for pain is 1.3-2 (10-point scale).8

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Author(s)
Auteur(s)
  • Émélie Braschi MD PhD CCFP
  • Sanja Kostov MD CCFP FCFP
  • Jessica Kirkwood MD CCFP (AM)

1. Perez-Lopez FR, Martinez-Domiguez SJ, Perez-Roncero GR. et al. Eur J Contracept Reprod Health Care. 2018 Jun;23(3):207-217.

2. Lopez LM, Bernholc A, Zeng Y et al. Cochrane Database Syst Rev. 2015 Jul 29;2015(7):CD007373.

3. Hashem AT, Mahmoud M, Aly Islam B et al. Int J Gynaecol Obstet. 2024 May;165(2):634-643.

4. Aksoy H, Aksoy Ü, Ozyurt S, et al. J Fam Plann Reprod Health Care 2016 Apr;42:83-7.

5. Panichyawat N, Mongkornthong T, Wongwananuruk T, et al. BMJ Sex Reprod Health 2021 Jul;47(3):159-65.

6. Karasu Y, Cömert DK, Karadağ B et al. J Obstet Gynaecol Res 2017 Jun;43(6):1061-6.

7. McNicholas CP, Madden T, Zhao Q, et al. Am J Obstet Gynecol 2012 Nov;207(5):384.e1-6.

8. Conti JA, Lerma K, Schneyer RJ, et al. Am J Obstet Gynecol 2019 Feb;220(2):177.

9. Rapkin RB, Achilles SL, Schwarz EB, et al. Obstet Gynecol 2016 Sep;128(3):621-8.

10. Sairally BZF, De Silva PM, Smith PP, Clark TJ. BMJ Open. 2025 Feb 17;15(2) :e089031.

11. Directorate of Women and Diversity Health. Pain management for Intrauterine Device (IUD) insertion. Clinician support February 2024. https://www.canada.ca/content/dam/dnd-mdn/documents/health/IUD_Insertion_and_Pain_Management.pdf. Accessed on Nov 10-2025.

EB and JK have no conflicts of interest to declare. SK has received speaking honoraria from Bayer in the past year.