Intrauterine contraception insertion pain: nursing interventions to improve patient experience

Abstract

Aims and objectives

To examine factors which contribute to the individual’s experience of pain in relation to intrauterine contraception insertion and determine evidence-based nursing strategies to best assess and manage this pain.

Background

Nurses are increasingly involved in consultations regarding intrauterine contraception. However, concerns regarding painful or difficult insertion may inhibit uptake and discourage nurses from promoting or inserting intrauterine contraception.

Design

Integrative review.

Methods

Database searches of CINAHL, PubMed, Wiley Online Library and the Cochrane Collaboration for relevant literature. Eight papers met the inclusion criteria and were analysed using an integrative review process.

Results

Physical causes and pharmacological interventions for insertion pain have been thoroughly investigated. Absence of previous vaginal delivery and anxiety may increase the likelihood of procedural pain. The literature fails to conclusively determine any universally effective prophylactic analgesia. Cervical anaesthesia may be beneficial in some cases and oral analgesia may relieve postprocedural pain. Distraction in the form of conversation, music or television can be effective in reducing anxiety.

Conclusions

A combination of physical, psychological and environmental factors contribute to the individual’s pain experience. Nurses have the potential to make a significant impact on pain outcomes by demonstrating clinical expertise and creating a trustful environment. Giving reliable information, acknowledging the significance of anxiety and providing reassurance and distraction are effective pain reducing strategies. Research into nonpharmacological approaches is warranted, especially those which reduce anxiety.

Relevance to clinical practice

Increasing uptake of long-acting reversible contraception is a public health goal. Providing effective pain management strategies to improve patient experience may encourage more nurses to recommend, or enhance their scope of practice to include, intrauterine contraception insertion.

What does this paper contribute to the wider global clinical community?

  • Prevention of unplanned pregnancies is a global concern.
  • Providing nurses with strategies to improve women’s experience of pain may increase uptake of intrauterine contraception.

Introduction

Long-acting reversible contraceptives (LARCs) are widely acknowledged as being extremely safe, reliable and cost-effective methods of preventing unplanned pregnancies (National Institute for Health and Care Excellence 2005). Intrauterine contraception (IUC) in the form of either the copper intrauterine device (Cu-IUD) or the levonorgestrel intrauterine system (LNG-IUS) is a highly effective but under-used method of LARC (Faculty of Sexual and Reproductive Healthcare (FSRH) 2015). Fear of painful insertion is a recognised barrier to the uptake of IUC (Asker et al2006, Lopez et al2015, Wiebe 2015). Insertion pain may be influenced by physical, psychological and provider-related factors. Nulliparity, anxiety or anticipation of pain (Lopez et al2015) and the skill of the healthcare provider (HCP) can all influence the individual’s pain experience. Nurses have a responsibility to facilitate informed decision-making regarding LARCs (Royal College of Nursing 2011) and to take a holistic view of each client’s individual reproductive healthcare needs (World Health Organisation 2004). It therefore follows that nurses must include consideration of pain as part of IUC provision and use evidence-based strategies to minimise this pain.

Aims

This review was conceptualised to examine the literature regarding pain related to IUC insertion from a nursing perspective. The majority of the existing literature aims to provide recommendations regarding pharmacological analgesic or anaesthetic interventions. However, there is scope for a broader appraisal of the topic which also considers nonpharmacological interventions and how aspects of care provision and attributes of the care provider may influence pain related outcomes and improve the patient’s experience.

This review aims to:

  • Identify and summarise the evidence regarding options for analgesia with proven efficacy.
  • Examine the nonphysical aspects to IUC insertion pain and explore nonpharmacological interventions.
  • Determine strategies that exploit core nursing attributes such as trust, advocacy and clinical expertise.

Methods

An initial search was performed with the aim of identifying relevant literature that could inform the development of strategies to enhance provision of nursing care in relation to IUC insertion pain. Databases considered most likely to yield the highest quality evidence were searched including the Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Collaboration database, Wiley Online Library and MEDLINE. In an attempt to capture literature relevant to both the Cu-IUD and LNG-IUS, the following keywords were used: intrauterine contraception, intrauterine device, intrauterine system, insertion and pain. The choice of keywords influences the results yielded (Timmons & McCabe 2005) and, cognisant of this, additional keywords anxiety, psychological, assessment, management and nursing were used along with the Boolean operators and/or to facilitate various combinations and phrases. Taking into account recent developments in IUC, such as the variety and modifications in design and size of applicators and devices, inclusion/exclusion criteria confined results to systematic reviews and randomised controlled trials with full text available online, published in English since 2005. As most IUC users live outside Europe, 80% in Asia with 64% of those in China (Buhling et al2014), no geographical limitations were imposed on the search in the hope of revealing literature which may provide an international perspective.

The CINAHL database yielded the most results from the initial search terms with the additional keywords and phrases failing to illicit a significantly greater amount or more relevant papers. Abstracts were reviewed to determine relevance to aims of this paper and reference lists were hand-searched to detect further resources. Greater confidence was placed in literature published in peer-reviewed journals (Aveyard & Sharp 2009).

The literature search process is represented in Fig. 1: Prisma Flow Diagram (2009).

The most common form of literature emergent from the search was reports of trials analysing the effectiveness of various forms of analgesia prior, during and post-IUC insertion. Many of these studies are assessed or referenced in the Cochrane Collaboration’s systematic review of randomised, controlled trials (Lopez et al2015) and/or the Faculty of Sexual and Reproductive Healthcare’s Clinical Guidance on IUC (FSRH 2015). Literature examining nonpharmacological interventions, exploring psycho-social factors of pain specific to the procedure or written from a nursing perspective, was notably less prevalent. With the aim of eliciting more comprehensive, relevant data, the literature search was expanded to include grey and anecdotal literature, nursing theories associated with concepts of care and pain theories.

Due to the diversity of the literature reviewed here, an integrative review process was deemed to be the most appropriate and was used with the intention that it would allow for analysis of various levels of evidence and elicit the most cohesive outcome. This approach is described as follows: ‘The integrative review method is an approach that allows for the inclusion of diverse methodologies (i.e. experimental and nonexperimental research) and has the potential to play a greater role in evidence-based practice for nursing’ (Whittemore & Knafl 2005, p. 547). Themes were identified from the literature and data assigned to the most relevant category. Evidence was synthesised to create a comprehensive and logical presentation of the hypothesis.

Results

Eight papers were included and assessed in the initial review (Table 1).

Table 1. Literature included in this review
First author, year (country of first author) Objective Design Sample size Main conclusions
Angioli et al2014 (Italy) Investigate the effects of music on anxiety and perception of pain during office hysteroscopy Prospective randomised trial 356 Music was effective in reducing anxiety and pain in women undergoing outpatient hysteroscopy
Bahamondes et al2014(Brazil) Provide practical strategies for the avoidance of intrauterine contraception (IUC) insertion pain Consensus recommendations based on the literature review and clinical experience 5 authors Counselling, environment, attributes and skill of the healthcare provider can all impact on the woman’s level of anxiety which can in turn influence her perception of pain
Brima et al2015 (UK) Compare expected & actual pain experienced with IUC insertion Convenience sampling 89 All women had high expectation of pain. Women without prior vaginal delivery had significantly higher actual pain than women with previous vaginal delivery (who had significantly greater expected pain than actual pain)
Brown & Trouton 2014(Canada) Examine the effects of parity and analgesia/anaesthesia on pain at IUD insertion Retrospective chart review 354 Cervical anaesthesia may cause slightly more pain without any obvious additional benefit. IUDs were well tolerated by nulliparous women
Faculty of Sexual & Reproductive Healthcare, 2015 (UK) Provide evidence-based recommendations and good practice points for health professionals on the use of IUC currently available in the UK Clinical guidance based on literature review Summary evidence tables ‘Available on request from the CEU’ (FSRH 2015)

No evidence to support the use of topical lidocaine, misoprostol or NSAIDs for improving ease of insertion or reducing IUC insertion pain.

Local anaesthetic block administered by cervical injection is not routinely required for IUC insertion but should be offered when cervical dilatation is required or difficult IUC insertion or removal is anticipated/experienced.

NSAIDs can be offered to women who experience pain after insertion

Galaal et al2011 (UK) Evaluate interventions designed to reduce anxiety levels during colposcopic examination Systematic review of RCTs 6 trials; 1102 participants Anxiety is reduced by playing music to women attending for outpatient colposcopy. Leaflets were not effective in reducing anxiety but increase knowledge & patient quality of life by reducing psychosexual dysfunction
Gemzell-Danielsson et al2013(Sweden) Critically evaluate the evidence for IUC insertion pain management strategies Literature review 17 trials; 3326 participants, 1 literature review No prophylactic pharmacological intervention reduces IUC insertion pain. NSAIDs may reduce postinsertion pain. Anxiety may contribute to higher perception of pain. ‘Verbal anaesthesia’ and the experience of the provider play a major role in decreasing anxiety and pain
Lopez et al2015 (USA) Review RCTs of interventions for reducing IUC insertion-related pain Systematic review of RCTs 33 trials; 5710 participants Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol, and naproxen had some effect on reducing IUC insertion-related pain in specific groups. The ineffective interventions do not need further research

Analysis of the literature revealed several themes which are discussed below:

  • Physical elements of pain: IUC insertion, predictors of pain, analgesia and anaesthesia, heat and cold, instruments and insertion technique.
  • Psychological elements of pain: anxiety, information, environment, distraction, trust.
  • Pain assessment.

Physical elements of pain

IUC insertion

Intrauterine contraception insertion is performed by inserting a speculum into the vagina, applying tissue forceps to the cervix to aid positioning, measuring the height of the uterine cavity by passing a uterine sound through the cervical os (dilating the os if necessary with a dilator) and fitting the device via an inserter through the cervical os to the depth of the uterine fundus. Pain is induced by IUC insertion from a noxious insult to the viscera of the cervix and uterus stimulating nociceptive receptors transmitting to the dorsal horn, the S2 to S4 parasympathetic nerves and T10 to L1 sympathetic fibres. There is potential for the woman to experience pain during each of these stages of insertion (Lopez et al2015) with as many as 17% of women rating this pain as severe (Bahamondes et al2014). Women were reported as experiencing varying levels of pain at tenaculum placement, IUC insertion and up to six hours postinsertion. However, there was a general consensus that uterine sounding elicited the highest pain scores (Lopez et al2015). Bimanual examination with palpation of the uterus will inform the clinician of which direction to sound the uterus and insert the IUC and may reduce pain incurred at both of these stages (Bahamondes et al2014).

Predictors of pain

Lopez et al. (2015) cite Hubacher et al. (2006) and Kaislasou et al. (2014) when identifying predictors associated with greater pain: nulliparity or absence of vaginal delivery, interval since last delivery and/or last menses, not currently breastfeeding and a history of dysmenorrhoea. As women are often advised to attend for insertion during their menses (as the cervical os may be more accessible and to exclude pregnancy), a woman with a history of dysmenorrhoea is likely to already be in pain before insertion commences. The physical sequelae to these factors are a narrower, more restricted cervical os which is more difficult to access and a greater degree of endometrial irritation and uterine cramping. Lopez et al. (2015) also consider patient’s age greater than thirty years as a contributory factor, although neither Mody et al. (2012), nor the largest study in the review (Hubacher et al2006) find evidence which supports this hypothesis. Brown and Trouton (2014) do not find a positive correlation between age and pain. Mody et al. (2012) are alone in attributing a lower body mass index to higher pain intensity.

In their UK study, Brima et al. (2015) conclude that sociodemographic factors such as age and race have little bearing on actual pain experienced and also determine the most common predictor of greater pain was never having a vaginal delivery. Participants with prior experience of a vaginal delivery reported scores of expected pain as much as 50% higher than actual insertion pain, whereas there was much less discrepancy between the pre- and postinsertion pain scores of women without a vaginal delivery. The authors urge clinicians to consider reducing the threshold for administering analgesia in nulliparous women and those with nonvaginal deliveries.

The effect of a full bladder on IUC insertion pain was investigated by Cameron et al. (2013), and this study is cited by Lopez et al. (2015) and the FSRH (2015). No significant difference between the pain scores of the intervention or control groups was found.

Analgesia and anaesthesia

The Cochrane Collaboration initially undertook a review and meta-analysis of trials of anaesthetic and analgesic interventions at IUC insertion in 2009 and concluded that ‘no interventions that have been properly evaluated reduce pain during or after IUD insertion’ (Allen et al2009, p. 2). The review has subsequently been updated (Lopez et al2015) to include relevant studies published between 2010–2015. It is explicit in its methodology and systematic in its approach to analysing and synthesising the substantial number of papers included (33 trials with a total of 5710 participants). Rigorous and consistent scrutiny of the various research techniques and controls is evident throughout this review. Interventions assessed include the following: local anaesthesia applied topically or directly into the cervix, cervical ripening agents, oral opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), inhaled nitric oxide.

The updated Cochrane review concludes that the ‘most effectiveness evidence was of moderate quality, having come from single trials. Lidocaine 2% gel, misoprostol, and most NSAIDs did not help reduce pain. Some lidocaine formulations, tramadol and naproxen had some effect on reducing IUC insertion-related pain in specific groups’ (Lopez et al2015, p. 2). Therefore, the review fails to establish enough high-quality evidence to support the use of any particular analgesic or anaesthetic preparation which would be universally effective, suitable or acceptable for all women undergoing IUC insertion. The authors also conclude that ‘practitioners still need better interventions than those generally used’ (Lopez et al2015, p. 22). The Cochrane review is successful in achieving its aim of analysing the effectiveness of interventions, synthesising results, identifying areas that do and do not warrant future investigation and providing guidance for practitioners. Synthesised data such as this are considered high-quality evidence (Greenhalgh 2014).

Gemzell-Danielsson et al. (2013) also undertook a literature review of pain management for IUC insertion. The authors considered seventeen studies: fifteen trials of pharmacological interventions (pre- and postinsertion oral analgesia, cervical priming and local anaesthesia) and two nonrandomised trials of nonpharmacological interventions. From these, the conclusion is made that ‘no prophylactic pharmacological intervention has been adequately evaluated to support the routine use for pain reduction during or after IUC insertion’ (Gemzell-Danielsson et al2013, p. 419).

The FSRH also published an updated version of their clinical guidance on IUC last year (FSRH 2015). Their recommendations regarding pain management occasionally differ from Lopez et al. (2015) but again, they find no universally effective analgesia and state ‘there is no evidence from current trials to support the use of topical lidocaine, misoprostol or NSAIDS for improving ease of insertion or reducing pain during insertion of intrauterine methods’ (FSRH 2015, p. 22). However, local anaesthetic block administered by cervical injection ‘should be offered when cervical dilatation is required or difficult IUC insertion or removal is anticipated/experienced’ (FSRH 2015 p. 22). The analysis of a randomised trial of para-cervical block of 1% lidocaine (Cirik et al2013) includes the observation that ‘Pain experienced during injection was not reported. Further studies are required to fully evaluate the use of LA cervical block for straightforward IUC insertion’ (FSRH 2015, p. 22). Brown and Trouton (2014) offer a different opinion on cervical anaesthesia and conclude that it ‘may cause slightly more pain, without any additional benefit’. However, the retrospective, nonrandomised nature of their study limits the generalisability of their findings. Gemzell-Danielsson et al. (2013) encountered difficulty evaluating the different local anaesthesia techniques in the papers they reviewed and advocate cervical anaesthesia for ‘reactive’ rather than routine administration when the degree of pain or difficulty of insertion warrants its use. Further study into the administration pain of intracervical injection and its acceptability to patients and clinicians is therefore warranted.

Heat and cold

Physical therapies, including use of heat and cold, should be considered as first-line treatments for pain (IASP 2010). The IASP acknowledges the link between IUC use and dysmenorrhoea and considers heat therapy as ‘likely to be beneficial’ in the treatment of dysmenorrhoea (Berkley 2013, p. 3). Bahamondes et al. (2014) give anecdotal testament of the benefits of a hot water bottle held suprapubically by the woman which was found to be comforting. Chemical warming packs may be a suitable alternative. Conversely, cold therapy was reported as being an effective treatment for labour pains (Shirvani & Ganji 2014). There is scope for further exploration of cold and heat therapies in relation to uterine cramping pain during and post-IUC insertion.

Instruments and insertion technique

Bahamondes et al. (2014) offer consensus recommendations on the avoidance of IUC insertion pain. The same authors published a review of the literature on the, mainly pharmacological, management of IUC insertion pain, which is also included here (Gemzell-Danielsson et al2013). The later paper aims to provide more practical and nonpharmacological strategies for clinical practice, the main weakness of which being that they are mostly anecdotal and nonevidence based. Inclusion in this review is justified by the expert status of the authors and their discussion of strategies that are scarcely found elsewhere. The authors also provide an international perspective on the subject as they are based, respectively, in South America, the UK, Austria, the USA and Sweden.

Recommendations regarding instrumentation and insertion procedure include use of the following:

  • Fine cervical dilator, inserted slowly to allow the os to stretch;
  • Metal, resterilisable instruments (as disposable plastic instruments are often ineffective);
  • Short bivalve speculum; fine tenaculum forceps;
  • Use of a dental syringe to administer cervical anaesthesia,
  • Tapered cervical dilators.

The FSRH (2015) also note that slow application of multitooth forceps is a common practice in minimising pain but find insufficient evidence to recommend any particular instrument or application technique.

The main pharmacological interventions (Table 2) and nonpharmacological interventions (Table 3) for pain emergent from the literature review have been summarised.

Table 2. Pharmacological interventions
Paper Intervention Indication Effectiveness

Lopez et al. (2015)

FSRH (2015)

Misoprostol via sublingual, buccal or vaginal administration Nulliparity or absence of vaginal delivery or any case which necessitated cervical dilation and used prior to insertion Neither paper found this intervention to be of benefit. Side effects including uterine cramping, shivering and headache were noted

Lopez et al. (2015)

FSRH (2015)

1% lidocaine para-cervical block Nulliparity or absence of vaginal delivery. Prior to insertion Both papers found this intervention to be of benefit
Lopez et al. (2015) 2% lidocaine gel applied topically to the cervix Prior and during intrauterine contraception (IUC) insertion No effect on pain at tenaculum placement or during IUC insertion
Lopez et al. (2015) 4% lidocaine gel applied topically to the cervix Nulliparity or absence of vaginal delivery, applied prior to insertion Reduction in pain during and post-IUC insertion
Lopez et al. (2015) 10% lidocaine spray Parous women with a previous vaginal delivery. Applied prior to insertion Beneficial
Lopez et al. (2015) Lidocaine and prilocaine (Emla) cream During and postinsertion Beneficial
FSRH 2015 Any topical lidocaine preparation Any category No benefit
FSRH 2015 Nonsteroidal anti-inflammatory (NSAIDs) Prior to IUC insertion Ibuprofen 600 mg administered prophylactically at differing intervals was found to have no benefit
Lopez et al. (2015) Oral NSAIDs During and post-IUC insertion. Nulliparous and multiparous women Naproxen 550 mg beneficial but ibuprofen has no benefit
FSRH 2015 Oral NSAIDs During and post-IUC insertion No reduction in pain during IUC insertion but NSAIDs including ibuprofen beneficial for postinsertion pain
Lopez et al. (2015) Opioid analgesics During and post-IUC insertion Tramadol 50 mg found to be slightly more beneficial than naproxen
Table 3. Nonpharmacological interventions
Paper Intervention Indication Effectiveness
Lopez et al. (2015) Inhaled scent of lavender essential oil All women prior to and during intrauterine contraception (IUC) insertion Reduced anxiety but not pain scores
Lopez et al. (2015) FSRH (2015) Full bladder All women, during IUC insertion No improvement in pain scores whether bladder full or empty
Bahamondes et al. (2014) Use of smaller surgical instruments All women, during IUC insertion Anecdotal evidence only
FSRH (2015) Use of multitoothed rather than single-tooth tissue forceps (applied slowly to the cervix) All women, during IUC insertion Not conclusively beneficial
Bahamondes et al. (2014) Hot water bottle All women, during IUC insertion Beneficial as a source of heat therapy and as a distraction
FSRH (2015) IUC device: comparison of CU-IUDs, 52 mg LNG-IUS and 13·5 mg LNG-IUS All women, during IUC insertion

No difference between framed CU-IUDs.

CU-IUD was less painful than 52 mg LNG-IUS insertion post topical lidocaine gel.

13·5 mg LNG-IUS less painful than 52 mg LNG-IUS but the trial failed to use a validated pain measurement tool

Angioli et al. (2014) Music All women, during hysteroscopy Beneficial; reduced anxiety and pain
Galaal et al. (2011) Music All women, during colposcopy Beneficial; reduced anxiety and pain

Psychological elements of pain

Anxiety

There is widespread recognition of the significance of nonphysical elements of the overall pain experience and the link between anxiety and pain (Gemzell-Danielsson et al2013, Bahamondes et al2014, Maguire et al2014). However, there is a paucity of literature that addresses this issue or provides practical strategies. Gemzell-Danielsson et al. (2013) identify the women most likely to be anxious as those with a history of sexual trauma, mood disorders, previous negative reaction to vaginal examination, previous painful IUC insertion or knowledge of another’s painful IUC insertion experience. Lopez et al. (2015) acknowledge the potential for anticipated pain anxiety to increase actual pain experienced, yet only include one trial of anxiety-reducing intervention in their review: the effect of inhaled lavender scent (Shahnazi et al2012). This could possibly be due to a lack of any additional studies available for analysis at the time. However, if this was the case, it is surprising that the authors do not recommend further research in this area. Similarly, the FSRH (2015) also acknowledge the significance of anxiety but fail to provide guidance regarding assessment, management strategies or counselling for this problem.

Information

Gemzell-Danielsson et al. (2013) and Brima et al. (2015) cite an earlier study (Newton & Reading 1977) when advocating psychological preparation interviews to reduce anxiety and pain expectation. Providing information and clarifying uncertainties resulted in higher tolerance of discomfort. Patients want the truth about pain (Kaufman 2009) and nurses have a duty to be truthful about treatments or procedures that are likely to be painful (Nursing & Midwifery Board of Ireland 2014). However, providing an accurate estimation of anticipated pain levels can prove challenging as pain is such an individual experience and women have differing preferences regarding the amount of information they wish to receive (Bahamondes et al2014). Also, giving the patient an expectation of pain or a belief that a treatment will be painful can exacerbate symptomatic pain, a condition termed nocebo hyperalgesia (Atlas & Wager 2012). Therefore, the nurse must employ considerable skill and a bespoke balance of honesty and reassurance in order to successfully counsel a patient prior to a painful procedure. It may be useful to explain to the patient that the level of pain experienced during IUC insertion is highly variable and therefore difficult to predict, whilst also reassuring her of the measures that will be taken to minimise any discomfort (Bahamondes et al2014).

Brima et al. (2015) compare the expectation of pain with actual pain levels during IUC insertion and discuss a possible link between anxiety and pain anticipation. All of the participants in this convenience sample study anticipated a high level of IUC insertion pain when completing a numerical pain rating scale prior to the procedure. However, women with a previous experience of a vaginal delivery had significantly lower actual than expected pain; median (p < 0·001). This result would suggest that any anxiety experienced by these women did not affect their actual pain experience. All of the participants received application of 2% lidocaine gel to the cervical canal which was given two minutes to take effect. The analysis would have benefitted from a control group against which to compare results. The authors acknowledge the positive influence that information given prior to the procedure may have on anxiety levels and state that all of the women in their study were counselled on the same day as the IUC insertion. However, the format or type of information the women received is not detailed. It would be interesting to consider the benefit (or otherwise) of information given prior to the day of insertion and there is scope here for further study. The main strength of the study is the conclusiveness of the two main findings: that all women report high levels of anticipated IUC insertion pain and those women without prior vaginal delivery experience a greater degree of actual pain. There is a clear recommendation for further investigation into assessment and management of anxiety and expected pain. It is also encouraging to note that 91% of the participants expressed satisfaction with the procedure.

Environment

Gemzell-Danielsson et al. (2013) discuss the importance of creating a trustworthy, unhurried and professional atmosphere within which to counsel patients undergoing IUC insertion. Ensuring privacy is paramount, temperature and ambience are also reported as being important, and women prefer an informal atmosphere in the clinical room. Women chose contraception services where their feelings of unease are managed well, staff communicate effectively and demonstrate sensitivity to their patients’ emotions and comfort during procedures (Dixon-Woods et al2001, IASP 2011). Asker et al. (2006, p. 89) describe patients’ concerns regarding the ‘mess and embarrassment’ of IUC fitting and recommend addressing these issues as part of the preinsertion counselling.

Distraction

Gemzell-Danielsson et al. (2013) highlight the importance of reducing anxiety via preinsertion counselling and providing distraction and reassurance during the procedure, a method they refer to as ‘verbal anaesthesia’. Guillebaud also advocates the use and benefits of conversation as a distraction during IUC insertion, a technique he terms ‘vocal local’ (Guillebaud 2004, p. 418). Having an assistant to help provide distraction is one of the most effective ways of reducing pain and anxiety (Bahamondes et al2014).

As discussed previously, anecdotal testament of the benefits of a hot water bottle held suprapubically by the woman was found to be comforting but, in addition, the action of holding the bottle gave women a distraction as in ‘something to do’ (Bahamondes et al2014, p. 56). A very recent study by Akintomide et al. (2016) reports that patients found watching television an effective distraction during reproductive health procedures including IUC insertion (this paper is not included for analysis here as it was published after the initial literature search for this review).

Trust

Kaufman (2009) advocates honesty whilst discussing pain to foster a trusting and mutually respectful relationship. Straightforward sharing of information and absence of false assurances can avoid the incidence of unexpected pain and consequent feelings of betrayal or deception. Women are sensitive to the relationship and interplay between HCPs wherein ‘a well-functioning team inspires confidence and reduces anxiety which may, in turn, have a positive impact on their perception of pain’ (Bahamondes et al2014, p. 55). This theory is supported by the IASP (2011) who comment on the therapeutic benefits of the patient’s perception of a clinician’s competence. The amount of IUC placements a HCP performs is inversely linked to quality of outcomes (Bahamondes et al2014). Maintaining a register of placements and auditing outcomes will assist a competence review.

The NMBI (2014) emphasise the principle that consent is only valid if the patient is fully informed. Kaufman (2009) questions whether consent to a procedure can be considered as being informed if the patient is not given a realistic expectation of the pain that the procedure will involve. If a patient feels they have been dealt with honestly and without deception, they are less likely to feel ill-treated. Quality of the clinician–patient relationship has a bearing on patient satisfaction and therapeutic outcomes. Fewer complaints are made against clinicians who consider the emotional needs of the patient, demonstrate empathic listening skills and are perceived as being genuinely caring (IASP 2011).

Lachman (2012) explores the ethos of caring in relation to nursing and the instinctive drive to ‘make better’ rather than inflict pain, even when nurses believe that a painful treatment will be beneficial. Similarly, Kaufman (2009) discusses the natural urge to reassure and the dilemmas clinicians face when tasked with giving truthful answers to questions about pain. Working within a framework of high-quality, evidence-based guidelines can support and increase nurses’ confidence to successfully manage challenging situations such as these (An Bord Altranais, 2000). Nurses should also take inspiration from Brilowski and Wendler’s (2005) observation of the comfort and reassurance that a nurse’s presence affords the patient; a simple action which should not be underestimated.

Pain assessment

Maguire et al. (2014; cited by Lopez et al2015) state that if providers fail to assess pain accurately, they may mislead patients as to the degree of expected pain which, as discussed earlier, may compromise trust in the nurse/client relationship. Their US-based randomised trial assessing the accuracy of providers’ assessment of pain in women undergoing IUC insertion concluded that providers significantly underestimate patients’ pain, rating an almost 50% underestimation of the maximum pain experienced and poor recognition of the most painful part of the procedure. It is worth considering whether the choice of assessment tool contributed to such a large discrepancy. A 100 mm visual analogue scale (VAS) was employed in their study with differences of 28·5 mm deemed clinically significant (Todd et al1996, Rowbotham 2001). However, the HCPs completed their assessments retrospectively and would have had difficulty monitoring the patients’ facial expressions whilst performing the insertion which could inhibit the clinicians’ interpretation of and degree of empathy with the patients’ pain (Botvinick et al2005). Similar results were found in studies on pain in relation to IUC insertion undertaken by Akintomide et al. (2015) via questionnaire in the UK and in the Iranian study by HajiEsmaeilou et al. (2014) using a VAS. Such concordant findings from three different continents reinforce the assumption that underestimation of patient’s pain is a universal problem.

Clues were sought concerning barriers to effective pain assessment. Nurses feel that mandatory pain assessment adds to their administrative duties, may not always facilitate their objective observations of the patient’s pain and often has limited benefit to the patient or impact on outcomes (Young et al2006). Some HCPs may not possess the degree of empathic recognition that is required for accurate observed pain assessment (Franck & Bruce 2009) and, even if they do, other barriers to effective pain management may exist such as prioritisation of other aspects of care or issues regarding status and power in the workplace (Lauzon-Clabo 2008). Wilson (2007) investigated whether having a greater knowledge of pain enabled nurses to effect better pain management. She established that specialist training or education was more influential than number of years in the nursing profession and better pain management directly corelated with an increase in patient well-being. However, if the clinical environment does not allow nurses to implement their knowledge, a cognitive dissonance is created which may lead to frustration and disengagement from the pain management process (Young et al2006, Wilson 2007). Brilowski and Wendler (2005) claim that the fundamental caring ethos of nursing, as initially conceptualised by Watson (1979), motivates nurses to prioritise caring actions when making decisions under pressure of time and resources. It therefore follows that nurses compliance with pain assessment will increase if it is perceived as being a beneficial caring action which directly improves pain management outcomes for the patient.

McCaffery and Pasero (1999) recommend that pain ratings be incorporated into assessment of other routine physical observations (such as blood pressure) and which supports the American Pain Society’s (1995) designation of pain as being the ‘fifth vital sign’. Gemzell-Danielsson et al. (2013) cite Murty (2003) when observing that anxiety may be indicated if the patient has taken analgesia prior to the appointment and/or presents with an elevated heart rate. This information could easily be incorporated into the nurse’s assessment.

Discussion

There is a clear deficit of recent investigation into nonpharmacological strategies for the reduction of anxiety and pain in relation to IUC insertion. Newton and Reading (1977) examined the effect of a psychological preparation interview given prior to IUD insertion on reported pain scores following the procedure. Pain scores were compared with a control group who did not receive any additional information and results showed a reduction in the group who had received counselling. Although it is almost thirty years since this research was conducted, it has still been cited by many of the papers included in this review. To find more recent literature which could inform strategies for anxiety and pain management, it is useful to consider research undertaken by related disciplines in female health. Gynaecological procedures which involve pelvic examination and cervical manipulation and which are routinely performed in an outpatient setting include colposcopy and hysteroscopy. A search of the Cochrane Collaboration database using various combinations of keywords (gynaecological, pain, anxiety, cervical, hysteroscopy) produced two papers which explore the relationship between anxiety and pain associated with these procedures: Galaal et al. (2011) and Angioli et al. (2014). Gemzell-Danielsson et al. (2013) caution against extrapolating and comparing data in this way as hysteroscopy may cause a greater degree of discomfort than IUC insertion. A hysteroscope has a larger diameter than an IUC device, and therefore, the cervix may require a greater degree of dilation and subsequent pain. Women are most likely to be referred for colposcopy to investigate the possibility of an abnormality and therefore may have heightened anxiety compared to women presenting for routine IUC insertion. Whilst remaining mindful of this, it is still possible to gain insights and useful data from these more contemporary papers.

Galaal et al. (2011) performed a systematic review of interventions to reduce anxiety in women undergoing colposcopy. Only one of the six RCTs included in the review also investigated any subsequent reduction in pain (Chan et al2003). This paper is of most interest here. Chan et al. (2003) played ‘slow-rhythm music’ during colposcopy examination to the intervention group of women whilst the control group were examined without background music. Participants in both groups were attending colposcopy for the first time. Results were as follows: ‘women in the music group experienced significantly less pain (mean VAS 3·32 [95% CI 2·86–3·78] vs. 5·03 [4·54–5·52], p < 0·001) and lower anxiety (mean STAI 39·36 [95% CI 37·33–41·39] vs. 44·16 [41·82–46·49], p = 0·002) during colposcopy examination than women in the no-music group’ (Chan et al2003, p 213).

The effect of various information interventions are also examined in the review. Meta-analysis of the effectiveness of various combinations of information leaflets, videos and counselling showed no benefit in reducing anxiety. However, information leaflets given in advance of the procedure increased patients’ knowledge and the point is made that this improves the quality of informed consent. The authors concluded that playing music during colposcopy should be considered as a simple means to reducing anxiety and pain (Galaal et al2011).

Angioli et al. (2014) also investigated the effectiveness of music as a tool to reduce anxiety and pain. Women responded positively to music played during ‘office’ hysteroscopy, recording lower systolic blood pressure and heart rate during, and lower anxiety and pain scores during and after the procedure compared to the control group (no music). There is clearly potential for music to be investigated and used as a tool to effect a reduction in anxiety and pain during IUC insertion.

Conclusion

This review has established the following:

  • Factors which may predispose painful IUC insertion include absence of vaginal delivery, dysmenorrhoea and anxiety.
  • Preinsertion counselling to provide information, answer questions and assess the potential degree of anxiety and pain should be provided and tailored to each individual’s needs. Leaflets may be useful to increase knowledge and the quality of informed consent.
  • Trust can be fostered by providing honest information regarding pain and advising the woman of measures that will be taken to minimise pain. Maintaining a caring, professional demeanour and high standards of clinical competence are essential.
  • There is no universally effective prophylactic analgesia. Cervical anaesthesia should be considered for difficult IUC placements. NSAIDs or Tramadol may be effective for postinsertion pain. A heat pack may also give comfort.
  • Good quality, fine instruments applied with care may minimise insertion pain.
  • Distraction in the form of conversation, television or music is an effective way of reducing anxiety and/or pain.
  • Women prefer an informal, caring atmosphere and comfortable environment which affords privacy, is sensitive to feelings of embarrassment and equipped to deal with any bleeding or ‘mess’.

 

Relevance to clinical practice

Increasing the use of IUC is a public health goal (Lopez et al2015). This paper has considered factors which influence pain in relation to IUC insertion and the associated clinical issues for nurses involved in the provision and care of women undergoing this procedure. Anxiety and absence of vaginal delivery are the two main predictors of pain discussed here. Anxiety affects us all, to varying degrees, and should be considered relevant in every health care encounter. There is a global trend for women to delay childbirth until a later age which increases the likelihood of caesarean section (United Nations 2010). It therefore follows that the incidence of women without prior vaginal delivery undergoing IUC insertion will continue to rise and special consideration for the pain related care of these women should be addressed. A positive experience of IUC insertion may see more women returning for subsequent reuse or encourage other women to opt for IUC. This paper asserts the conclusion that nurses can be highly influential in effecting an increase in the uptake of this safe and effective form of contraception.

Healthcare providers also have anxieties regarding the patient’s pain experience. ‘If there is an intervention to decrease pain with IUD insertion, more providers may feel comfortable inserting IUDs – especially in women at higher risk of pain’ (Mody et al2012, p. 708). HCPs fear painful and/or difficult placements, and this may lead them to recommend other methods of contraception (Gemzell-Danielsson et al2013). If nurses have effective strategies to address IUC insertion pain, they will feel better equipped to recommend, assist with or insert IUCs.

It is also worth noting Perla and Parry’s (2011) assertion that consideration of the opinions of service users rather than sole reliance on evidence from scientific enquiry is essential to improve the quality of service provision. This recommendation is echoed by Dixon-Woods et al. (2001) in relation to procuring and considering the views of users of specialist sexual health services. Reflecting on ‘easy’ and ‘difficult’ IUC placements and obtaining patient feedback would assist HCPs to evaluate care and plan for future improvements.

Further research into anxiety-reducing and nonpharmacological interventions is warranted.

 

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