Department of Obstetrics & Gynecology; Indiana University School of Medicine, Indianapolis, IN.
Department of Obstetrics & Gynecology; Indiana University School of Medicine, Indianapolis, IN.
Am J Obstet Gynecol. 2018 Feb;218(2):236.e1-236.e9. doi: 10.1016/j.ajog.2017.10.017. Epub 2017 Nov 8.
Intrauterine devices have been gaining popularity for the past 2 decades. Current data report that >10% of women who use contraception are using an intrauterine device. With <1% failure rates, the intrauterine device is one of the most effective forms of long-acting reversible contraception, yet evidence shows that fear of pain during intrauterine device placement deters women from choosing an intrauterine device as their contraceptive method.
The objective of this analysis was to estimate the association between anticipated pain with intrauterine device placement and experienced pain. We also assessed other factors associated with increased discomfort during intrauterine device placement. We hypothesized that patients with higher levels of anticipated pain would report a higher level of discomfort during placement.
We performed a secondary analysis of the Contraceptive CHOICE Project. There were 9256 patients enrolled in Contraceptive CHOICE Project from the St. Louis region from 2007-2011; data for 1149 subjects who came for their first placement of either the original 52-mg levonorgestrel intrauterine system or the copper intrauterine device were analyzed in this study. Patients were asked to report their anticipated pain before intrauterine device placement and experienced pain during placement on a 10-point visual analog scale. We assessed the association of anticipated pain, patient demographics, reproductive characteristics, and intrauterine device type with experienced pain with intrauterine device placement.
The mean age of Contraceptive CHOICE Project participants in this subanalysis was 26 years. Of these 1149 study subjects, 44% were black, and 53% were of low socioeconomic status. The median expected pain score was 5 for both the levonorgestrel intrauterine system and the copper intrauterine device; the median experienced pain score was 5 for the levonorgestrel intrauterine system and 4 for the copper intrauterine device. After we controlled for parity, history of dysmenorrhea, and type of intrauterine device, higher anticipated pain was associated with increased experienced pain (adjusted relative risk for 1 unit increase in anticipated pain, 1.19; 95% confidence interval, 1.14-1.25). Nulliparity, history of dysmenorrhea, and the hormonal intrauterine device (compared with copper) also were associated with increased pain with intrauterine device placement.
High levels of anticipated pain correlated with high levels of experienced pain during intrauterine device placement. Nulliparity and a history of dysmenorrhea were also associated with greater discomfort during placement. This information may help guide and treat patients as they consider intrauterine device placement. Future research should focus on interventions to reduce preprocedural anxiety and anticipated pain to potentially decrease discomfort with intrauterine device placement.
宫内节育器在过去 20 年中越来越受欢迎。目前的数据显示，>10%使用避孕措施的女性正在使用宫内节育器。宫内节育器的失败率<1%，是最有效的长效可逆避孕方法之一，但有证据表明，对宫内节育器放置过程中疼痛的恐惧阻止了女性选择宫内节育器作为避孕方法。
本分析的目的是估计对宫内节育器放置过程中预期疼痛与实际疼痛之间的关联。我们还评估了与宫内节育器放置过程中不适增加相关的其他因素。我们假设预期疼痛水平较高的患者在放置过程中会报告更高水平的不适。
我们对避孕选择项目进行了二次分析。2007 年至 2011 年期间，圣路易斯地区有 9256 名患者参加了避孕选择项目；本研究分析了 1149 名首次放置原始 52mg 左炔诺孕酮宫内节育系统或铜宫内节育器的患者的数据。患者被要求在放置宫内节育器前报告预期疼痛，并在放置过程中对疼痛进行 10 分制视觉模拟评分。我们评估了预期疼痛、患者人口统计学特征、生殖特征和宫内节育器类型与宫内节育器放置过程中实际疼痛的关联。
本亚分析中避孕选择项目参与者的平均年龄为 26 岁。在这 1149 名研究对象中，44%是黑人，53%来自低社会经济地位群体。预期疼痛中位数为 5 分，无论是左炔诺孕酮宫内节育系统还是铜宫内节育器；实际疼痛中位数为 5 分，左炔诺孕酮宫内节育系统和 4 分，铜宫内节育器。在控制了产次、痛经史和宫内节育器类型后，较高的预期疼痛与较高的实际疼痛相关（预期疼痛增加 1 个单位的调整相对风险，1.19；95%置信区间，1.14-1.25）。未产、痛经史和激素宫内节育器（与铜宫内节育器相比）也与宫内节育器放置过程中的疼痛增加相关。
高水平的预期疼痛与宫内节育器放置过程中的实际疼痛水平相关。未产和痛经史也与放置时的不适感增加有关。这些信息可能有助于指导和治疗考虑宫内节育器放置的患者。未来的研究应集中于减少术前焦虑和预期疼痛的干预措施，以潜在减少宫内节育器放置的不适。
