Anticipated Pain During Intrauterine Device Insertion

TA Hunter, S Sonalkar, CASchreiber, LK Perriera, MD Sammel, AY Akers

J Pediatr Adolesc Gynecol. 2020 February; 33(1):27-32


1)      The authors discuss that negative perspectives from social references and fear are barriers to IUD placement in adolescents.  What are other perceived barriers to adolescents receiving IUDs within your practice or institution?  

Answer: Journal Club participants can discuss barriers they have experienced within their practice involving IUD insertion in adolescents.  These barriers could involve patient and parent concerns (safety, efficacy, social influences).  Provider barriers include lack of experience with adolescent patients, and concerns with use in nulliparous or non-sexually active adolescents.  Same day insertion, insurance coverage, provider availability, or lack of understanding of adolescent consent and confidentiality could also be barriers on a systems level.  

2)      The authors discuss that additional counseling prior to IUD insertion can reduce pain complaints with IUD insertion.  How do you counsel patients about IUDs and what do you include in the counseling? Does patient age or any other factor affect what you include in the counseling?  

Answer: Counseling may vary among participants based on experience or level of training.  Discussion could include how detailed of explanation do individuals give regarding IUD insertion, and whether they use additional tools such as models or diagrams with their explanation.  There may be variability in detail of discussion of anticipated bleeding patterns, mechanism of action, and risks such as uterine perforation, infection and ectopic pregnancy.  Why a patient is receiving an IUD (menstrual suppression or contraception), adolescent development (cognitive,emotional, and social), and level of parental involvement or concern could impact time spent on counseling topics.  

3)      The methodology is described as a secondary analysis from a multisite, single-blind, randomized trial.  What is a secondary analysis, and what are the advantages and disadvantages to using this type of analysis? 

Answer:  Secondary analysis involves examining already collected data to answer a research question other than the primary question for which the data was initially collected.  Secondary analysis can also mean analyzing data collected by someone else (ie: large databases).  Advantages include saving time, money, and avoiding unnecessary duplication of research effort.  There is disadvantage in that the data and study design has already been completed.  Data therefore may not facilitate a particular research question.  

4)      Anticipated pain score was the primary outcome of interest.  What were the predictor variables that were included? Before learning the results of the study, did you think any of these predictor variables would be associated with higher anticipated pain scores?  

Answer:  Predictor variables were age category (14-17 vs 18-22), race (Black or African American, White or other), PHQ-4 (screen negative vs positive), randomization group (sham block vs lidocaine block), prior sexual activity (yes vs no) and prior speculum exam (yes vs no).  Journal Club participants can discuss whether they perceived that any of these predictors would impact anticipatory pain.  This could vary based on level of training, and personal and clinical experience.  

5)      In univariate analysis what were the factors that were identified as potential predictors of anticipated pain of IUD insertion? Did the results remain unchanged with stepwise linear regression analysis? What is the significance of these findings? 

Although there was a trend to higher anticipated pain scores among patients with prior sexual activity, no prior speculum exam, and positive PHQ-4 screen for anxiety/depression,  these did not reach statistical significance. However, univariate analysis identified only age and race as potential predictors of anticipated pain of IUD insertion, with Black or African American participants reporting an anticipated pain score of 68 compared to 51 among White participants and 64 among other races (p=0.012). Similarly, younger participants (14-17 years) had a higher median anticipated pain score of 69 compared to 59 among older participants (18-22 years)( p= 0.016.

Backward stepwise linear regression analysis showed that only race was associated with anticipated pain. 

These findings have significant implications on the approach to counseling patients and signals providers to consider cultural context when counseling patients, particularly as it relates to race and the consideration for both conscious and unconscious biases.   

6)      What were the findings of the adjusted analysis for perceived pain at each IUD insertion procedure step. Figure 2. Are these results expected? 

Excluding baseline assessment, at each IUD insertion procedure step participants with higher anticipated pain scores had significantly higher perceived pain scores.  After adjusting for treatment group, women with high anticipated pain had a mean perceived pain score of 65+ 29 mm vs 44.5+ 28mm among women with low anticipated pain score. (p<0.003).

These results are not unexpected as there is evidence that pain and pain perception is multifactorial and influenced by psychological, biological, cognitive, behavioral, and social factors. Therefore, it is not surprising that the anxiety associated with increased anticipation of pain can lead to increased experienced pain. Can you think of a particular way that being anxious can lead to more perceived pain?  (ex. Tensing of muscles) 

7)      The authors argue that complex social and structural realities rather than a biological basis is the cause for the higher anticipated pain scores among persons of Black race. What are some of the examples the authors give to support their argument? What are some things that can be done in clinical practice to aid in helping patients expectations?

The authors list a variety of examples which can lead to increased fear, pain and anxiety in the healthcare setting and mistrust of the healthcare system including 1) longstanding history of exploitation and racial discrimination within the healthcare system, 2) inequality in the burden of maternal and infant mortality 3) physician bias regarding beliefs of pain severity and underreporting of pain 4) higher rates of adverse outcomes among Black and Latinx children.

The authors suggest asking qll women about their anxiety and anticipated pain and preferences regarding pain management as a method to help combat the anticipated pain expectations. This allows the providers to set expectations. Participants may also suggest other interventions, such as but not limited to allowing patients to speak with or read or view video testimonials from others who have had the procedure completed, use of small dose anti-anxiolytic and allowing the presence of a support person or music. In addition, including implicit bias training to reduce racial bias among healthcare providers and increasing diverse representation amongst providers in clinical practices. 

8)      What were provider specific limitations identified in this study. Could these limitations have played a significant role in the outcomes?

Provider demographic factors and level of experience was not collected in this study. Both factors may play a substantial role in patient experience and anticipation of pain. For example, someone who is more experienced will more likely be able to speak to a breadth of patient experiences and provide additional reassurance based on past experiences compared to a person with less experience and variances in clinical practice. In addition, provider demographics including, race, ethnicity, gender and socioeconomic status may affect patient experience.

9)      Would you make any practice changes after reading this study? 

Open for participants. Recommend participants discuss practice specific experiences.