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Comment on ‘Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives’: authors’ response
  1. Luis Bahamondes, MD
  1. Professor of Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; bahamond{at}
  1. Diana Mansour, FRCOG, FFSRH
  1. Consultant in Community Gynaecology and Reproductive Healthcare, Newcastle Hospitals, Community Health, New Croft Centre, Newcastle upon Tyne, UK; Diana.Mansour{at}
  1. Christian Fiala, MD
  1. Director, Gynmed Clinic, Vienna, Austria and Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; christian.fiala{at}
  1. Andrew M Kaunitz, MD
  1. Professor and Associate Chair, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA; andrew.kaunitz{at}
  1. Kristina Gemzell-Danielsson, MD
  1. Professor of Obstetrics and Gynecology and Department Chair, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; kristina.gemzell{at}

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There has been much interest in our review article ‘Practical advice of pain associated with insertion of intrauterine contraceptives’1 and we thank Professor Guillebaud for his comments.2

In relation to the specific points raised by Professor Guillebaud we would like to add our own remarks.

  1. We are aware that some experienced healthcare professionals (HCPs) do not use a tenaculum to stabilise the cervix when fitting intrauterine contraceptives (IUCs) to minimise pain but it is standard practice to recommend its use to reduce the risk of uterine perforation and maximise the likelihood of high fundal placement. It is standard practice and should be recommended except in specific situations. Currently there are no published data to suggest that any one tenaculum or forceps induces less pain; however, from our clinical experience we advocate gently applying a fine tenaculum (sometimes marketed for use in saline infusion sonography) or Judd-Allis forceps.

  2. When undertaking a literature review before writing our article we read the paper from 1978 describing the use of tolfenamic acid in a double-blind randomised trial.3 We did not later cite it as tolfenamic acid is not widely available and often only approved for veterinary use.

  3. We want to thank Professor Guillebaud for drawing our attention to his paper4 that we failed to locate using the normal search engines. We note that taking 500 mg mefenamic acid 1 hour before fitting a copper-7 intrauterine device did not alleviate pain at the time of insertion and although there was some improvement in pain 10 minutes following the procedure, this was not statistically significant.

  4. We tried to restrict our literature search to pain-relief strategies associated with IUC insertion rather than studying other gynaecological procedures that may themselves be more painful.

  5. The very recent Goldthwaite et al. study5 continues this important debate. These authors found that women who received 2 ml 1% lidocaine at the 12 o'clock position had lower mean visual analogue scores at tenaculum placement (p<0.001) compared to controls receiving topical 2% lidocaine gel; however, there were higher mean pain levels with application of the lidocaine injection. Their final conclusion was that “satisfaction with tenaculum placement was similar for the two groups”.


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  • Competing interests None.

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