Intrauterine instillation of mepivacaine substantially reduces pain during intrauterine device (IUD) placement, according to the results of a randomized controlled trial.
On a 100-mm visual analogue scale (VAS), mean pain score during IUD placement was 43.8 mm for participants who received mepivacaine via a hydrosonography catheter vs 58.6 mm for those who received sodium chloride via the same route of administration (placebo), with a mean difference of 14.8 mm (95 percent confidence interval [CI], 10.0–19.6; p<0.001). [JAMA 2026;doi:10.1001/jama.2026.14217]
Results were similar when mean pain scores were assessed with clinician included as a random effect. The adjusted mean pain difference was 14.2 mm (95 percent CI, 9.7–18.6; p<0.001), corresponding to a 23.7-percent reduction in pain.
More participants in the mepivacaine than in the placebo group reported the IUD placement pain as tolerable (98.3 percent vs 91.4 percent). Nearly one in five participants (17.5 percent) in the mepivacaine group reported severe pain (VAS score ≥70 mm) as compared with about one in three individuals (34.5 percent) in the placebo group.
Additionally, a greater proportion of participants in the mepivacaine group than in the placebo group indicated that they would choose an IUD for contraception again (93.2 percent vs 82 percent) and would recommend intrauterine mepivacaine instillation as a pain relief method to a friend (79 percent vs 68.6 percent).
Dr Karin Elgemark, a researcher and PhD student at the Karolinska Institutet's Department of Clinical Sciences at Danderyd Hospital in Stockholm, Sweden. Photo by Viktor ElgemarkImproving patient experience
These findings highlight intrauterine mepivacaine instillation as “a simple approach to improve patient experience” during IUD placement, noted first author Dr Karin Elgemark from Karolinska Institutet, Stockholm, Sweden, and colleagues in their paper.
In an email to MIMS, Elgemark discussed the importance of studying a new option for pain management during IUD placement. “Pain during IUD placement can be substantial, and no single pain management method works well for everyone,” she said.
“Intrauterine mepivacaine provides another option: it is administered directly into the uterus through a thin catheter shortly before placement, without injections or premedication. It adds only a few minutes to the procedure, and our study showed that it reduced pain compared with placebo and was well tolerated,” Elgemark told MIMS.
Mean VAS pain score during instillation was 18.2 mm in the mepivacaine group vs 25.1 mm in the placebo group. Nearly everyone who participated in the trial rated the instillation pain as tolerable (98.9 percent).
Meanwhile, existing approaches to relieve pain during IUD placement—including intracervical/intrauterine lidocaine gel, intracervical injections, and paracervical block—may cause substantial discomfort at administration, potentially reducing acceptability. [Obstet Gynecol 2017;130:795-802; Obstet Gynecol 2018;132:575-582; Am J Obstet Gynecol 2020;222:245.e1-245.e10; Acta Obstet Gynecol Scand 2019;98:1500-1513]
“Concerns about pain can be a barrier to choosing an IUD. In our study, participants receiving mepivacaine were more likely to say that, knowing what the procedure felt like, they would choose an IUD again. However, we did not study whether this translates into increased IUD uptake in routine care,” Elgemark said.
“The goal is ultimately to support people in choosing the contraceptive method that is right for them, rather than to increase IUD use itself,” she added.
Addressing patient fear of pain
For clinicians encountering patients who are considering an IUD but are hesitant or anxious due to the procedural pain, Elgemark offered the following advice: “Take concerns about pain seriously and discuss pain management before the procedure. Give realistic information about what the procedure involves and what pain management options are available.”
Elgemark also emphasized that “clinicians consider factors associated with greater pain, such as nulliparity and dysmenorrhea, while recognizing that pain during IUD placement remains difficult to predict.
“Most importantly, involve the person in deciding what pain management is appropriate based on their individual needs and preferences,” she said.
Conducted at several gynaecological clinics and youth health centres in Sweden, the study included 370 participants (mean age 21.7 years) who opted for IUDs with smaller-diameter placement tubes (levonorgestrel 19.5 or 13.5 mg or copper IUD).
The participants were randomly assigned to intrauterine instillation of 10 mL of mepivacaine (20 mg/mL) or sodium chloride (9 mg/mL) via a hydrosonography catheter 2 min before IUD placement.
Adverse events at 3-month follow-up did not significantly differ between the mepivacaine and placebo groups. There were no serious adverse events documented.
The next step in the research is to compare intrauterine mepivacaine instillation to other pain management options, according to Elgemark and colleagues.