By Anita Brakman, MS

Senior Director of Education, Research, and Training

Physicians for Reproductive Health

New York City

Taylor Rose Ellsworth, MPH

Director, Education, Research, and Training

Physicians for Reproductive Health

New York City

Melanie Gold, DO, DABMA, MQT, FAAP, FACOP

Medical Director, School-Based Health Centers

New York-Presbyterian Hospital

Columbia University Medical Center

New York City

On Jan. 1, 2018, The Joint Commission implemented new and revised pain assessment and management standards for accredited hospitals. The additions and revisions require hospitals to “provide at least one non-pharmacological pain treatment modality.”1 There are several non-pharmacologic approaches to offer adolescents to help manage anxiety and pain related to intrauterine device (IUD) insertions. The ones we have found to be especially helpful are hypnotic language, music, heat therapy, social support (“IUD doula”), acupressure, and aromatherapy.

Hypnotic language can relieve adolescents’ anxiety and increase comfort prior to, during, and after IUD insertions. Before the procedure, it is helpful to inquire about past experiences with gynecologic exams or procedures as well as prior experiences of sexual abuse or assault, and issues around control. It can be helpful to suggest: “You can listen to what I am saying … and at the same time tune out and go to a place where you feel relaxed, comfortable, and in control.” One way to incorporate hypnotic imagery into the IUD procedure is to ask the patient to imagine being in her favorite place, performing an activity she enjoys. Suggest that she notice all five senses that are associated with that place and activity.

Give verbal suggestions for feeling comfort and control, such as “now you might notice the feeling of the bed supporting your back, the crinkling sound of the clean white paper,” and “you may find it helpful to place your hand on your own abdomen and feel that deep breath into your belly as you breathe in comfort, and breathe out tension or discomfort.” Rather than telling the patient what she will feel, use open-ended statements such as, “you may feel something now.” Allowing for patients’ widely varying responses to stimuli creates an expectation that is less likely to invoke a nocebo reaction.2

Offer statements like “now you may notice a different feeling, it may be like pressure, or pulling, or stretching, or like you have to pee, but if it bothers you, let me know.” Avoid using language that sets up an expectation of pain, such as, “this next part will be painful.” At the conclusion of the procedure, suggest positive expectations by saying, “it may surprise you to notice how much easier each future gynecologic exam may be now that you know how to help yourself relax with your breathing.” Suggest, “you can practice slow, deep breathing whenever you want to help yourself feel calmer and more relaxed.”

Playing ambient music in the room can be therapeutic as well; it is calming, distracting, and appears to reduce anxiety and pain. Nilsson recommends that music be non-lyrical, slow (fewer than 80 beats per minute), low in volume (fewer than 60 decibels), last for at least 30 minutes, and be chosen by the patient with informed support from the provider.3 Although there is little literature on the use of music specifically for IUD procedures, it is common practice to play soothing music during IUD insertions. When played in the room, rather than by headphones, music has the capacity to reduce the anxiety of everyone present.

Likewise, although there currently are no high-quality research trials assessing the relationship between heat therapy and IUD-related discomfort, we have found adolescents undergoing IUD insertions like heat therapy in the form of a heat pack for relief of pelvic cramping after IUD insertions.

In addition, we have found social support, such as hand-holding and verbal assurance during the IUD insertion by a nurse, medical assistant, or friend of the patient, can be helpful. It is useful to instruct the support person to give the patient two fingers to “squeeze and put all the bothersome or nervous feelings into those fingers.” It is now our standard of care to include a medical assistant or a supportive peer to serve as a support or “IUD doula.”

We also incorporate acupressure into our IUD provision practice. Acupoints, which are points on the body where energy flows, can be stimulated in a variety of ways. We have incorporated acupressure, a cost-free and non-invasive technique, into the standard of care for adolescents receiving IUD insertions at New York-Presbyterian Hospital’s School-Based Health Centers (NYC SBHCs) since February 2018. Pressing bilaterally for 2-3 minutes on the acupoint called Spleen 6, also known as San Yin Jiao, located four fingers above the top of the inner ankle bone (medial malleolus), has been found to alleviate uterine pain and related stress in a safe manner.4-6

We also offer aromatherapy to assist with anxiety and pain management. Two studies assessed the effect of aromatherapy on IUD-related pain and anxiety. Both studies involved inhalation of lavender essential oil by female participants in Iran. The studies produced contradictory results; one found a significant decrease in anxiety for the experimental group, but no significant difference in reported pain between the experimental group and control group (which inhaled diluted milk).7 The second study found the experimental group had significantly less post-procedural pain compared to the placebo group (which inhaled sesame oil) and the control group (which did not inhale anything).8 More studies on aromatherapy to manage IUD-related pain are necessary in order to make definitive statements about its efficacy as a non-pharmacological treatment option.9

Non-pharmacologic modalities for pain and anxiety prevention and management related to IUD insertion have the potential to support adolescents in combination with pharmacologic modalities, or alone when pharmacologic modalities are contraindicated or fail to be effective. Our clinical experience is that these nonpharmacologic approaches are useful, and we recommend them as we await the outcome of more high-quality trials.

REFERENCES

  1. The Joint Commission. Pain Management — Leadership responsibilities for providing nonpharmacologic modalities for managing pain. Available at: https://bit.ly/2JvZasW.
  2. Krauss BS. “This may hurt”: predictions in procedural disclosure may do harm. BMJ 2015;doi:10.1136/bmj.h649.
  3. Nilsson U. The anxiety- and pain-reducing effects of music interventions: A systematic review. AORN J 2008;87:780-807.
  4. Kashefi F, Khajehei M, Ashraf AR, et al. The efficacy of acupressure at the Sanyinjiao point in the improvement of women’s general health. J Altern Complement Med 2011;17:1141-1147.
  5. Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen on the severity of primary dysmenorrhea. J Tradit Chin Med 2002;22:205-210.
  6. Chen HM, Chen CH. Effects of acupressure on menstrual distress in adolescent girls: A comparison between Hegu-Sanyinjiao matched points and Hegu, Zusanli single point. J Clin Nurs 2010; 19:998-1007.
  7. Shahnazi M, Nikjoo R, Yavarikia P, et al. Inhaled lavender effect on anxiety and pain caused from intrauterine device insertion. J Caring Sci 2012;1:255-261.
  8. Mirmohamad Aliei M, Khazaie F, Rahnama P, et al. Effect of lavender on pain during insertion of intrauterine device: A clinical trial. J Babol Univ Med Scien 2013;15:93-99.
  9. Holmes P. About aroma acupoint therapy. Available at: https://bit.ly/2hOHKID.