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Doctors Misread Pain of IUD Placement
Less than half of the doctors and patients agreed on the time of maximal pain during the procedure.
By Ed Susman, MedPage Today
Medically Reviewed byDori F Zaleznik, MD
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TUESDAY, May 8, 2012 (MedPage Today) —Doctors asked to estimate the pain their patients felt during insertion of an intrauterine contraceptive device didn't even come close, researchers reported here.
On a 100-point visual analog scale, patients' mean perceived pain score was 63.8 (moderate pain), while the clinicians who inserted the device thought their patients' pain score was a mean of 35.3, representing mild pain, reported Karla Maguire, MD, MPH, assistant professor of clinical obstetrics and gynecology at the University of Miami Health System.
That 28.5-point difference was statistically significant, Maguire said at the annual meeting of the American College of Obstetricians and Gynecologists in San Diego.
She noted that just 19 percent of the doctors were able to come within 10 points of patient-reported pain, while 23 percent of the physicians were more than 50 points off in determining the pain involved in positioning the intrauterine device.
"Women have pain at intrauterine device insertion," she said. "Some women have more pain than others. This pain may be a barrier to intrauterine device utilization."
Maguire noted that clinicians often underestimate the pain experienced by their patients in a variety of clinical situations. She suggested that failure of clinicians to recognize the level of pain experienced by patients may have resulted in a lack of research into the problem.
The research team analyzed data collected in a randomized placebo-controlled trial of 200 women that tested intracervical lidocaine gel as an analgesic during intrauterine device insertion. The trial did not show that the gel was more effective than placebo in preventing pain during the procedure, Maguire said.
The study enrolled adult women ages 18 to 45, excluding women with a recent pregnancy. The women rated pain at four time points, assessing the most severe pain at any of those points: tenaculum placement, uterine sounding, intrauterine device insertion, and speculum removal.
The clinicians — attending physicians or midlevel providers or residents — also tried to assess the most painful part of the procedure as experienced by the women. Maguire's research shows that by and large the physicians had no clue as to the level of pain the women were experiencing.
"I think this is a study that gives new meaning to the old joke, 'This isn't going to hurt me a bit,'" said session moderator Caela Miller, MD, of the Uniformed Services University of Health Sciences, in Washington, and a member of the ACOG scientific program committee.
The study shows that "as doctors we need to learn to communicate more with our patients," she toldMedPage Today.
Maguire noted that less than one woman in 100 who uses an intrauterine device becomes pregnant during the first year of use, and that 80 percent or more of women remain on the devices for contraception after the first year. About 5.5 percent of women in the United States use intrauterine devices for contraception.
The mean age of the patients in the study was 27.4 years, and 77 percent of the women in this study were Hispanic; 77 percent of the women in the study were high school graduates; and 70 percent of the women had at least one child.
Although none of the 200 women said that the procedure was painless, 15, or 8 percent, of the 200 doctors thought that their patients experienced no pain in the procedure, Maguire said. Overall, she said, there was a 41 percent agreement between the patients and their doctors about the point in time of the greatest pain and the level of pain.
The midlevel providers were 6.6 points closer to estimating pain levels than attending physicians, but were no better at assessing the point of maximum pain than attending physicians, Maguire said.
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