Mepivacaine reduces pain during IUD placement

Intrauterine mepivacaine modestly reduced pain and improved tolerability during IUD placement.
*Randomized controlled trial; Level 2 (OCEBM 2011).

Citation

Elgemark K, Envall N, Kopp Kallner H. Intrauterine Mepivacaine Instillation vs Placebo for Pain During IUD Placement. JAMA. Published online September 17, 2026. doi:10.1001/jama.2026.14217

Background

Pain concerns reduce use of intrauterine devices, and current pain-control options are inconsistent or uncomfortable. This trial tested a simple local anesthetic method during placement.

Patients

370 nulliparous people aged 18 to 31 years in Sweden choosing smaller-tube intrauterine devices. Exclusions included pregnancy, device replacement, pelvic infection, cervical stenosis, local anesthetic allergy, and preprocedure pain medicine use.

Intervention

10 mL intrauterine mepivacaine 20 mg/mL, instilled 2 minutes before device placement.

Control

10 mL saline placebo instillation.

Outcome

Primary: pain during placement on a 0- to 100-mm visual scale. Secondary outcomes included tolerability, overall experience, additional pain medicine, and adverse events.

Follow-up Period

Procedure visit; safety follow-up at 3 months.

Results

Outcome Mepivacaine Placebo Effect
Pain during placement (primary) 43.8 mm 58.6 mm Adjusted mean difference 14.2 mm lower (95% CI 9.7 to 18.6)
Pain rated tolerable 98.3% 91.4% RR 1.08 (95% CI 1.02 to 1.13); NNT 15 (95% CI 9 to 43)
Severe placement pain 17.5% 34.5% RR 0.51 (95% CI 0.35 to 0.74)
Worse experience than expected 15.3% 33.7% RR 0.46 (95% CI 0.30 to 0.68)
Vasovagal reaction 7.9% 18.2% RR 0.43 (95% CI 0.24 to 0.78)

RR = relative risk; NNT = number needed to treat.

The primary analysis included randomized participants with available pain data, not a full intention-to-treat analysis. Per-protocol results were similar. The investigators considered a 10-mm pain reduction clinically meaningful. Saline instillation is not usual care; it was used to preserve blinding.

Limitations

The study did not compare mepivacaine with paracervical block, oral medicine, or usual care. Anxiety and clinician-rated insertion difficulty were not measured. Catheter position was not confirmed by ultrasound. Findings apply mainly to young nulliparous patients receiving smaller-tube devices.

Funding

Swedish Research Council; no funder role. Some author industry disclosures.

Clinical Application

Consider offering intrauterine mepivacaine for nulliparous patients choosing smaller-tube devices, while continuing shared decisions about other pain-control options.