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Analgesia for intrauterine contraception insertion — DFSRH MCQ

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EasyDuloxetineAnalgesia for intrauterine contraception insertionDFSRH

A 29-year-old nulligravid woman requests interval copper intrauterine device insertion. Pregnancy has been reasonably excluded, and there is no identified infection risk or anatomical contraindication. She has severe primary dysmenorrhoea and previously experienced severe pain during a cervical biopsy. She wishes to remain awake for insertion and requests pharmacological analgesia. She takes duloxetine 60 mg daily for generalised anxiety disorder. Her mental health is stable, but missing a single dose has previously caused vertigo and paraesthesia. She has no bleeding disorder, takes no anticoagulant or antiplatelet medication, and has no allergy to local anaesthetics or non-steroidal anti-inflammatory drugs. Which is the most appropriate plan for procedural analgesia?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Continue duloxetine and offer 10% lidocaine cervical spray before insertion

Explanation lettering: E = shown as A · D = shown as B · A = shown as C · C = shown as D · B = shown as E

FSRH recommends discussing and offering analgesia or anaesthesia to everyone undergoing intrauterine contraception insertion. This woman has features associated with greater insertion pain, including nulligravidity, dysmenorrhoea and a previous painful cervical procedure. Topical 10% lidocaine spray is therefore an appropriate office-based option and has evidence of benefit for insertion-related pain. Duloxetine should be continued. It is an SNRI, and its product information advises caution when it is combined with serotonergic agents such as tramadol because of the risk of serotonin syndrome. Tramadol also has limited and inconsistent evidence for IUC insertion analgesia, making A an inferior elective choice when a non-serotonergic local treatment is available. B compounds this problem: a five-day interruption is unnecessary and abrupt duloxetine discontinuation can produce withdrawal symptoms, which this patient has previously experienced. D is plausible because NSAIDs may help post-insertion cramping, but prophylactic ibuprofen has not consistently reduced pain during insertion and should not be the sole strategy for this patient. Duloxetine also warrants caution with drugs affecting platelet function, although short-course NSAID use is not absolutely contraindicated. E is disproportionate because she wants awake office insertion and has not failed appropriately supported insertion or requested general anaesthesia.

Reference: FSRH Guideline: Intrauterine Contraception (March 2023; amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf Duloxetine 20 mg gastro-resistant capsules, hard — Summary of Product Characteristics (29 May 2025) — https://www.medicines.org.uk/emc/product/13590/smpc