Pain relievers for bleeding and pain related to intrauterine devices used for birth control

Heavy menstrual bleeding and cramping are the most common reasons why women stop using an intrauterine device (IUD) for birth control. A class of drugs (nonsteroidal anti-inflammatory drugs, or NSAIDs) reduces menstrual bleeding and cramping in women who are not using an IUD. These drugs, such as naproxen and ibuprofen, are sold over-the-counter as pain relievers in many countries. Hence, researchers have studied whether these same drugs might reduce bleeding and pain associated with use of intrauterine devices. This might lead to more comfortable use of IUDs for longer periods of time.

We searched for and summarized all the randomized controlled trials that looked at using these drugs to treat bleeding or pain related to an IUD. We also included trials that studied the use of these drugs to prevent these problems.

We found 15 trials from 10 countries, with more than 2700 women studied. These drugs reduced both bleeding and pain with intrauterine device use. Whether one drug is better than another was not clear. Similarly, the best dosing was not clear. Preventive treatment with these drugs around the time of IUD insertion had mixed results. No serious problems were reported, but stomach upset and sleepiness can occur with this class of drugs. Because of their safety, low cost, and wide availability, these drugs are appropriate treatment for women who have troublesome bleeding or pain with IUD use.

Authors' conclusions: 

Nonsteroidal anti-inflammatory drugs reduce bleeding and pain associated with IUD use. NSAIDs should be considered first-line therapy; if NSAIDs are ineffective, tranexamic acid may be considered as second-line therapy. Prophylactic ibuprofen administration with the first six menses after insertion appears unwarranted.

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Background: 

Heavy bleeding and pain are the most common reasons why women discontinue intrauterine devices (IUDs). Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs.

Objectives: 

This review summarizes all randomized controlled trials studying use of nonsteroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. Trials of prophylactic use of these drugs around the time of IUD insertion were also included.

Search strategy: 

We searched for relevant trials in PubMed, CENTRAL, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). We wrote to the authors of trials identified to seek other published or unpublished trials.

Selection criteria: 

We included all randomized controlled trials in any language that tested one or more nonsteroidal anti-inflammatory drugs for treatment or prevention of bleeding or pain associated with IUD insertion or use.

Data collection and analysis: 

Two authors independently abstracted data from relevant trials, and we entered data into RevMan for analysis.

Main results: 

We found 15 trials from 10 countries; the total number of participants was 2702. Nonsteroidal anti-inflammatory drugs (naproxen, suprofen, mefenamic acid, ibuprofen, indomethacin, flufenamic acid, alclofenac, and diclofenac) were effective in reducing menstrual blood loss associated with IUD use. This held true for women with and without complaints of heavy bleeding. Similarly, these drugs were effective in reducing pain associated with IUD use. In contrast, prophylactic use of nonsteroidal anti-inflammatory drugs had mixed results; studies with ibuprofen found no effect on pain after insertion on IUD discontinuation. No important differences emerged in the one trial comparing the effect of different NSAIDs on bleeding.

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