Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial.

OBJECTIVE: Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel. STUDY DESIGN: A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement. RESULTS: Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p<.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p<.001]. Satisfaction with tenaculum placement was similar for the two groups. CONCLUSION: Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.

Contraception during the perimenopause.

Although the absolute risk of pregnancy is lower during the perimenopause due to decreased fertility and decreased coital frequency, unintended pregnancy occurs at ratios similar to those observed in young women, and pregnancies that do occur are at high risk for maternal complications and poor outcomes such as miscarriage or chromosomal abnormalities. Therefore all premenopausal women should receive counselling that includes discussion of sexual habits and contraception during routine health care encounters. The majority of US women in this age group use permanent contraception, but other methods can be safe and effective and can have non-contraceptive benefits. No contraceptive method is contraindicated based on age alone. However, estrogen-containing methods should be reserved for women without cardiovascular or thrombotic risk factors. The levonorgestrel intrauterine system (LNG-IUS, Mirena(®)) has particular benefits during perimenopause and is safe for use in nearly all women. The LNG-IUS is approved for treatment of heavy menstrual bleeding, a common concern during the perimenopause. A substantial literature supports the use of the LNG-IUS for endometrial protection during transition from contraception to hormone therapy, although this is off-label in the United States. Reliable contraception should be used until menopause is confirmed either by cessation of menses for 2 years prior to age 50, for 1 year after age 50, or by two elevated follicle-stimulating hormone (FSH) values ≥20-30IU/l while off hormonal methods for at least 2 weeks. Sterility cannot be assumed until at least age 60 because spontaneous pregnancies have been reported in women up to age 59.