to the editor: We were pleased to see Hardeman and Weiss' recent update on intrauterine devices (IUDs).¹ They addressed many common misconceptions about IUDs, including use in adolescents, in patients who are nulliparous, and in patients with a history of sexually transmitted infection. The authors did not mention use of lidocaine during IUD insertion, either topically or via cervical block. Cervical lidocaine has been used for pain control for multiple outpatient gynecologic procedures, including colposcopy, endometrial biopsy, hysteroscopy, and cervical dilation and aspiration.² Although the available evidence is somewhat mixed, the risk of harm is low, with a primary risk of pain, bleeding, and vasovagal symptoms with injected lidocaine.³

Multiple trials have evaluated the use of topical lidocaine in a gel or spray formulation to decrease pain from the injection and from the procedure itself. These formulations may be less readily available and seem to have less effect on decreasing pain.⁴

Lidocaine can be injected into the anterior lip of the cervix to decrease pain with tenaculum placement.⁵ An alternative option is to inject lidocaine into the cervix at the 3- and 9-o'clock positions where the nerve bundles that innervate the cervix are located.⁶ For other outpatient gynecologic procedures, multiple other sites of the cervix have been injected for anesthesia, including the 4- and 8-o'clock positions or the 2-, 4-, 8-, and 10-o'clock positions.²

in reply: We would like to thank Drs. Pippitt and Gunning for their comments regarding our article. Because a prior article in American Family Physician had thoroughly reviewed IUD insertion techniques,¹ this was not the primary focus of our article. However, we appreciate the information they have shared about methods for decreasing pain from IUD placement.