Efficacy and Safety of EMLA Cream in Reducing Pain During Intrauterine Device Insertion: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: Intrauterine devices(IUDs) are a safe and effective method of reversible contraception. However, pain and anxiety during IUD insertion may limit its global utilization. Evidence for EMLA(lidocaine-prilocaine) cream efficacy in pain reduction with IUD insertion is limited.Objective: To systematically and meta-analytically evaluate the efficacy and safety of EMLA(5% lidocaine-prilocaine cream) compared to placebo in reducing pain during intrauterine device(IUD) insertion.Methods: We comprehensively searched PubMed, Scopus, Web of Science, and Cochrane Library till May 2024. We included only randomized placebo-controlled trials(RCTs) and used Cochrane Risk of Bias Tool 2 for quality assessment. Our primary outcome was pain during IUD insertion and uterine sounding, while provider ease of IUD insertion, women's satisfaction, and drug side effects are secondary outcomes. We summarized pooled outcomes as mean difference(MD) or risk ratio(RR) with a 95% confidence interval(CI).Results: Four studies were included (N=432 women) with a low risk of bias overall. EMLA cream significantly lowered pain at tenaculum placement(MD= -1.68, 95% CI [-2.5, -0.86], p <0.0001), uterine sounding(MD= -1.8, 95% CI[-2.51, -1.08], p <0.00001), and IUD insertion(MD= -1.74, 95% CI [-2.63, -0.85], p =0.0001) than placebo. The EMLA cream lowered the need for additional analgesia(RR= 0.2, 95% CI [0.07, 0.57], p =0.002) and increased provider ease of IUD insertion(MD= -1.4, 95% CI [-1.68, -1.13], p <0.00001). Side effects were comparable between both groups.Conclusion: EMLA cream is a safe, effective pain-lowering medication with improved patient satisfaction during IUD insertion. The reduction in pain scores was clinically significant, with a low risk of bias.