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Following a 7-month trial on the use of Entonox® for the relief of pain or anxiety during intrauterine device (IUD) or intrauterine system (IUS) fitting, we now offer this method of pain relief to all women attending for an intrauterine procedure. It is available to any patient who wishes to use it but its use is entirely optional. Entonox can be used alongside other analgesics and there is no need for the woman to decide beforehand.
Our services currently insert a minimum of 20 IUDs/IUSs per week at two clinic sites in Central Buckinghamshire, UK. The clinics serve all ages and client groups who mainly self-refer, as well as accepting general practitioner (GP) referrals for emergency IUDs.
Reducing pain and anxiety for these procedures has been much debated over the last few years. Hutt1 and more recently Akintomide et al.2 have advocated an increased use of intracervical local anaesthesia. Hutt3 suggests that lignocaine gel is ineffective and that “…it is simply a salve to our guilty consciences”.
Entonox provides pain relief and conscious sedation for a variety of short-term procedures4 and is licensed for such indications.5 The manufacturer of Entonox, BOC, expects that within a minute of discontinuing breathing Entonox the effect has worn off so clients could drive within 30 minutes of the procedure. This is confirmed in the Summary of Product Characteristics (SPC).5 Our National Health Service Trust states that clients should not drive for 12 hours after using Entonox. We counsel women prior to procedures and are hoping that the Trust will take a more pragmatic stance in the future in the light of BOC's guidance and the information within the SPC. Our current information states: “[Entonox] wears off within a minute or two of stopping breathing it, however, please note that: (a) it is currently a Trust policy that she should not drive herself home if she has used Entonox so needs to arrange a lift, and (b) she should not use Entonox if she has recently had a ‘burst eardrum’ or within 48 hours of SCUBA diving”.
Since introducing Entonox in our clinics, we have had a steady rise in the number of clients opting for IUD/IUS. Some state that they choose our service “… because you have the ‘gas and air’”. However, some women also state that at a previous procedure carried by their GP they had not been advised to take any analgesics beforehand nor were they offered any at the procedure. The clinics run a large teaching practice for both GPs and nurses, and the many GPs we talk to who state that they never give intracervical local anaesthesia as “women don't need it” are perhaps unaware of the number of women who choose to go to a Level 3 service for their next IUD/IUS in the hope of a better experience when analgesia is available. I suggest that these women are reluctant to tell their GPs, whom they like and trust, that the procedure was less than perfect.
Striking the balance between letting women know that Entonox is available and worrying some who say “…if it is so painful you need ‘gas and air’ I am not having one”, has been something we have addressed in our literature and by having a poster containing information and comments in the waiting room.
The final word needs to go to one of our satisfied clients: “10 years of contraception and gas to breathe when it's fitted, what's not to like?”.
Journal readers who would like further information on using Entonox for procedures or who are interested in the questionnaire from which the quotations above were taken and its audit may e-mail me direct.
Competing interests None.
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