Misoprostol Unhelpful for IUD Insertion

October 7, 2013

Misoprostol for cervical ripening prior to insertion of an IUD in nulliparous women not only did not improve ease of insertion for the provider but resulted in increased procedure-related pain.

The use of self-administered misoprostol for cervical ripening prior to insertion of an intrauterine device (IUD) does not improve ease of insertion for the provider or decrease reported pain for the patient, according to the results of a new study.1

Despite the benefits of IUDs in terms of their effectiveness, relative safety, and low long-term costs compared with other types of contraception, the percentage of women who choose these devices remains relatively low. According to a recent report, just 5.6% of all contraceptive users use IUDs as their method of choice.2 Among the barriers to IUD use in women who have never had a child are fear of pain with insertion, adverse effects, and provider perception of difficulty with insertion.

Misoprostol, a synthetic prostaglandin E1 analog, has long been used off-label for cervical ripening and induction of labor. Because the drug can be administered via several routes-oral, vaginal, sublingual, and buccal-self-administration is possible.

Considering this, it made sense for researchers to test whether buccal misoprostol dosed prior to IUD insertion in nulliparous women eased the insertion process and decreased pain in a double-blind, randomized, controlled trial. The participants were randomized to either buccal placement of misoprostol, 400 mcg, or placebo. Using a 100-mm visual analog scale, researchers measured provider-reported ease of insertion and patient-reported pain. A total of 73 women completed the study. The baseline characteristics of the study participants were similar, reported the researchers.

According to provider perception, the ease of insertion was similar between study groups, with the study group being rated 28.97 mm and the control group being rated 22.33 mm on a 100-mm scale (P=0.18). However, patients who received misoprostol, compared with those who received placebo, reported higher rates of pain both immediately before IUD insertion (10.84 mm vs 2.11 mm; P=0.003) and after IUD insertion (46.50 vs 35.14; P=0.040).

According to the evidence provided in this trial, not only does misoprostol not improve ease of IUD insertion for the provider, it seems to be associated with an increase in patient pain. Therefore, based on these results, the use of misoprostol for cervical ripening before IUD insertion cannot be recommended for nulliparous women.

Despite some reports that providers perceive IUD insertion in nulliparous women as difficult, the results of this study indicate that this is not the case. In addition, the pain that women experience upon IUD insertion seems to be acceptable and not prohibitive.

Overall, the use of buccal misoprostol for cervical ripening prior to IUD insertion does not ease the insertion process for providers and does increase the level of patient-reported pain.

Pertinent Points:
- Misoprostol for cervical ripening before IUD insertion in nulliparous women does not ease the insertion process nor does it decrease pain. Rather, it seems to be associated with an increase in reported pain.
- Overall, providers do not perceive IUD insertion in this group of women to be “difficult,” and women perceive the pain of IUD insertion to be “acceptable.”

References:

1. Lathrop E, Haddad L, McWhorter CP, Goedken P. Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial. Contraception. 2013 Aug 6. pii: S0010-7824(13)00544-1. doi: 10.1016/j.contraception.2013.07.011. [Epub ahead of print]
2. Guttmacher Institute. Contraceptive use in the United States [fact sheet]. August 2013. Available at: http://www.guttmacher.org/pubs/fb_contr_use.html Accessed September 25, 2013.