1. Among nulligravidas, women receiving pre-procedure misoprostol experienced easier and less painful intrauterine device (IUD) insertion.
2. Women who received misoprostol before IUD insertion were more likely to experience cramping after taking misoprostol but not at 24 hours after insertion.
Evidence Rating Level: 2 (Good)
Study Rundown: This study found that vaginal administration of a 400μg misoprostol tablet four hours before IUD insertion reduces the difficulty of and pain associated with IUD placement in nulligravid women. Findings suggest that this dosage, timing and route of misoprostol administration facilitate IUD insertions in nulligravidas and might be considered for standard practice.
Strengths of this study include a double-blind, RCT study design and assessment of outcomes through multiple measures. Limitations include a small sample size and use of some subjective measures. Reproduction of results in a larger study population would confirm the findings of this investigation. Future studies might also evaluate whether observed benefits hold in primi-, and multi-gravid women and might also incorporate assessment of contraceptive efficacy.
In-Depth [double-blind, randomized controlled trial]: This trial evaluated the vaginal administration of 400μg of misoprostol 4 hours prior to IUD insertion among 179 nulligravid Brazilian women between 2009 and 2011. Women were randomized to misoprostol (n=86) or placebo (n=93) and had two 200μg misoprostol tablets or two placebo tablets placed in the posterior vaginal fornix. Outcomes assessed included difficulty of IUD placement; cervical dilatation; pain at insertion; the woman’s subjective experience of placement; and side effects during insertion and at several time points afterward (immediate, 24 hours, 30 days).
Compared to controls, women who took misoprostol were less likely to have cervical dilatation ≤ 4mm (RR 0.49, CI 0.33-0.70) were less likely to have a difficult IUD placement, as reported by physicians (RR 0.49, CI 0.33-0.72). Women receiving misoprostol were also less likely to experience moderate or severe pain (RR 0.56, CI 0.41-0.76) and were less likely and to report having a disagreeable or very disagreeable experience (RR 0.49, CI 0.35-0.68). However, women in the misoprostol group were more likely to experience cramps (RR 1.40, CI 1.05-1.86) subsequent to insertion of the vaginal tablets but this difference did not persist at 24 hours after insertion (RR 1.15, CI 0.77-1.73).
By Denise Pong and Leah Hawkins, MD, MPH
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