Cervical softening with vaginal misoprostol before intrauterine device insertion

Practical Tips for Intrauterine Device Counseling, Insertion, and Pain Relief in Adolescents: An Update

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed intrauterine devices as first-line contraceptive choices for nulliparous and parous adolescents. Practical concerns about intrauterine devices might be barriers to use for teens and clinicians; this review is devoted to "practical tips" for clinicians, on the basis of an update of the available literature as well as the author's clinical experience. Counseling about contraceptive choices, preventive guidance about possible side effects, informed consent, and pain management are addressed to promote successful use of this long-acting reversible contraption option.

Medications to ease intrauterine device insertion: a systematic review

BACKGROUND

Potential barriers to intrauterine device (IUD) use include provider concern about difficult insertion, particularly for nulliparous women.

OBJECTIVE

This study aims to evaluate the evidence on the effectiveness of medications to ease IUD insertion on provider outcomes (i.e., ease of insertion, need for adjunctive insertion measures, insertion success).

SEARCH STRATEGY

We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that examined medications to ease interval insertion of levonorgestrel-releasing IUDs and copper T IUDs.

RESULTS

From 1855 articles, we identified 15 RCTs that met our inclusion criteria. Most evidence suggested that misoprostol did not improve provider ease of insertion, reduce the need for adjunctive insertion measures or improve insertion success among general samples of women seeking an IUD (evidence Level I, good to fair). However, one RCT found significantly higher insertion success among women receiving misoprostol prior to a second IUD insertion attempt after failed attempt versus placebo (evidence Level I, good). Two RCTs on 2% intracervical lidocaine as a topical gel or injection suggested no positive effect on provider ease of insertion (evidence Level I, good to poor), and one RCT on diclofenac plus 2% intracervical lidocaine as a topical gel suggested no positive effect on provider ease of insertion (evidence Level I, good). Limited evidence from two RCTs on nitric oxide donors, specifically nitroprusside or nitroglycerin gel, suggested no positive effect on provider ease of insertion or need for adjunctive insertion measures (evidence Level I, fair).

CONCLUSIONS

Overall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls. Among women with a recent failed insertion who underwent a second insertion attempt, one RCT found improved insertion success among women using misoprostol versus placebo.

Objective Assessment of Cervical Stiffness after Administration of Misoprostol for Intrauterine Contraceptive Insertion

PURPOSE

The goal of this study was to objectively quantify cervical stiffness in misoprostol users prior to IUC insertion and at follow-up consultation to evaluate the feasibility of assessing cervical stiffness and to study the influence of misoprostol on cervical softening.

MATERIALS AND METHODS

This was a cross-sectional study that evaluated 40 women who wished to use the LNG IUS. These women were evaluated immediately before LNG IUS insertion and 6 weeks later at follow-up consultation. Participants received 200 μg of misoprostol combined with 75 mg of diclofenac in a single tablet orally (Arthrotec forte 75/200(®), Pfizer, USA) 6-12 h prior to insertion in "off label" use. On both occasions, cervical stiffness was determined using a novel medical device based on the aspiration technique. The Wilcoxon rank-sum and the Wilcoxon signed-rank test were applied to compare cervical stiffness assessments at insertion of the IUD and at follow-up.

RESULTS

For the first time, cervical stiffness was quantitatively assessed in misoprostol users prior to IUD insertion, proving that the aspiration technique enables detection of pharmacologically induced cervical changes, and also that misoprostol has a detectable softening effect on cervical tissue.

CONCLUSION

The clinical value of the detected cervical softening after misoprostol administration remains unclear. Aspiration measurements could be helpful in searching for the ideal candidate, the appropriate route, dosage and interval of misoprostol intake prior to IUC insertion.

Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians

OBJECTIVES

To assess whether clinical skills training in cervical dilation and paracervical anesthesia, as well as the introduction of a clinical protocol for difficult insertions, increased intrauterine device (IUD) insertion success rates among advanced practice clinicians (APCs) including women's health and family practice nurse practitioners, physician assistants and certified nurse midwives.

STUDY DESIGN

This prospective study assessed an intervention to improve IUD insertions among APCs at six family planning clinics in Utah. We collected data on IUD insertions performed by participating clinicians during two observation phases: preintervention (Phase 1) and postintervention (Phase 2). Using electronic medical records, we tracked patient characteristics, IUD insertion success, difficulties and failures. We constructed a mixed-effects logistic regression model to control for provider and patient demographics influencing insertion success rates.

RESULTS

Nine clinicians participated in both preintervention and postintervention phases. The analysis included 428 IUD insertion procedures (242 preintervention and 186 postintervention). During Phase 1, 31/242 (12.8%) insertions failed. Insertion rates in Phase 2 improved with only 8/186 (4.3%) failures. Using mixed-effects logistic regression, the odds of a successful insertion postintervention was 4.8 times greater than preintervention (aOR=4.8.95% CI 1.8-12.7) when controlling for provider and patient characteristics. Increased risk of insertion failure was associated with nulliparity and younger age during Phase 1, but not during Phase 2.

CONCLUSIONS

A brief training for APCs and the use of a clinical protocol for difficult insertions may be able to improve IUD insertion rates.

IMPLICATIONS

Clinics with high rates of IUD insertion failure can improve care with a simple intervention, which may yield significant benefits in IUD service delivery.

Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion failure: a double blind RCT

STUDY QUESTION

Is pretreatment with misoprostol useful in insertion of intrauterine contraceptives (IUCs) after insertion failure at the first attempt?

SUMMARY ANSWER

Pretreatment with intravaginal administration of 200 mcg of misoprostol after IUC insertion failure 10 and 4 h before the second attempt of IUC placement was significantly better than placebo at facilitating the insertion of an IUC.

WHAT IS KNOWN ALREADY

One of the reasons for low use of IUCs is the concept that insertion is difficult. Misoprostol was used in several randomized clinical trials (RCT) before IUC insertion to facilitate the insertion. In general, the results showed no significant differences when compared with placebo. However, most previous studies have been carried out among unselected women whereas the present study is among women with previous insertion failure.

STUDY DESIGN, SIZE, DURATION

This was a double blind RCT conducted between February 2013 and October 2014. Participants were 104 women who requested an insertion of an IUC and the insertion failed at the first attempt. After insertion failure, the women received a sealed envelope with misoprostol or placebo. The randomization system (1: 1) in one block size was computer-generated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at a tertiary care centre. The women were instructed to insert vaginally one tablet of misoprostol 200 µg (Prostokos, Hebron, Cariacica, PE, Brazil) or placebo 10 and 4 h before the woman returned to the clinic for a new insertion attempt. The outcomes were successful IUC insertion and the use of a cervical dilator immediately prior to the insertion procedure.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 2639 women requested the insertion of an IUC during the study period. The IUC was inserted at the first attempt in 2535 women (96%) and 104 women in whom we were unable to insert the device were eligible to participate in the RCT. Four women declined and 100 women were randomized (55 for the misoprostol group and 45 for the placebo group). From the 100 participating women, the levonorgestrel-releasing intrauterine system (LNG-IUS) was chosen by 55 and 37 women and the TCu380A intrauterine device (Cu-IUD) was chosen by none and 8 women in the misoprostol and placebo group, respectively. Seven and three women allocated to misoprostol and placebo, respectively, never returned to the clinic after randomization. We placed the IUC in 42 (87.5%) out of the 48 women and in 26 (61.9%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.0066). Regarding the Evaluable Population the relative risk (RR) of successful insertions was 1.41 (95% confidence interval (CI) for absolute difference (8.2, 43.0), P = 0.0066); in the Intent-to-Treat Population the RR (95% CI) was 1.32 (0.3, 36.9). Multiple regression analysis showed that the significant variables associated with the insertion failure were the number of Caesarean section ≥1 (P = 0.020) and the use of placebo (P = 0.026). Dilators were used in 21 (43.7%) out of the 48 and 21 (50%) out of the 42 women randomized to misoprostol and placebo, respectively (P = 0.804).

LIMITATIONS, REASONS FOR CAUTION

The limitations were that the majority of the women chose the LNG-IUS, and consequently the data for the Cu-IUD were limited, and there was a small number of nulligravidas.

WIDER IMPLICATIONS OF THE FINDINGS

The results show that IUC insertion difficulties and failures are not common. Pretreatment with intravaginal misoprostol facilitated IUC insertion after failure of insertion at the first attempt, and insertion failure was associated with number of Caesarean sections.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/10085-0, and from the National Research Council (CNPq), grant #573747/2008-3. All the TCu380A IUDs were donated by Injeflex, São Paulo, Brazil, and all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations were provided in the form of unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov NCT01754649.

Sublingual misoprostol prior to insertion of a T380A intrauterine device in women with no previous vaginal delivery

OBJECTIVE

To investigate whether sublingual misoprostol administered one hour before intrauterine device (IUD) insertion reduces failed insertions, insertion-related complications and pain in parous women delivered only by elective caesarean section (CS).

METHODS

Single-blind randomised controlled trial conducted in Ismailia, Egypt, between July 2010 and December 2011. Women who had never delivered otherwise than by elective CS and desirous of using an IUD were randomly allocated to receive sublingually 400 μg misoprostol and 100 mg diclofenac (misoprostol group) or 100 mg diclofenac alone (control group) one hour before IUD insertion. Outcome measures were failed insertion, ease of insertion judged by the investigators, insertion-related complications, and patients' satisfaction.

RESULTS

In all, 255 women (130 and 125 in the study and control groups, respectively) had an IUD inserted. Seven insertions failed: five in the control group, and two in the study group. Ease of insertion and patients' satisfaction were comparable in both groups. Abdominal pain and nausea were the commonest side effects reported in the misoprostol group.

CONCLUSION

Sublingual administration of misoprostol one hour before IUD insertion in parous women with no previous vaginal delivery does not facilitate the procedure and may cause undesirable side effects. This approach is not recommended as a standard treatment.

Practical tips for intrauterine devices use in adolescents

The American Congress of Obstetricians and Gynecologists (ACOG) has endorsed intrauterine devices (IUDs) as first-line contraceptive choices for both nulliparous and parous adolescents. The committee opinion did address some of the practical elements of IUD use in adolescents, but because these practical concerns may be barriers to use for both teens and clinicians, this review is devoted to "practical tips," based on the available literature as well as the author's clinical experience. Counseling, informed consent, techniques of pain management, and preventive guidance about possible side effects are addressed in an effort to promote successful use of this long-acting reversible contraception (LARC) option.

Failed IUD insertions in community practice: an under-recognized problem?

BACKGROUND

The data analysis was conducted to describe the rate of unsuccessful copper T380A intrauterine device (IUD) insertions among women using the IUD for emergency contraception (EC) at community family planning clinics in Utah.

METHODS

These data were obtained from a prospective observational trial of women choosing the copper T380A IUD for EC. Insertions were performed by nurse practitioners at two family planning clinics in order to generalize findings to the type of service setting most likely to employ this intervention. Adjuvant measures to facilitate difficult IUD insertions (cervical anesthesia, dilation, pain medication, and use of ultrasound guidance) were not utilized. The effect of parity on IUD insertion success was determined using exact logistic regression models adjusted for individual practitioner failure rates.

RESULTS

Six providers performed 197 IUD insertion attempts. These providers had a mean of 14.1 years of experience (range 1-27, S.D. ±12.5). Among nulliparous women, 27 of 138 (19.6%) IUD insertions were unsuccessful. In parous women, 8 of 59 IUD insertions were unsuccessful (13.6%). The adjusted odds ratio (aOR) showed that IUD insertion failure was more likely in nulliparous women compared to parous women (aOR=2.31, 95% CI 0.90-6.52, p=.09).

CONCLUSION

The high rate of unsuccessful IUD insertions reported here, particularly for nulliparous women, suggests that the true insertion failure rate of providers who are not employing additional tools for difficult insertions may be much higher than reported in clinical trials. Further investigation is necessary to determine if this is a common problem and, if so, to assess if the use of adjuvant measures will reduce the number of unsuccessful IUD insertions.

Role of the levonorgestrel intrauterine system in effective contraception

Norgestrel, a synthetic progestin chemically derived from 19-nortestosterone, is six times more potent than progesterone, with variable binding affinity to various steroid receptors. The levonorgestrel-releasing intrauterine system (LNG IUS) provides a long-acting, highly effective, and reversible form of contraception, with a pearl index of 0.18 per 100 women-years. The locally released hormone leads to endometrial concentrations that are 200-800 times those found after daily oral use and a plasma level that is lower than that with other forms of levonorgestrel-containing contraception. The contraceptive effect of the LNG IUS is achieved mainly through its local suppressive effect on the endometrium, leading to endometrial thinning, glandular atrophy, and stromal decidualization without affecting ovulation. The LNG IUS is generally well tolerated. The main side effects are related to its androgenic activity, which is usually mild and transient, resolving after the first few months. Menstrual abnormalities are also common but well tolerated, and even become desirable (eg, amenorrhea, hypomenorrhea, and oligomenorrhea) with proper counseling of the patient during the choice of the method of contraception. The satisfaction rates after 3 years of insertion are high, reaching between 77% and 94%. The local effect of the LNG IUS on the endometrium and low rates of systemic adverse effects have led to its use in other conditions rather than contraception, as for the treatment of endometrial hyperplasia, benign menorrhagia, endometriosis, adenomyosis, and uterine fibroids.

Cervical lidocaine for IUD insertional pain: a randomized controlled trial

OBJECTIVE

Anticipated pain with intrauterine device (IUD) insertion may be a barrier to widespread use. Our objective was to evaluate the efficacy of intracervical 2% lidocaine gel for pain relief with IUD insertion.

STUDY DESIGN

We performed a double-blind, randomized controlled trial of women undergoing IUD insertion. Participants were randomly assigned to 2% lidocaine or placebo gel. Study gel (3 mL) was placed 3 minutes prior to IUD insertion. Pain scores were measured at various time points using a 10-point visual analog scale.

RESULTS

Of the 200 participants randomized, 199 completed the study. Pain scores among lidocaine and placebo arms were similar at tenaculum placement (lidocaine and placebo: median, 4; range, 0-10; P = .15) and with insertion (lidocaine: median, 5; range, 1-10; placebo: median, 6; range, 0-10; P = .16). These results did not differ by parity.

CONCLUSION

Topical or intracervical 2% lidocaine gel prior to IUD insertion does not decrease pain scores.

Vaginal misoprostol aids in difficult intrauterine contraceptive removal: a report of three cases

BACKGROUND

Intrauterine devices are the most used long-acting reversible contraceptive method worldwide. Under normal circumstances, removal of an intrauterine contraceptive (IUC) is an uncomplicated procedure requiring gentle traction on the string.

STUDY DESIGN

We report three cases of nonvisible IUC strings where, following use of vaginal misoprostol, the IUC strings were visualized and the IUCs were removed intact with gentle traction.

CONCLUSIONS

The uterotonic and uterocontractile effects following vaginal misoprostol facilitated removal in three cases of nonvisible IUC strings. We suggest that clinicians consider including vaginal misoprostol alone or prior to planned repeat office or procedure-clinic interventions for nonvisible IUC strings.

A survey of provider experience with misoprostol to facilitate intrauterine device insertion in nulliparous women

BACKGROUND

There is a significant need for research on treatments that provide pain relief during intrauterine device (IUD) insertion. Misoprostol is frequently used before IUD insertion but is not always necessary and its use may increase pain and side effects. This survey evaluated how providers who perform IUD insertion in nulliparous women report using misoprostol to facilitate the procedure.

STUDY DESIGN

An anonymous Internet-based survey was distributed to members of three professional organizations with family planning providers.

RESULTS

Of 2211 survey respondents, 1905 (86%) reported providing IUDs to nulliparous women. Of those providing IUDs to nulliparous women, 947/1905 (49.7%) reported using misoprostol, and 380 (40%) of 947 of misoprostol users reported using the treatment empirically with all nulliparous IUD insertions. There was wide variation reported in dose, route and timing of misoprostol administration. Providers most commonly reported learning of misoprostol use for IUD insertion by word of mouth rather than through the literature.

CONCLUSIONS

Despite conflicting published data, nearly half of survey respondents use misoprostol before IUD insertion. Considerable variation in the timing of misoprostol use may explain differences in perception of its effectiveness. Evidence-based information about misoprostol for IUD insertion in nulliparous women, including pharmacokinetics, efficacy and optimal dosing, is needed.

Safety, Efficacy, and Patient Acceptability of the Copper T-380A Intrauterine Contraceptive Device

The ParaGard Copper T 380A intrauterine device (CuT380A) provides reversible contraception that is as effective as sterilization for up to 20 years. The CuT380A is a mainstream, first-line contraceptive option for most healthy women, including nulligravid women, as well as many women who have serious medical problems. Because it is the most cost-effective method of birth control, the CuT380A is the preferred IUD, except for women who desire lighter or no menstrual blood loss. Surveys reveal that 95% of US CuT380A users are “very” or “somewhat” satisfied with their method. This article describes current candidates for IUD use, discusses the mechanisms of action of the CuT380A, provides guidance to reduce barriers to IUD access, suggests counseling points for patients, and outlines techniques to reduce the risks and side effects that can be associated with use of the CuT380A.

Double-blind, randomized, placebo-controlled study on the effect of misoprostol on ease of consecutive insertion of the levonorgestrel-releasing intrauterine system

BACKGROUND

Misoprostol has been studied intensively to produce cervical dilatation. To date, no studies have evaluated the effectiveness, safety or acceptability of this treatment for repeat intrauterine device insertions.

STUDY DESIGN

This study was a randomized, double-blind, placebo-controlled trial on the consecutive use of the levonorgestrel-releasing intrauterine system (LNG-IUS). Women who had used their first LNG-IUS for 4 years and 3 to 9 months and opted for an immediate replacement with a second LNG-IUS received a single sublingual dose of 400 mcg misoprostol or placebo 3 h prior to the LNG-IUS insertion.

RESULTS

The proportion of easy insertions as judged by the investigator was 93% (40/43) in subjects randomized to misoprostol and 91% (42/46) in the placebo group (p=1.0 for the difference of proportions). No or mild pain at insertion was reported by 37% and 35% of subjects in the misoprostol and placebo groups, respectively. However, adverse events related to the study drug were more common in the misoprostol group.

CONCLUSION

Sublingual misoprostol did not have a significant effect on the ease of insertion in subjects having a repeat insertion of the LNG-IUS.

The effects of the prostaglandin E analogue Misoprostol and follicle-stimulating hormone on cervical penetrability in ewes during the peri-ovulatory period

Two experiments in parous Welsh Mountain ewes determined the pattern of natural cervical relaxation over the peri-ovulatory period and investigated FSH and Misoprostol as cervical relaxants to facilitate transcervical passage of an insemination pipette into the uterine cavity. Following synchronisation of oestrus using progestagen sponges and PMSG (500 IU) the depth of cervical penetration was determined using a modified cattle insemination pipette as a measuring device. Penetration of the cervix was least at the time of sponge removal and increased to a maximum at 72 h after sponge removal and then declined. Intra-cervical administrations of either ovine FSH (Ovagen; 2mg) or Misoprostol (1mg; a Prostaglandin E(1) analogue) facilitated cervical penetration. Ovagen given 24h after sponge removal allowed transcervical intrauterine penetration in 100% of ewes at 54 and 60 h after sponge removal while Misoprostol given 48 h after sponge removal allowed trans-cervical penetration in 100% of ewes at 54 h. A combination of Ovagen and Misoprostol was as effective but not more so than Ovagen or Misoprostol alone. These results show that there is natural relaxation of the cervix at oestrus and that maximum relaxation occurs 72 h after sponge removal, which is too late for the correct timing of insemination. The intra-cervical administration of FSH or Misoprostol enhanced relaxation of the cervix and both were able to relax the cervix to allow intrauterine penetration 54 h after sponge removal, the optimum time for insemination. The results also show that FSH is biologically active after intracervical, topical application.