Elsevier

Contraception

Volume 84, Issue 6, December 2011, Pages 594-599
Contraception

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

https://doi.org/10.1016/j.contraception.2011.03.011Get rights and content

Abstract

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.

Introduction

The intrauterine device (IUD) may be the ideal contraceptive method for young, nulliparous women between sexual debut and first desired pregnancy. This 7- to 8-year period is the most critical span of contraceptive need. Unintended pregnancy during this window is most likely to lead to abortion [1]. The IUD has a long duration of use, is highly effective, has a high degree of user satisfaction and leaves little room for user error, making it the perfect method for the new contraceptor. Nulliparity itself is not a contraindication for IUD use, yet many providers are reluctant to offer young women the IUD. Concerns about IUD use in nulliparous women include the possibility that insertion of the device through the nulliparous or nulligravid cervix is technically more difficult for the provider and more painful for the nulliparous patient, compared with insertions in parous women. In an attempt to facilitate IUD insertion for nulliparous women, off-label use of misoprostol has been promoted by several sources including Contraceptive Technology [2, p. 128] and the Association of Reproductive Health Professionals Update on Intrauterine Contraception [2], [3]. The practice of using misoprostol to facilitate IUD insertion has gained wide popularity. A summary of current published data regarding misoprostol use in IUD insertions is presented in Table 1 [4], [5], [6], [7], [8], [9]. The study designs vary in route and timing of misoprostol dose and in outcome measures.

Misoprostol is a prostaglandin E1 analogue, FDA approved for the prevention and treatment of gastric ulcers and is designed to be ingested orally. Misoprostol has specific effects on the uterus, causing uterine contractions, cervical dilation and increase in uterine tone. These attributes have led to the medication's common use in obstetric and abortion care, where it has been shown to be effective [[10], [11]]. While misoprostol has not been studied as rigorously in nonpregnant women, a systematic review of its use before hysteroscopy demonstrated a reduced need for cervical dilation and a reduced incidence of cervical laceration compared with placebo while noting a greater incidence of side effects [12]. Among the studies of prostaglandin use for IUD insertion, all have noted an increase in pain and/or side effects with treatment [4], [5], [6], [7], [8], [9]. Two experimental design trials using prostaglandin (one PGf2α and one with misoprostol) before IUD insertion have shown that IUD insertion was easier for the provider with treatment [4], [6]. Three additional experimental designs failed to show a difference in ease of inserion among the treatment and control groups but did note that insertion was generally easy [7], [8], [9]. In one case series of patients with a failed IUD insertion attempt, all had a successful IUD insertion 1 day after being treated with misoprostol [5]. Among the studies using misoprostol, all have used a 400-mcg dose, but the studies vary with respect to route and timing, both of which may contribute to side effects and tissue effect at the cervix. In all but one of the studies, women noted more side effects in the treatment groups. This descriptive study sought to examine current provider experience using misoprostol to facilitate IUD insertion in nulliparous women.

Section snippets

Materials and methods

The principal investigator (K.W.) developed survey questions using SurveyMonkey to query research participants. This survey was pilot tested among a local group of clinicians. The survey design allowed for conditional branching. This produced a smaller denominator as we obtained the sample of interest: providers who insert IUDs in nulliparous women and who use misoprostol. All participants regardless of whether or not they provided IUDs to nulliparous women or used misoprostol were queried

Results

A total of 9349 invitations were sent via email, with 2211 surveys at least partially completed, providing a 23.6% response rate (Fig. 1). Demographic data describing the participants is included in Table 2. Overall, 1905/2211 (86%) reported that they did provide IUDs to nulliparous women. Providers who were less than 1 year out of training were the most likely to provide an IUD to a nulliparous woman, when compared with providers grouped in 5-year increments of increasing experience (p=.02) (

Discussion

The 2211 family planning providers sampled here came from a variety of training backgrounds and commonly insert IUDs in nulliparous women. With 85% of our respondents indicating they employ one or more ancillary techniques to facilitate an IUD insertion, our research underscores the desire providers have to improve the IUD insertion experience and the need for more research in this area. The wide variety in timing and route of administration of misoprostol may explain the differences in

Acknowledgment

The authors gratefully acknowledge the assistance of the staff and membership of National Association of Nurse Practitioners in Women's Health and the American College of Nurse–Midwives their assistance with this survey. There was no outside funding for this study.

References (15)

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