Key messages

• Using misoprostol (a medication that softens and widens the cervix - the neck of the womb) before placing an intrauterine device (IUD - a contraceptive device placed inside the womb) makes little to no difference to pain when a tool (a tenaculum) is used to hold the cervix in place during IUD placement or pain after IUD placement. It may make little to no difference to pain during placement, ease of placement for providers, or need for cervical widening; and probably makes little to no difference to placement success, except for women who recently tried unsuccessfully to have an IUD placed.

• Misoprostol-related unwanted effects like stomach cramps and diarrhea probably increase, but it may make little to no difference to other unwanted events. We don't know whether misoprostol use affects women's satisfaction with the procedure.

What is an intrauterine device?

An intrauterine device (IUD) is a small t-shaped device inserted through the cervix (the neck of the womb) into the womb to prevent pregnancy. IUDs need to be placed by a trained doctor, nurse, or healthcare provider. IUD placement may be a painful procedure, and it may be more difficult for women who have not had a baby or who have already tried unsuccessfully to have an IUD placed. Serious unwanted events are rare with IUD placement but women may experience non-serious unwanted effects similar to period pain (cramps) or light bleeding.

What is misoprostol?

Misoprostol is a medication that is commonly used to start labor and to treat bleeding following birth. It causes the cervix to soften and widen, and so might make IUD placement less painful for women and easier for providers. Misoprostol may cause some unwanted effects like cramps, sickness or diarrhea. Sometimes women may feel dizzy, sweaty or light-headed. An IUD is an effective and reversible contraceptive method, so identifying ways to reduce pain and improve ease of placement for providers may reduce barriers to IUD access and use.

What did we want to find out?

We wanted to find out if misoprostol reduces pain, makes IUD placement easier for providers, reduces the need for other methods to widen the cervix, improves placement success and women's satisfaction with the procedure, and whether it causes unwanted effects.

What did we do?

We searched for studies that examined misoprostol for routine IUD placement compared to placebo (a sham medication) or no treatment. We combined and analyzed the studies' results and rated our confidence in the evidence, based on factors such as study methods.

What did we find?

We found 14 RCTs with 1972 women. The studies took place in North America, South America, Europe, and Africa. All the studies compared misoprostol with placebo or no treatment.

Main results

Pain. Misoprostol:

• results in little to no difference in pain during tenaculum placement (a tenaculum is a tool that holds the cervix in place during IUD placement) (3 studies, 261 women);

• may result in little to no difference in pain during IUD placement (7 studies, 766 women);

• results in little to no difference in pain after IUD placement before leaving the clinic (5 studies, 448 women).

Providers' ease of placing the IUD

• Misoprostol may result in little to no difference in ease of IUD placement for providers (8 studies, 848 women).

Need for cervical dilation. Misoprostol:

• may result in little to no difference in the need for cervical widening for women without a recent failed placement attempt (6 studies, 562 women);

• probably results in little to no difference in the need for cervical widening for women with a recent failed placement attempt (1 study, 90 women).

Placement success. Misoprostol:

• probably results in little to no difference in placement success for women without a recent failed placement attempt (12 studies, 1579 women);

• probably results in a slight increase in placement success for women with a recent failed placement attempt (1 study, 90 women).

Patient satisfaction

• We are not sure whether misoprostol increases patient satisfaction with the IUD placement procedure (2 studies, 226 women).

Unwanted effects. Misoprostol:

• probably results in an increase in stomach cramps (7 studies, 781 women);

• probably results in a slight increase in diarrhea (9 studies, 940 women);

• may result in little to no difference in dizziness or light-headedness (6 studies, 780 women).

What are the limitations of the evidence?

Some studies did not report key information about what we wanted to know, and some studies were different from each other, so we couldn't include them in our analyses. We had planned to examine whether certain factors affected the results, such as whether women had previously given birth vaginally, the dose of misoprostol used, or the type of IUD placed, but there were not enough studies to do this in a meaningful way.

How up to date is this evidence?

The evidence is up to date to 23 September 2024.