OT/ Cytotec for IUD placement? *update-ish

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Joined: 01/18/06
Posts: 1626
OT/ Cytotec for IUD placement? *update-ish

*Today is Mirena day. Cytotec went in 15 minutes ago. :eek: I'll repost after the procedure. I know a few people were interested to know how it goes.

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I have a script from my Gynecologist for a Mirena IUD and some cytotec that she wants me take 4 hours before insertion of the iud.

I know this is still technically 'off label' use, but any reason why I should be concerned? I'm not pregnant and both kids were vaginal so I'm sure it wont take much to dilate me.

Thoughts?

TyrantOfTheWeek's picture
Joined: 12/26/05
Posts: 1147

Never heard of anyone doing that....I'd call and ask her what's the deal.

Spacers's picture
Joined: 12/29/03
Posts: 4100

That seems very odd to me. I could see if you'd never had a baby or if you'd had a failed insertion attempt in the past, they might recommend something to help dilate you, but then why not one of those spongey things that absorb liquid & swell up? They use those for abortions, why not for IUD insertion? They usually insert Mirena during AF so you're a bit open anyway, but I missed that window since I got my first PPAF & called to schedule the insertion, and then the next AF came just two weeks later. So my Mirena was inserted mid-cycle and even then my OB didn't say anything about dilation. The worst part was measuring the length, that's a bit crampy, but the rest of it was a breeze. You should expect to be crampy for a couple of weeks, and you might spot after sex for a few months, but it's been great other than that. I haven't had anything more than spotting for four months! Good luck with yours!

Joined: 01/18/06
Posts: 1626

Thanks guys. And thanks for all that info Stacey! I'm looking forward to not using condoms anymore!

I did call my midwife actually and she said it's normal up here for cyt to be used for iud placement, and she herself used it too. So, I'm gonna just go with it.

krazykat's picture
Joined: 08/11/07
Posts: 1143

Never heard of it before, but I found this and thought it might be a useful resource for you:

Q. Does misoprostol aid prior to IUD insertion?
A. Yes, misoprostol appears to soften the cervix and decrease complications.

Answer
Evidence is suggestive that misoprostol is useful for IUD insertions. Misoprostol softens the cervix and reduces the chance of complications such as perforation, pain, and bleeding. In addition, RCTs have shown that misoprostol improves the ease with which the cervix can be dilated and reduces complications in premenopausal women, postmenopausal women, and nulliparous women undergoing operative hysteroscopy, though the studies are small.
(see Faculty of Family Planning and Reproductive Health Care of the RCOG)

As with many issues surrounding misoprostol, the optimum dosing and regimen remain in question. The doses referenced below range from 200 – 400 mcg given 12 -24 hours before the procedure. (see Regimens below)

Other Resources:
FAQ: For nulliparous women undergoing IUD insertion does cervical priming with misoprostol or other agents facilitate the insertion?
http://www.ffprhc.org.uk/admin/uploads/No1456.pdf

Insertion of an intrauterine contraceptive device, UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey=gen_gyne/21041&type=A&selectedTitle=2~24

Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005 Jan 1;71(1):95-102
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15663031

Faculty of Family Planning and Reproductive Health Care of the RCOG
http://www.ffprhc.org.uk/

Regimens

In favor
Atmaca R, et al
The study group received local estrogen cream and other group received chlindamycine phosphate cream as placebo. The patients were given oral misoprostol 24 and 12 hours before the procedure for uterine cavity evaluation.

Barcaite E, et al
The study group (n=51) received 400 microg of vaginal misoprostol at least 12 h before the procedure

Darwish AM, et al
Misoprostol 200 microg was inserted into the posterior fornix of the vagina for patients in group A (n=72), while laminaria tents were inserted intracervically in group B patients (n=72)

Thomas JA, et al
Patients were randomly allocated, by means of computer-generated numbers, to receive either placebo or 400 microg of misoprostol 12 and 24 hours before surgery.

Not in favor
Fernandez H, et al
Four groups of 12 women were randomly assigned to receive either placebo or vaginal misoprostol in doses of 200, 400 or 800 micro g 4 h before the surgical procedure.

Expanded References
In favor
CONCLUSION: Vaginal misoprostol applied before hysteroscopy reduced cervical resistance and the need for cervical dilation in perimenopausal and postmenopausal women, with only mild adverse effects
Barcaite E, et al Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. Int J Gynaecol Obstet. 2005 Nov;91(2):141-5
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16102766

As a conclusion, misoprostol treatment alone is not effective to get cervical priming in postmenopausal women, and as shown in our study, pretreatment with local estrogen overcome the failure. To get a beneficial effect of misoprostol on cervical ripening, estrogenic activity is necessary and when pretreated with local estrogen, misoprostol ameliorates cervical priming in postmenopausal women
Atmaca R, et al Priming effect of misoprostol on estrogen pretreated cervix in postmenopausal women. Tohoku J Exp Med. 2005 Jul;206(3):237-41
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15942151

CONCLUSIONS: Both misoprostol and laminaria were equally effective in inducing proper cervical priming prior to operative hysteroscopy with minimal time of cervical dilatation. Nevertheless, misoprostol may be superior due to easy application, reduced cost, and patient convenience and acceptability.
Darwish AM, et al Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol.
Hum Reprod. 2004 Oct;19(10):2391-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15333607

CONCLUSIONS: Misoprostol demonstrates a benefit over placebo in the ease of cervical dilatation in premenopausal and postmenopausal women and in those pretreated with a gonadotropin-releasing hormone analog. Adverse effects were more common in the treatment group but did not preclude the patients from taking the medication.
Thomas JA, et al The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial. Am J Obstet Gynecol. 2002 May;186(5):876-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12015500

CONCLUSION: Vaginal misoprostol applied before operative hysteroscopy reduced the need for cervical dilation, facilitated hysteroscopic surgery, and minimized cervical complications.
Preutthipan S, Herabutya Y. Vaginal misoprostol for cervical priming before operative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2000 Dec;96(6):890-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11084173

CONCLUSION: Vaginal misoprostol lessens the cervical resistance in women undergoing hysteroscopy and facilitates the procedure, with only mild side effects.
Preutthipan S, Herabutya Y. A randomized controlled trial of vaginal misoprostol for cervical priming before hysteroscopy. Obstet Gynecol. 1999 Sep;94(3):427-30.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10472872

Endometrial biopsy and hysteroscopy are important investigations in women presenting with abnormal vaginal bleeding. Endometrial biopsy is often performed as an outpatient procedure by endometrial aspiration. Difficulty in entering the internal cervical os may be encountered, especially in nulliparous women. The same problem may occur during hysteroscopy or dilatation and curettage. It is well known that use of a cervical priming agent is effective in reducing complications during cervical dilatation in pregnant women. However, its use in non-pregnant women is not well established. We compared oral misoprostol versus placebo for a cervical priming effect in non-pregnant women prior to hysteroscopy. The cumulative force required for cervical dilatation was significantly lower whereas the baseline cervical dilatation was significantly greater in the misoprostol group. Another potential use of misoprostol is for cervical dilatation prior to IUD insertion in nulliparous women.
We conclude that oral misoprostol is effective for pre-operative cervical dilatation in non-pregnant women.
Ngai SW, Chan YM, Liu KL, Ho PC Oral misoprostol for cervical priming in non-pregnant women. Hum Reprod. 1997 Nov;12(11):2373-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9436666

Expanded References
Not in favor
CONCLUSION: There was no significant benefit from applying 400 micro g vaginal misoprostol 6 h prior to dilatation and curettage in postmenopausal women.
Bunnasathiansri S et al Vaginal misoprostol for cervical priming before dilatation and curettage in postmenopausal women: a randomized controlled trial. J Obstet Gynaecol Res. 2004 Jun;30(3):221-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15210047

CONCLUSIONS: Vaginal misoprostol applied 4 h before operative hysteroscopy at three different doses did not reduce the need for cervical dilatation, did not facilitate hysteroscopic surgery, and increased pre-operative pain
Fernandez H, et al Vaginal misoprostol for cervical ripening before operative hysteroscopy in pre-menopausal women: a double-blind, placebo-controlled trial with three dose regimens. Hum Reprod. 2004 Jul;19(7):1618-21
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15155607

CONCLUSION: Sublingual misoprostol 100 mug does not facilitate cervical dilatation before hysteroscopy. This may be related to leuprolide's hypoestrogenic effect.
Bisharah M et al A randomized trial of sublingual misoprostol for cervical priming before hysteroscopy. J Am Assoc Gynecol Laparosc. 2003 Aug;10(3):390-1.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14567819

CONCLUSION: Vaginal misoprostol was not shown to reduce the need for cervical dilatation in postmenopausal women. It cannot convert diagnostic hysteroscopy from a hospital procedure into an office one in postmenopausal women with tight cervical os.
Fung TM, et al A randomised placebo-controlled trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women. BJOG. 2002 May;109(5):561-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12066947

CONCLUSION: Oral misoprostol 400 microg caused more uterine cramping and pain in nonpregnant women undergoing office endometrial biopsy when given 3 hours before biopsy attempt. No other cervical effects were noted.
Perrone JF, et al Oral misoprostol before office endometrial biopsy. Obstet Gynecol. 2002 Mar;99(3):439-44.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11864671

CONCLUSIONS: These data showed that there were no significant benefits from giving misoprostol pre-operatively in postmenopausal women, and it was concluded that oral misoprostol had no significant cervical priming effect in postmenopausal women.
Ngai SW et al The use of misoprostol prior to hysteroscopy in postmenopausal women. Hum Reprod. 2001 Jul;16(7):1486-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11425834

Other
Penney G, et al FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception. Journal of Family Planning and Reproductive Health Care 2004 30:29-42
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15006311

Cervical priming with the aid of a single 15-ME-PGF2a vaginal suppository prior to IUD insertion resulted in cervical changes which facilitated the procedure….The cervical ripening and dilatation produced by the suppository increased the ease of IUD insertion , and expanded the time frame in which an IUD insertion could be performed. The method was well tolerated by all patients and eliminated the nausea and syncope often associated with IUD insertion
Lauersen NH et al A new iud insertion technique utilizing cervical priming with prostaglandin. Contraception. 1982 Jul;26(1):59-63.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7128135

Here's the link, and it's at the very bottom of the page: http://www.ihs.gov/medicalprograms/mch/m/Mfaqs.cfm#iudInsert

Chimmy's picture
Joined: 08/03/01
Posts: 2776

Interesting! I never used cytotec either but can see why it would help. Insertion wasn't painful for me at all, my sister has had it placed in twice now & it wasn't painful for her the first time but was the 2nd but she was 6 weeks pp and still tender I think.

KUP on how things go, I'll be curious Smile

Amber_daisy's picture
Joined: 10/17/06
Posts: 567

Never heard of it being used for IUD placement before. I had an IUD placed by and OBGYN prior to having any babies and didn't have a hitch with it.

TiggersMommy's picture
Joined: 02/14/10
Posts: 6043

Interesting. When I had my IUD put in it was really rather uncomfortable. Not painful but not a walk in the park either. I was about 2.5 months PP (I think) and the MW said my uterus is on the short side, almost too short to insert an IUD. Perhaps it would have been less uncomfortable with a little dilation assistance. Once she measured me and determined my uterus was actually that short and it wasn't due to improper placement of the "dip stick" she popped it in and I was good to go. So far so good! IUDs rock!

mommys's picture
Joined: 05/08/06
Posts: 6264

They didn't use anything on me. It wasn't very painful!

I loved my IUD though 3 years without more than spotting - yippee! Best wishes!

Joined: 05/24/05
Posts: 944

I'm planning on getting one after this babe.. nice to hear that so many of you have had positive experiences. I've never heard of cytotec being used here, but I suppose it makes sense.

Illiana's picture
Joined: 09/29/05
Posts: 338

I'd probably do it if it's been a long time since you've had a baby.. A friend of mine just got one inserted and she was in pain for several days BUT her son is 14 (only child) and she's tiny (like size 1). I had mine put in about 5-6 months pp with dd and i didn't even flinch and I wasn't on AF at all (didn't know i was supposed to be) But mine also fell out after about six months also. I keep thinking about putting in another one but i'm nervous about the odds of a second one falling out.

Joined: 01/18/06
Posts: 1626

:bump:

Joined: 05/24/05
Posts: 944

Good luck! I'll keep your cervix in my thoughts. Wink