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

Adherence to Recommended Practices for Provision of Long-Acting Reversible Contraception Among Providers in a Large U.S. Health Care System

Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p = 0.001; implant: 57% vs. 26%, p = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p = 0.001; implant: 65% vs. 27%, p < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.

Uptake of online HIV-related continuing medical education training among primary care providers in Southeast United States, 2017-2018

Primary care providers play a vital role for HIV prevention and care in high burden areas of the Southeast United States. Studies reveal that only a third of these providers had previous HIV-related training. We evaluated the effects of targeted online continuing medical education training on HIV-related knowledge, attitudes and practices among providers in the Southeast. During April 2017–February 2018, we administered baseline and six-month follow-up surveys to assess changes attributed to online training among a representative sample of providers from six Southeast locations. Data were analyzed using logistic regression analysis (p < 0.05). Baseline and follow-up surveys were completed by 349 participants (61.2% female, 64.6% white, 69.6% physicians, and 27.5% aged 40 years or less); 18% (n = 63) of whom visited online training websites sent following the baseline survey. Comparing baseline versus follow-up responses, providers who completed online training were half as likely to identify “patients’ age” (30% vs. 15%) and “patients’ race” (3% vs. 1.4%) as barriers to discussing sex with clients; survey responses by participants who declined training remained unchanged. Based on baseline versus follow-up responses, providers who visited online training websites were more likely to become familiar with preexposure prophylaxis (PrEP) (38% vs. 58%); participants who declined training remained unchanged at 45%. No impact on clinical practices such as PrEP prescriptions was identified. Targeted online training can enhance HIV readiness and should be explored for providers in the Southeast, particularly for enhancing PrEP service delivery.

HIV prescriptions on the frontlines: Primary care providers' use of antiretrovirals for prevention in the Southeast United States, 2017

HIV disproportionately affects persons in Southeast United States. Primary care providers (PCPs) are vital for HIV prevention. Data are limited about their prescribing of antiretrovirals (ARVs) for prevention, including non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART). We examined these practices to assess gaps. During April-August 2017, we conducted an online survey of PCPs in Atlanta, Baltimore, Baton Rouge, Miami, New Orleans, and Washington, DC to assess HIV-related knowledge, attitudes and practices. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were used to estimate correlates of nPEP, PrEP and ART prescribing practices. Adjusting for MSA and specialty, the weighted sample (n = 820, 29.6% adjusted response rate) comprised 60.2% white and 59.4% females. PCPs reported ever prescribing nPEP (31.0%), PrEP (18.1%), and ART (27.2%). Prescribing nPEP was associated with nPEP familiarity (aPR = 2.63, 95% CI 1.59, 4.35) and prescribing PrEP (aPR = 3.57, 95% CI 2.78, 4.55). Prescribing PrEP was associated with PrEP familiarity (aPR = 4.35, 95% CI 2.63, 7.14), prescribing nPEP (aPR = 5.00, 95% CI 2.00, 12.50), and providing care for persons with HIV (aPR = 1.56, 95% CI 1.06, 2.27). Prescribing ART was associated with nPEP familiarity (aPR = 1.89, 95% CI 1.27, 2.78) and practicing in outpatient public practice versus hospital-based facilities (aPR = 2.14 95% CI 1.51, 3.04), and inversely associated with collaborations involving specialists (aPR = 0.60, 95% CI 0.42, 0.86). A minority of PCPs surveyed from the Southeast report ever prescribing ARVs for prevention. Future efforts should include enhancing HIV care coordination and developing strategies to increase use of biomedical tools.

HIV-Related Training and Correlates of Knowledge, HIV Screening and Prescribing of nPEP and PrEP Among Primary Care Providers in Southeast United States, 2017

The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.

Different analgesics prior to intrauterine device insertion: is there any evidence of efficacy?

OBJECTIVES

The aims of this study were to compare three different interventions to reduce pain related to insertion of the intrauterine device (IUD), namely, lidocaine, misoprostol and a non-steroidal anti-inflammatory drug, against a placebo, and to assess the advantages of one drug over another, if any.

METHODS

This was an open-label randomised placebo-controlled trial of 200 women assigned to receive one of the following medications prior to IUD insertion: 10 ml 1% lidocaine paracervical block, 400 μg oral misoprostol, oral naproxen or placebo tablets. The primary outcome measure was the level of pain experienced at different steps of IUD insertion and 15 min after the procedure, measured by a visual analogue scale (VAS).

RESULTS

Between July 2015 and March 2016, 208 women were invited to participate in the study: eight refused and the remaining 200 women were randomised equally into four treatment groups (50 participants in each group). All characteristics were similar between the groups. The mean pain scores recorded during speculum placement, tenaculum application, uterine sounding, IUD insertion and 15 min after insertion were similar among the four groups (p > .05). Adjuvant methods to facilitate insertion, insertion failure or device expulsion were similar between the groups (p > .05). Complications were reported in 17 participants (8.5%); all resolved spontaneously with no further management (p > .05).

CONCLUSION

Despite finding that none of the study drugs seemed effective prior to IUD insertion, insertion did not cause severe pain. The negative findings indicate the need for future research into new strategies to decrease pain during IUD placement.

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.

Practical Advice for Emergency IUD Contraception in Young Women

Too few women are aware of the very high efficacy of intrauterine copper devices (IUDs) to prevent pregnancy after unprotected intercourse. Women who frequently engage in unprotected intercourse or seek emergency contraception (EC) are at high risk of unplanned pregnancy and possible abortion. It is therefore important that these women receive precise and accurate information about intrauterine devices as they may benefit from using an IUD for EC as continuing contraception. Copper IUDs should be used as first choice options given their rapid onset of action and their long-term contraceptive action which require minimal thought or intervention on the part of the user. In the United States, there is only one copper IUD presently available which limits treatment options. There are numerous copper IUDs available for use in EC, however, their designs and size are not always optimal for use in nulliparous women or women with smaller or narrower uteruses. Utilization of frameless IUDs which do not require a larger transverse arm for uterine retention may have distinct advantages, particularly in young women, as they will be suitable for use in all women irrespective of uterine size. This paper provides practical information on EC use with emphasis on the use of the frameless IUD.

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.

Intrauterine contraception in nulliparous women: a prospective survey

Background

Intrauterine contraception is a first-line option for young women, yet relatively few prospective studies have been performed in nulliparous women using currently available devices, and many providers are still reluctant to provide this option.

Methods

Between January 2012 and June 2014, 109 nulliparous women, aged 18–30 years, who had an intrauterine device (IUD) placed at a student health clinic [88 levonorgestrel-intrauterine system (LNG-IUS) users and 21 Cu T 380A (IUD) users] were surveyed at 1, 6, 12 and 18 months after insertion.

Results

Overall satisfaction was high; at follow-up survey 83% of 100 women (mean use 13.4 months) were ‘happy’ or ‘very happy’ with their IUD, and there were no differences in satisfaction between the two IUD types. Some 75% of participants stated that the insertion procedure went ‘very well’, despite 78% rating insertion pain as moderate to severe, and 46% experiencing vasovagal symptoms. The 12-month continuation rate was 89%, with discontinuations for expulsion (3%), side effects (6%), lack of anticipated benefit (1%) and pregnancy (1%). Users of the Cu T 380A were more likely to have heavy menses (74% vs 2%; p<0.0001) or moderate to severe cramping (68% vs 20%; p=0.0002) compared with LNG-IUS users. There were no uterine perforations or diagnoses of pelvic inflammatory disease. The rate of failed insertions during the study period was 6.2%.

Conclusions

Despite significant symptoms with insertion, intrauterine contraception is safe, effective and ultimately well tolerated in nulliparous women and should be provided to this population in both university and community health settings.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial

OBJECTIVE

To examine the effects of preprocedure misoprostol on intrauterine device (IUD) placement in nulliparous women.

STUDY DESIGN

In this randomized controlled double-blind trial at the University of New Mexico reproductive health clinic, nulliparous women requesting an IUD were randomized to 400 mcg of buccal misoprostol or placebo 2-8 hours before insertion. Primary outcomes included pain on a 10-cm visual analog scale and women's perception of the value of delaying insertion for an effective medication. Provider ease of insertion and need for adjunctive insertion measures were also assessed, on a visual analog scale. Participants indicated maximum pain after IUD insertion, pain level they would tolerate to avoid delay in IUD insertion, and preference for IUD insertion without delay if an effective medication was available.

RESULTS

Of 85 women enrolled, 3 were ineligible; 42 were randomized to misoprostol and 40 to placebo. There were no differences between groups in worst insertion pain, (5.8 ± 2.0 vs 5.9 ± 2.0, P = .94), provider ease of insertion (2.2 ± 2.2 vs 2.5 ± 2.2; P = .54) or adjunctive measures (14% vs 25%; P = .27). The groups were willing to tolerate the same mean pain (4.9 ± 2.5 vs 5.7 ± 2.4, P = .18) to avoid waiting for medication. The majority of women (85%) preferred to wait for an effective medication.

CONCLUSION

Misoprostol for nulliparous women did not decrease pain or improve the ease of insertion of an IUD. Most women were willing to wait for a medication that decreases pain, indicating a need to pursue alternatives for pain control with IUD insertion.

IUDs: beyond the basics

This article reviews the changes in patient selection for intrauterine devices (IUDs) and evidence-based practices regarding counseling and management of common IUD issues. Where evidence-based research is lacking, expert opinion and common standards of practice are reviewed, and current clinical resources are identified.

Management of pain associated with the insertion of intrauterine contraceptives

BACKGROUND

Most intrauterine contraception (IUC) placements do not require pain relief. However, small proportions of nulliparous (∼17%) and parous (∼11%) women experience substantial pain that needs to be proactively managed. This review critically evaluates the evidence for pain management strategies, formulates evidence-based recommendations and identifies data gaps and areas for further research.

METHODS

A PubMed literature search was undertaken. Relevant articles on management of pain associated with IUC insertion, published in English between 1980 and November 2012, were identified using the following search terms: ‘intrauterine contraception’, ‘insertion’ and ‘pain’. RCTs were included; further relevant articles were also identified and included as appropriate.

RESULTS

Seventeen studies were identified and included: 12 RCTs and one non-randomized study of pre-insertion oral analgesia, cervical priming and local anaesthesia; one systematic review and one RCT on post-insertion analgesia and two non-randomized studies on non-pharmacological interventions. There was no conclusive evidence that any prophylactic pharmacological intervention reduces pain associated with IUC insertion. However, most of the regimens studied were adopted from hysteroscopy or abortion and effectiveness in specific subsets of women has not been studied adequately. A systematic review found non-steroidal anti-inflammatory agents (NSAID) to be effective in reactively treating post-insertion pain, but no benefit was found with prophylactic use.

CONCLUSIONS

No prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUC insertion. Women's anxiety about the procedure may contribute to higher levels of perceived pain, which highlights the importance of counselling, and creating a trustworthy, unhurried and professional atmosphere in which the experience of the provider also has a major role; a situation frequently referred to as ‘verbal anaesthesia’.

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.