Katherine Ward

Self-administered misoprostol or placebo before intrauterine device insertion in nulliparous women: A randomized controlled trial

OBJECTIVES: To estimate the effects of self-administered misoprostol compared with placebo before intrauterine device (IUD) insertion in nulliparous women. METHOD: Nulliparous women requesting either the copper T380A or levonorgestrel IUD were randomized to self-administer either 400 &mgr;g of misoprostol or placebo (vaginally or buccally) 3–4 hours before the IUD insertion appointment. The primary outcome was health care provider–perceived ease of insertion recorded on a visual analog scale (anchors: 0 extremely easy, 100 impossible). Patients completed questionnaires addressing pain using a validated visual analog scale (anchors: 0 none, 100 worst imaginable) before insertion, immediately postinsertion, and before clinic discharge. RESULTS: Of the 108 women enrolled in the study, 54 received misoprostol and 54 received placebo. There was no significant difference in perceived ease of insertion between the two groups (25.0 mm [standard error 3.5] compared with 27.4 mm [standard error 3.5], P=.64). Patients who received misoprostol before IUD insertion had significantly higher pain scores before placement (17.1 mm [standard error 3.5] compared with 4.7 mm [standard error 2.0], P=.003). Groups did not differ in perception of pain during IUD insertion (58.4 mm [standard error 3.3] compared with 56.9 mm [standard error 3.0], P=.74). There were two expulsions in the misoprostol group and none in the placebo group. Failed insertions, need for adjuvant pain medication, and need for cervical dilation or ultrasonographic guidance did not differ between the two groups. CONCLUSION: Self-administered misoprostol before IUD insertion does not ease IUD insertion or reduce patient-perceived pain in nulliparous women. These data do not support the routine use of misoprostol before IUD insertion in nulliparous women. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00886834. LEVEL OF EVIDENCE: I

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.

Genitourinary syndrome of menopause: A new name for an old condition

Genitourinary syndrome of menopause (GSM) is the new name for the conditions that formerly included vulvovaginal atrophy and atrophic vaginitis. GSM better describes the range of conditions associated with low estrogen levels in menopause and invites patient discussion without the use of words that might be uncomfortable to say. This article discusses the physiology of GSM and reviews both hormonal and nonhormonal treatment options.

We should really keep in touch: predictors of the ability to maintain contact with contraception clinical trial participants over 12 months

OBJECTIVES This study assesses the ability to maintain contact with participants enrolled in an emergency contraception (EC) trial with 12 months of follow-up based on the modes of contact they provided at enrollment. STUDY DESIGN Data came from a clinical trial offering women the copper intrauterine device or oral levonorgestrel for EC. A modified Poisson regression was used to assess predictors associated with the ability to contact study participants 12 months after enrollment. RESULTS Data were available for 542 participants; 443 (82%) could be contacted at 12 months. Contact at 12 months was greatest for those whose preferred the method of contact was text messaging, e-mail or any (62/68; 91% contacted) and worst for the 18 who had a landline phone (only 7 contacted; 39%). After controlling for age, having an e-mail address, text messaging, language preference, type of EC chosen and insurance, preferred contact other than phone increased the likelihood of follow-up by 10% [risk ratio (RR) 1.1 95% confidence interval (CI) 1.0-1.2], while having a landline reduced a womans likelihood of being contacted at 12 months by 50% compared to women with a contract cell (RR 0.5, 95% CI 0.3-1.0). CONCLUSION The few women with a landline for contact had poor follow-up at 1 year, while women who preferred e-mail or text had the highest rate of follow-up. IMPLICATIONS Understanding how best to reduce loss to follow-up is an essential component of conducting a contraceptive clinical trial. Improved participant retention maximizes internal validity and allows for important clinical outcomes, such as pregnancy, to be assessed.

An Update on Menopause Management

Abstract Menopause‐related symptoms frequently lead women to seek health care. Recommendations for prescribing hormone therapy have changed significantly since the publication of initial results from the Womens Health Initiative (WHI) study in 2002. The North American Menopause Society and the American College of Obstetricians and Gynecologists have newer guidelines based on long‐term analyses of the WHI participants as well as emerging data from other clinical trials. Women with an intact uterus who are using systemic estrogen must also use a progestogen; however, there are 2 new selective estrogen receptor modulators on the market for use without a progestogen. This review discusses current recommendations and new medications as well as the risks and benefits related to hormone therapy. Evidence‐based alternatives to hormone therapy to treat symptoms of menopause are also presented.