Highlight
- Meta-analysis of 14 randomized controlled trials shows misoprostol provides little to no benefit in reducing pain or improving provider ease during routine IUD placement.
- Significant side effects include increased abdominal cramping and diarrhea prior to placement.
- Women with previous failed IUD placement attempts may experience improved placement success rates when given misoprostol.
- Routine use is not recommended for all patients due to limited benefit and increased adverse effects.
Background
Intrauterine devices (IUDs) are a highly effective, long-acting reversible form of contraception, but procedural pain and technical challenges during placement can be barriers to their use. Misoprostol, a synthetic prostaglandin E1 analog, is known to cause cervical ripening and dilation, theoretically making IUD insertions less painful and technically easier. However, prior evidence has been mixed, and many clinicians remain uncertain about its routine clinical utility.
Study Design
This comprehensive Cochrane review included 14 randomized controlled trials (RCTs) involving 1972 women across four continents. Eligible participants were undergoing interval IUD placement—outside immediate postpartum or postabortion timing. Interventions compared oral, buccal, or vaginal misoprostol with placebo or no treatment. Outcomes included measures of pain at various stages of the procedure, ease of placement, need for cervical dilation, placement success, patient satisfaction, side effects, and adverse events. Risk of bias was assessed using the RoB 2 tool, and certainty of evidence rated with GRADE methods. Data synthesis employed random-effects meta-analysis for continuous and dichotomous outcomes.
Key Findings
Pain Outcomes
High-certainty evidence showed misoprostol produced little to no difference in pain during tenaculum placement (MD −0.73) or after insertion prior to discharge (MD −0.01). Low-certainty evidence suggested possible minimal benefit during the IUD insertion itself (MD −0.47).
Provider Ease and Cervical Dilation
Low-certainty evidence indicated misoprostol may provide little to no improvement in ease of placement (MD −0.89). For women without prior failed IUD placement, it showed negligible impact on cervical dilation need (RR 0.84) or placement success rates (RR 1.01). In contrast, women with a recent failed attempt had moderately-certainty evidence of improved placement success (RR 1.41).
Patient Satisfaction
Very low-certainty evidence suggested possible increases in patient satisfaction (MD 2.00), but statistical uncertainty limits clinical interpretation.
Side Effects and Adverse Events
Moderate-certainty evidence found misoprostol significantly increased preplacement abdominal pain or cramping (RR 2.14) and diarrhea (RR 1.76). Low-certainty evidence showed little to no effect on vasovagal reactions.
Expert Commentary
From an evidence-based standpoint, the routine use of misoprostol for interval IUD placements is not warranted due to lack of meaningful benefit and increased side effects. Selective use may be justified in women who have experienced prior insertion failure, where improved placement success could outweigh potential discomfort. Current contraceptive guidelines from several health organizations align with these findings, advising against universal prophylactic misoprostol use for routine insertions.
The limitations of the available RCT data include heterogeneity in dosing regimens, timing of administration, assessment tools for pain, and IUD type. Future research should focus on patient subgroups, optimal dosing schedules, and early identification of those most likely to benefit from cervical priming.
Conclusion
Misoprostol has limited utility for routine IUD placement in most women, with evidence supporting targeted use in select cases such as previous failed placement attempts. Clinicians should weigh potential benefits against increased risk of cramping and gastrointestinal side effects. More consistent patient selection criteria and tailored protocols may improve clinical outcomes and patient experiences.
Funding and ClinicalTrials.gov
This systematic review was supported by the Research Participation Program at the Centers for Disease Control and Prevention (CDC), administered by the Oak Ridge Institute for Science and Education. Registered protocol (2022): doi.org/10.1002/14651858.CD015584
References
Zapata LB, Snyder E, Nguyen AT, Kapp N, Ti A, Whiteman MK, Curtis KM. Misoprostol for intrauterine device placement. Cochrane Database Syst Rev. 2025 Sep 23;9(9):CD015584. doi: 10.1002/14651858.CD015584.pub2.