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The effect of nitroglycerin on the IUD insertion experience in nulliparous women

Paula Bednarek, Oregon Health and Science University, 2010
See also executive summary and publication in Contraception.

Project abstract

Increasing accessibility of long-acting reversible contraceptive methods, like intrauterine devices (IUDs), is an important strategy to reduce the risk of unintended pregnancy. Unfortunately, fear of IUD insertion in nulliparous women is common among health care providers and women alike, and this limits IUD use.

Anecdotally, health care providers assume that placement is more difficult. Women worry about pain with insertion, and their fear is not unfounded as data have shown that nulliparous women report approximately twice as much pain compared to parous women.

Although misoprostol and ibuprofen have been studied as ways to improve the IUD insertion experience, neither has proved effective, and misoprostol actually has been shown to increase pain.

To increase acceptance of this highly effective contraceptive, there is need to investigate novel, low-cost, easily applied and accessible techniques to improve the insertion experience. Nitric oxide (NO) is a free radical molecule that mediates a wide range of physiologic processes. Nitroglycerin, a NO donor, has been studied in the context of cervical ripening for first trimester abortion and term labor induction. The safety and efficacy of nitroglycerin gel applied to mucosal surfaces is well established, through its routine use for treatment of anal fissures. It is also readily available, stable at room temperature and inexpensive.

We propose a pilot study to evaluate the efficacy and tolerability of nitroglycerin as an intervention to improve the IUD insertion experience for both patient and provider. A total of 30 nulliparous women will be randomized to receive intracervical placebo or a high or low dose of nitroglycerin gel prior to IUD placement.

The primary outcome is subject-reported pain with IUD insertion. Secondary outcomes include provider-reported ease of insertion; subject-reported pain at other time points; adverse effects; and need for additional dilation.


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