Medical habit or necessity? Investigating misoprostol use for IUD insertion in Europe

The routine use of misoprostol prior to insertion of intrauterine devices (IUDs) is not recommended. Despite this lack of recommendations, a notable proportion of IUD users received misoprostol without any apparent indication within the framework of a large non-interventional study. Here we describe prescribing patterns of misoprostol prior to IUD insertion and assess their alignment with guideline-based indications.

Our study is a non-interventional cohort study that enrolled women with newly inserted IUDs between 2014 and 2023.

The study was conducted in ten European countries: Austria, Czech Republic, Finland, France, Germany, Italy, Poland, Spain, Sweden, and the United Kingdom. Data was captured via questionnaires from IUD users and inserting physicians, and included medication type and cervical preparation before IUD insertion, uterine anatomy, and any procedural complications.

13.2% of 97,189 study participants received misoprostol before IUD insertion (unrelated to pregnancy termination), with usage varying significantly across countries. Austria (48.0%) and Germany (35.3%) had the highest rates, followed by Spain (7.1%) while other countries reported usage below 2.5%. Anatomical risk factors for failed insertion (e.g. cervical stenosis) were present in only a minority of participants. Nulliparity seemed to be a determining factor for misoprostol use.

The observed discrepancies between local IUD insertion practices and current best-practice guidelines highlight the need for ongoing professional education and may inform future updates to evidence-based contraceptive care protocols.

NCT02146950.

Misoprostol was frequently used before IUD insertion despite lacking medical indication and showing wide variation across Europe, revealing discrepancies between practice and guidelines and highlighting the need for better alignment with evidence-based care.