Effect of vaginal misoprostol plus isosorbide mononitrate on pain perception during copper intrauterine device insertion in women delivered only by elective cesarean section

To examine the analgesic effect of vaginal misoprostol plus isosorbide mononitrate (IMN) versus misoprostol alone in alleviating pain during intrauterine device (IUD) insertion in women delivered only by elective cesarean section (CS). A Randomized controlled trial enrolled reproductive-aged parous women delivered only by elective CS requesting Copper-T 380A IUD for contraception. Eligible women for IUD insertion based on WHO guidelines were recruited and randomized (1:1) to vaginal misoprostol 200 mcg plus IMN 40 mg or vaginal misoprostol 200 mcg plus placebo (n=113 in each group). Three hours prior to IUD insertion, both tablets were self-inserted into the vagina. The primary outcome was the ease of IUD insertion score utilizing a 10-cm Visual Analogue Scale (VAS). Both arms were comparable in the baseline criteria. A higher ease of insertion score was determined among the IMN group (mean±SD: 6.1±1.04 vs. 3.35 ± 1.31, p=0.029). Additionally, the duration of IUD insertion was significantly shorter in the IMN group (4.82 ± 0.65 vs. 5.18 ± 0.89 min, p-0.001). Seventy-three (64.6%) women in the IMN group reported no/Mild pain versus 48 women (42.5%) in the other group (p=0.001). No significant differences between both groups regarding the adverse effects of the study medications. Administration of vaginal misoprostol plus IMN three hours before copper IUD insertion in women delivered only by elective CS seems to ease the insertion and decrease the associated pain with no serious adverse effects.