A levonorgestrel-releasing intrauterine system (Mirena) provides better bleeding and cramping control than etonogestrel (Implanon) (Item 134-8). The World Health Organization approved Mirena for nulliparous women in 2005. I prep the patient with misoprostol (Cytotec) 200 μg the previous evening and 200 μg one to two hours before the appointment. I also have the patient take 600 mg ibuprofen 30 minutes before coming in. It is important to warn of the potential side effects of Cytotec (e.g., nausea, cramping). To optimize insertion, consider scheduling the procedure around the fourth or fifth day of the patient’s menses.—LAURA LANG, ARNP, WHNP-BC, Cedar Rapids, Iowa

I agree that among the various progestin options, Mirena has optimal efficacy, reducing menstrual blood loss by 30%-70% within the first few months of insertion. But all options should be considered and presented to the patient. Not every patient is a good candidate for Mirena, and some women—especially those with menorrhagia—may have fibroids or other uterine cavity abnormalities that make proper placement difficult or impossible. Most contraindications to intrauterine contraceptive (IUC) use (e.g., nulliparity, multiple sexual partners, history of a sexually transmitted infection) have been discarded as not evidence-based, but some do remain. While many patients’ fears about IUC use can be overcome with thorough education, not every woman will choose an IUC when presented with a range of options. While the patient described here could certainly choose a Mirena IUC, any of the progestins mentioned may be appropriate and efficacious, depending on her clinical profile and preferences.

With regard to the question of misoprostol use for cervical ripening, this can indeed ease the insertion process for women with no history of vaginal births. I recommend one of three regimens: 400 μg PO 8-12 hours prior to insertion; 200 μg vaginally 8-12 hours prior to insertion; or 400 μg sublingual one hour prior to insertion.

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A randomized clinical trial demonstrated the efficacy of the sublingual dose in facilitating IUC insertion in nulliparous women (Hum Reprod. 2007;22:2647-2652). Women taking misoprostol should be warned that side effects may include stomach upset, diarrhea, and chills.—Lisa Stern, APRN (139-15).