4/4/06njm

**Q. Ever had problems with a stenotic cervix? E.G., for an IUD
placement or EmBx?**

A. Cervical priming with misoprostol can be helpful in non-pregnant
women. See Details

You probably already know this, but I just heard this tip on an ACOG
Update cassette tape about hysteroscopy.\* This tip should apply to
other procedures that require cervical cannulation, as well, making
insertion much easier and less traumatic.

Oral / vaginal misoprostol for cervical priming in non-pregnant women

-IUD insertion in nulliips (including previous C/S but never dilated)

-Endometrial biopsy (EMBx), or even Paps, in postmenopausal women with
stenotic cervices

The Faculty of Family Planning and Reproductive Health Care Clinical
Effectiveness Unit also offers a helpful Frequently Asked Question (link
below) on this topic.

NB: The literature is very mixed on how effective this therapy actually
is. In fact in the literature review below it was about 50 / 50 on which
authors thought it was effective, or not. Unfortunately essentially all
the centers used different regimens, plus used different methods to
evaluate effectiveness. It appears to be more effective if the
misoprostol is given at least 8 hours or sooner before the procedure.

**Regimen A**

400 mcg orally the night before the insertion

(Ngai SW, et al, 1997)

**Regimen B**

The ACOG Update Module discusses different regimens for pre- and post-
menopausal patients:

(These can be done orally or vaginally)

[Pre menopausal:]{.underline}

200 mcg 8 -12 hours pre procedure

[Post menopausal:]{.underline}

Start 2 days pre procedure taking 200 mcg 48 hours pre and a second 200
mcg dose 8 -- 12 hours pre procedure.

There are other regimens that have worked successfully, see **Regimens**
below

**Other Regimens**

[Atmaca
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Atmaca+R"%5BAuthor%5D),
et al

The study group received local estrogen cream and other group received
chlindamycine phosphate cream as placebo. The patients were given oral
misoprostol 24 and 12 hours before the procedure for uterine cavity
evaluation.

[Barcaite
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Barcaite+E"%5BAuthor%5D),
et al

The study group (n=51) received 400 microg of vaginal misoprostol at
least 12 h before the procedure

[Darwish
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Darwish+AM"%5BAuthor%5D),
et al

Misoprostol 200 microg was inserted into the posterior fornix of the
vagina for patients in group A (n=72), while laminaria tents were
inserted intracervically in group B patients (n=72)

[Thomas
JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Thomas+JA"%5BAuthor%5D),
et al

Patients were randomly allocated, by means of computer-generated
numbers, to receive either placebo or 400 microg of misoprostol 12 and
24 hours before surgery.

[Preutthipan
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Preutthipan+S"%5BAuthor%5D),
[Herabutya
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Herabutya+Y"%5BAuthor%5D)

One hundred fifty-two women with definite intrauterine lesions were
randomly assigned to receive either 200 microg vaginal misoprostol or
placebo.

[Preutthipan
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Preutthipan+S"%5BAuthor%5D),
[Herabutya
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Herabutya+Y"%5BAuthor%5D)

Ninety-one women scheduled to have hysteroscopy were randomized to
receive either vaginal misoprostol or placebo

[Ngai
SW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ngai+SW"%5BAuthor%5D),
[Chan
YM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chan+YM"%5BAuthor%5D),
[Liu
KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Liu+KL"%5BAuthor%5D),
[Ho
PC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ho+PC"%5BAuthor%5D)

44 nulliparous women presenting to Hong Kong\'s Queen Mary Hospital for
diagnostic hysteroscopy and endometrial biopsy and curettage were
randomly assigned to receive either 400 mcg of misoprostol 12 hours
prior to the procedure (n = 21) or placebo (n = 23).

**Resources:**

'Hysteroscopy, Replacing Old Gynecologic Procedures'. ACOG Update Series
Vol. 30,

No. 10, p 2

**Hot Topics: Gynecology (CCC Corner newsletter November 2005)**

**Have you ever had problems with a stenotic cervix?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#gyn>

**Oral misoprostol for cervical priming in non-pregnant women**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0206_Coll.cfm>

**(**Scroll down to Nancy Brannin, Santa Fe, in alpha order)

**References**

**In favor**

As a conclusion, misoprostol treatment alone is not effective to get
cervical priming in postmenopausal women, and as shown in our study,
pretreatment with local estrogen overcome the failure. To get a
beneficial effect of misoprostol on cervical ripening, estrogenic
activity is necessary and when pretreated with local estrogen,
misoprostol ameliorates cervical priming in postmenopausal women

[Atmaca
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Atmaca+R"%5BAuthor%5D),
et al Priming effect of misoprostol on estrogen pretreated cervix in
postmenopausal women. [Tohoku J Exp
Med.](javascript:AL_get(this, 'jour', 'Tohoku J Exp Med.');) 2005
Jul;206(3):237-41\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15942151>

CONCLUSION: Vaginal misoprostol applied before hysteroscopy reduced
cervical resistance and the need for cervical dilation in perimenopausal
and postmenopausal women, with only mild adverse effects

[Barcaite
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Barcaite+E"%5BAuthor%5D),
et al Vaginal misoprostol for cervical priming before hysteroscopy in
perimenopausal and postmenopausal women. [Int J Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2005 Nov;91(2):141-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16102766>

CONCLUSIONS: Both misoprostol and laminaria were equally effective in
inducing proper cervical priming prior to operative hysteroscopy with
minimal time of cervical dilatation. Nevertheless, misoprostol may be
superior due to easy application, reduced cost, and patient convenience
and acceptability.

[Darwish
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Darwish+AM"%5BAuthor%5D),
et al Cervical priming prior to operative hysteroscopy: a randomized
comparison of laminaria versus misoprostol.\
[Hum Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2004
Oct;19(10):2391-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15333607>

CONCLUSIONS: Misoprostol demonstrates a benefit over placebo in the ease
of cervical dilatation in premenopausal and postmenopausal women and in
those pretreated with a gonadotropin-releasing hormone analog. Adverse
effects were more common in the treatment group but did not preclude the
patients from taking the medication.

[Thomas
JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Thomas+JA"%5BAuthor%5D),
et al The use of oral misoprostol as a cervical ripening agent in
operative hysteroscopy: a double-blind, placebo-controlled trial. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2002
May;186(5):876-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12015500>

CONCLUSION: Vaginal misoprostol applied before operative hysteroscopy
reduced the need for cervical dilation, facilitated hysteroscopic
surgery, and minimized cervical complications.

[Preutthipan
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Preutthipan+S"%5BAuthor%5D),
[Herabutya
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Herabutya+Y"%5BAuthor%5D).
Vaginal misoprostol for cervical priming before operative hysteroscopy:
a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2000
Dec;96(6):890-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11084173>

CONCLUSION: Vaginal misoprostol lessens the cervical resistance in women
undergoing hysteroscopy and facilitates the procedure, with only mild
side effects.

[Preutthipan
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Preutthipan+S"%5BAuthor%5D),
[Herabutya
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Herabutya+Y"%5BAuthor%5D).
A randomized controlled trial of vaginal misoprostol for cervical
priming before hysteroscopy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 1999
Sep;94(3):427-30.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10472872>

Endometrial biopsy and hysteroscopy are important investigations in
women presenting with abnormal vaginal bleeding. Endometrial biopsy is
often performed as an outpatient procedure by endometrial aspiration.
Difficulty in entering the internal cervical os may be encountered,
especially in nulliparous women. The same problem may occur during
hysteroscopy or dilatation and curettage. It is well known that use of a
cervical priming agent is effective in reducing complications during
cervical dilatation in pregnant women. However, its use in non-pregnant
women is not well established. We compared oral misoprostol versus
placebo for a cervical priming effect in non-pregnant women prior to
hysteroscopy. The cumulative force required for cervical dilatation was
significantly lower whereas the baseline cervical dilatation was
significantly greater in the misoprostol group. Another potential use of
misoprostol is for cervical dilatation prior to IUD insertion in
nulliparous women.

We conclude that oral misoprostol is effective for pre-operative
cervical dilatation in non-pregnant women.

[Ngai
SW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ngai+SW"%5BAuthor%5D),
[Chan
YM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chan+YM"%5BAuthor%5D),
[Liu
KL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Liu+KL"%5BAuthor%5D),
[Ho
PC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ho+PC"%5BAuthor%5D)
Oral misoprostol for cervical priming in non-pregnant women. [Hum
Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 1997
Nov;12(11):2373-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9436666>

**References**

**Not in favor**

CONCLUSION: There was no significant benefit from applying 400 micro g
vaginal misoprostol 6 h prior to dilatation and curettage in
postmenopausal women.

[Bunnasathiansri
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bunnasathiansri+S"%5BAuthor%5D)
et al Vaginal misoprostol for cervical priming before dilatation and
curettage in postmenopausal women: a randomized controlled trial. [J
Obstet Gynaecol
Res.](javascript:AL_get(this, 'jour', 'J Obstet Gynaecol Res.');) 2004
Jun;30(3):221-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15210047>

Four groups of 12 women were randomly assigned to receive either placebo
or vaginal misoprostol in doses of 200, 400 or 800 micro g 4 h before
the surgical procedure.

CONCLUSIONS: Vaginal misoprostol applied 4 h before operative
hysteroscopy at three different doses did not reduce the need for
cervical dilatation, did not facilitate hysteroscopic surgery, and
increased pre-operative pain

[Fernandez
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fernandez+H"%5BAuthor%5D),
et al Vaginal misoprostol for cervical ripening before operative
hysteroscopy in pre-menopausal women: a double-blind, placebo-controlled
trial with three dose regimens. [Hum
Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');) 2004
Jul;19(7):1618-21\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15155607>

CONCLUSION: Sublingual misoprostol 100 mug does not facilitate cervical
dilatation before hysteroscopy. This may be related to leuprolide\'s
hypoestrogenic effect.

[Bisharah
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bisharah+M"%5BAuthor%5D)
et al A randomized trial of sublingual misoprostol for cervical priming
before hysteroscopy. [J Am Assoc Gynecol
Laparosc.](javascript:AL_get(this, 'jour', 'J Am Assoc Gynecol Laparosc.');)
2003 Aug;10(3):390-1.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14567819>

CONCLUSION: Vaginal misoprostol was not shown to reduce the need for
cervical dilatation in postmenopausal women. It cannot convert
diagnostic hysteroscopy from a hospital procedure into an office one in
postmenopausal women with tight cervical os.

[Fung
TM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fung+TM"%5BAuthor%5D),
et al A randomised placebo-controlled trial of vaginal misoprostol for
cervical priming before hysteroscopy in postmenopausal women.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2002
May;109(5):561-5.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12066947]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12066947)

CONCLUSION: Oral misoprostol 400 microg caused more uterine cramping and
pain in nonpregnant women undergoing office endometrial biopsy when
given 3 hours before biopsy attempt. No other cervical effects were
noted.

[Perrone
JF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Perrone+JF"%5BAuthor%5D),
et al Oral misoprostol before office endometrial biopsy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2002
Mar;99(3):439-44.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11864671>

CONCLUSIONS: These data showed that there were no significant benefits
from giving misoprostol pre-operatively in postmenopausal women, and it
was concluded that oral misoprostol had no significant cervical priming
effect in postmenopausal women.

[Ngai
SW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ngai+SW"%5BAuthor%5D)
et al The use of misoprostol prior to hysteroscopy in postmenopausal
women. [Hum Reprod.](javascript:AL_get(this, 'jour', 'Hum Reprod.');)
2001 Jul;16(7):1486-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11425834>

**Other**

**Enquiry Response No. 1456, Frequently Asked Question:**

"For nulliparous women undergoing IUD insertion, does cervical priming
with misoprostol or other agents facilitate the insertion? "

<http://www.ffprhc.org.uk/admin/uploads/No1456.pdf>

**Faculty of Family Planning and Reproductive Health Care Clinical
Effectiveness Unit**

<http://www.ffprhc.org.uk/>

[Penney
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Penney+G"%5BAuthor%5D),
et al FFPRHC Guidance (January 2004). The copper intrauterine device as
long-term contraception. Journal of Family Planning and Reproductive
Health Care 2004 30:29-42

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15006311>

Cervical priming with the aid of a single 15-ME-PGF2a vaginal
suppository prior to IUD insertion resulted in cervical changes which
facilitated the procedure....The cervical ripening and dilatation
produced by the suppository increased the ease of IUD insertion , and
expanded the time frame in which an IUD insertion could be performed.
The method was well tolerated by all patients and eliminated the nausea
and syncope often associated with IUD insertion

[Lauersen
NH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lauersen+NH"%5BAuthor%5D)
et al A new iud insertion technique utilizing cervical priming with
prostaglandin.
[Contraception.](javascript:AL_get(this, 'jour', 'Contraception.');)
1982 Jul;26(1):59-63.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7128135>