***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Misoprostol is an agent that may ripen the cervix in nonpregnant women . Here , we investigate whether vaginal misoprostol administered prior to intrauterine device ( IUD ) insertion reduces the number of failed insertions , insertion-related complications and pain during insertion . METHODS We conducted a double-blinded , multicenter r and omized controlled trial among patients requesting an IUD . Nulli- and multi-parous women were included , and both copper-containing and levonorgestrel-releasing IUDs were used . Participants were allocated to either 400 μg misoprostol or placebo ( administered 3h prior to IUD insertion ) . The primary outcome measure was failed insertion . Secondary outcome measures were insertion-related complications , pain , difficulty of insertion and side-effects . RESULTS Two hundred and seventy participants were r and omized . After drop out for various reasons ( mainly no show ) , 199 participants had an IUD inserted ; 102 received misoprostol and 97 received placebo .  Only three insertions failed ; two in the misoprostol group and one in the placebo group [ P = 0.59 , relative risk ( RR ) 1.9 , 95 % confidence interval ( CI ) 0.2 - 20.6 ] . The overall incidence of insertion-related complications was 21.8 % in the misoprostol versus 19.1 % in the placebo group ( mainly vasovagal-like reactions ) and did not differ between groups ( P = 0.65 , RR 1.1 , 95 % CI 0.7 - 2.0 ) . No difference in pain scores between groups was found . Side-effects were more common in the misoprostol group ( P = 0.05 , RR 1.3 , 95 % CI 1.0 - 1.7 ) . CONCLUSION The study showed no benefit for use of misoprostol prior to IUD insertion . However , there is a tendency of possible harm regarding side-effects . Therefore , we would not recommend st and ard pretreatment with misoprostol . The trial was registered in the European Clinical Trials Data base EudraCT 2006 - 006897 - 60 In a double-blind , r and omized , placebo-controlled study conducted at a contraception clinic , 55 women ( three nulliparous ) were given either ibuprofen 600 mg or placebo 1 - 4 hours prior to insertion of IUD , 4 - 6 hours after insertion of IUD and the following morning . Pain was assessed by ten point Numerical Rating Scales during insertion , in the first 4 - 6 hours and in the following three days . No benefit of ibuprofen was demonstrated at insertion or at any other time during the first three days . The patients were further r and omized to type of IUD : TCu-380A and Nova T ( R. ) . No difference in pain scores was evaluated between these OBJECTIVES : To estimate the effects of self-administered misoprostol compared with placebo before intrauterine device ( IUD ) insertion in nulliparous women . METHOD : Nulliparous women requesting either the copper T380A or levonorgestrel IUD were r and omized to self-administer either 400 & mgr;g of misoprostol or placebo ( vaginally or buccally ) 3–4 hours before the IUD insertion appointment . The primary outcome was health care provider – perceived ease of insertion recorded on a visual analog scale ( anchors : 0 extremely easy , 100 impossible ) . Patients completed question naires addressing pain using a vali date d visual analog scale ( anchors : 0 none , 100 worst imaginable ) before insertion , immediately postinsertion , and before clinic discharge . RESULTS : Of the 108 women enrolled in the study , 54 received misoprostol and 54 received placebo . There was no significant difference in perceived ease of insertion between the two groups ( 25.0 mm [ st and ard error 3.5 ] compared with 27.4 mm [ st and ard error 3.5 ] , P=.64 ) . Patients who received misoprostol before IUD insertion had significantly higher pain scores before placement ( 17.1 mm [ st and ard error 3.5 ] compared with 4.7 mm [ st and ard error 2.0 ] , P=.003 ) . Groups did not differ in perception of pain during IUD insertion ( 58.4 mm [ st and ard error 3.3 ] compared with 56.9 mm [ st and ard error 3.0 ] , P=.74 ) . There were two expulsions in the misoprostol group and none in the placebo group . Failed insertions , need for adjuvant pain medication , and need for cervical dilation or ultrasonographic guidance did not differ between the two groups . CONCLUSION : Self-administered misoprostol before IUD insertion does not ease IUD insertion or reduce patient-perceived pain in nulliparous women . These data do not support the routine use of misoprostol before IUD insertion in nulliparous women . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00886834 . LEVEL OF EVIDENCE : Abstract Objective To investigate whether sublingual misoprostol administered one hour before intrauterine device ( IUD ) insertion reduces failed insertions , insertion-related complications and pain in parous women delivered only by elective caesarean section ( CS ) . Methods Single-blind r and omised controlled trial conducted in Ismailia , Egypt , between July 2010 and December 2011 . Women who had never delivered otherwise than by elective CS and desirous of using an IUD were r and omly allocated to receive sublingually 400 μg misoprostol and 100 mg diclofenac ( misoprostol group ) or 100 mg diclofenac alone ( control group ) one hour before IUD insertion . Outcome measures were failed insertion , ease of insertion judged by the investigators , insertion-related complications , and patients ’ satisfaction . Results In all , 255 women ( 130 and 125 in the study and control groups , respectively ) had an IUD inserted . Seven insertions failed : five in the control group , and two in the study group . Ease of insertion and patients ’ satisfaction were comparable in both groups . Abdominal pain and nausea were the commonest side effects reported in the misoprostol group . Conclusion Sublingual administration of misoprostol one hour before IUD insertion in parous women with no previous vaginal delivery does not facilitate the procedure and may cause undesirable side effects . This approach is not recommended as a st and ard treatment OBJECTIVE Anticipated pain with intrauterine device ( IUD ) insertion may be a barrier to widespread use . Our objective was to evaluate the efficacy of intracervical 2 % lidocaine gel for pain relief with IUD insertion . STUDY DESIGN We performed a double-blind , r and omized controlled trial of women undergoing IUD insertion . Participants were r and omly assigned to 2 % lidocaine or placebo gel . Study gel ( 3 mL ) was placed 3 minutes prior to IUD insertion . Pain scores were measured at various time points using a 10-point visual analog scale . RESULTS Of the 200 participants r and omized , 199 completed the study .  Pain scores among lidocaine and placebo arms were similar at tenaculum placement ( lidocaine and placebo : median , 4 ; range , 0 - 10 ; P = .15 ) and with insertion ( lidocaine : median , 5 ; range , 1 - 10 ; placebo : median , 6 ; range , 0 - 10 ; P = .16 ) . These results did not differ by parity . CONCLUSION Topical or intracervical 2 % lidocaine gel prior to IUD insertion does not decrease pain scores STUDY QUESTION Is the pain associated with levonorgestrel-releasing intrauterine system ( LNG-IUS ) insertion reduced by intracervical anesthesia in women without previous vaginal birth ? SUMMARY ANSWER Intracervical anesthesia was not associated with reduced pain in women without previous vaginal birth . WHAT IS KNOWN ALREADY The pain associated with the insertion of intrauterine contraceptives ( IUCs ) is a limiting factor for the use of these contraceptives by some women . No prophylactic pharmacological intervention has proven efficacy in relieving pain during or after the insertion of IUCs . However , previous studies included women with previous vaginal delivery , and injectable intracervical anesthesia was not evaluated in any of these studies . STUDY DESIGN , SIZE , DURATION This was a r and omized , open , parallel-group clinical trial that evaluated 100 women without previous vaginal delivery who wished to use the LNG-IUS for the first time . These women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h later . PARTICIPANTS / MATERIAL S , SETTING , METHODS The 100 women were r and omized into two groups : ( i ) use of a non-steroidal anti-inflammatory drug ( NSAID ) ( ibuprofen , 400 mg ) 1 h prior to LNG-IUS insertion ; or ( ii ) 2 % lidocaine intracervical injection 5 min prior to LNG-IUS insertion . The women were evaluated immediately after LNG-IUS insertion and then 2 h and 6 h after insertion . Two pain scales were used ( the visual analogue scale and the facial pain scale ) in addition to assessing the ease of insertion ( as rated by the provider ) and the level of discomfort during the procedure ( as rated by the patient ) . Multivariate logistic regression was performed to analyze the predictors associated with moderate/severe pain . MAIN RESULTS AND THE ROLE OF CHANCE The pain and discomfort associated with LNG-IUS insertion , and the ease of insertion of the LNG-IUS did not differ between the groups . Nulliparity was more associated with moderate/severe pain [ adjusted odds ratio ( OR ) : 3.1 ( 95 % confidence interval ( CI ) : 1.3 - 7.80 ] . Injectable intracervical anesthesia use reduced the risk of moderate/severe pain by 40 % [ adjusted OR : 0.6 ( 95 % CI : 0.2 - 1.4 ) ] . The difference between the mean pain score in the intracervical anesthesia group and the NSAID group was < 10 % ; thus , the effect size of the intervention was not significant . LIMITATIONS , REASONS FOR CAUTION Intracervical anesthesia was compared with an oral medication in this study . Intracervical injection of a saline solution or even a dry needling as the placebo for a double-blind study could be a more adequate control ; however , this approach was not a protocol approved by the institutional review board . Considering that the majority of the insertions were easy ( > 80 % in both groups ) , the results may not be extrapolated to difficult insertions with moderate/severe pain where local anesthesia may have a role . WIDER IMPLICATION S OF THE FINDINGS The findings can be generalized to most insertions in nulliparous women or in those without a previous vaginal delivery . There is currently no evidence to recommend the routine use of prophylactic intracervical anesthesia prior to LNG-IUS insertion ; there is no evidence that this treatment reduces insertion-related pain . STUDY FUNDING /COMPETING INTERESTS RAF and CSV give occasional lectures for Bayer Healthcare . This study received funding from the National Institute of Hormones and Women 's Health , National Council for Scientific and Technological Development ( CNPq ) . TRIAL REGISTRATION NUMBER NCT02155166 Background Bladder distension is thought to cause the uterine axis to become more aligned with the cervical canal . Among women undergoing assisted conception it has been demonstrated that having a full bladder facilitates the passage of an intrauterine catheter for embryo transfer . Objective To determine if insertion of intrauterine contraceptive devices is easier in women who have a full bladder at the time of insertion . Methods 200 women requesting intrauterine contraception with a pre-filled bladder were r and omised to delayed emptying ( after insertion ; n=100 ) or immediate emptying ( before insertion ; n=100 ) . Comparisons were made between doctors ’ reported ease of insertion and women 's pain scores . Results There was no significant difference with reported ease of insertion between the groups . Doctors reported that insertions were either ‘ very easy ’ or ‘ quite easy ’ in 82 % and 83 % of women in the immediate and delayed emptying groups , respectively ( 95 % CIs for difference −10 % to + 11 % ) . There was no significant difference in reported pain scores , with mean pain scores ( out of 10 ) of 3.8 and 4.4 in the delayed and immediate emptying groups , respectively . Conclusions Bladder filling does not have a significant effect on ease of insertion of an intrauterine method of contraception . Insertion is mostly associated with low levels of discomfort , even in the presence of a full bladder STUDY QUESTION How effective is the vaginal administration of misoprostol in dilating the cervix prior to inserting an intrauterine device ( IUD ) in nulligravidas ? SUMMARY ANSWER The use of misoprostol at a dose of 400 µg administered vaginally 4 h prior to IUD insertion increased the ease of insertion and reduced the incidence of pain during the procedure , although the frequency of cramps increased following misoprostol use . WHAT IS KNOWN AND WHAT THIS PAPER ADDS Misoprostol 
    Output:
    
Lidocaine 2 % gel , misoprostol , and most NSAIDs did not help reduce pain .
Some lidocaine formulations , tramadol , and naproxen had some effect on reducing IUC insertion-related pain in specific groups .