In China, most women with
intrauterine devices (IUDs) ask to have them removed following the menopause. As the cervix is stenotic after the menopause and most IUDs do not have a thread attached, various medical methods are used for cervical ripening prior to IUD removal. A systematic review of the relevant literature was conducted to compare different medical methods for cervical priming with no treatment, or with other methods, prior to IUD removal in postmenopausal women. Multiple electronic databases including the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, the WHO Reproductive Health Library (2011) and the Chinese Biomedical Literature Database were searched systematically. Reference lists of articles published in English or Chinese between 1980 and 2011 were searched. All randomized controlled trials (RCTs) on IUD removal following the menopause using medical agents compared with no treatment, or with other treatments, were included. Outcomes were the ease of IUD removal, need for forced cervical dilatation, cervical width, procedure time, severe
pain and any side-effects. Data were processed using RevMan 5 software. Thirty original RCTs were eligible for inclusion. Most medical agents such as oestrogens,
mifepristone,
misoprostol and methyl
carboprost were highly effective for facilitating IUD removal, and reduced the need for further dilatation during the procedure. In particular, treatment with
mifepristone or
misoprostol prior to IUD removal was found to increase the width of the cervical canal and reduce the procedure time.
Mifepristone was more effective than vaginal
misoprostol for cervical dilatation, but it showed similar effectiveness to
misoprostol and
nilestriol in terms of the ease of IUD removal. Sublingual
misoprostol was superior to oral
misoprostol for facilitating IUD removal. A dose of
misoprostol as low as 200μg was effective for cervical priming. For vaginal and oral
misoprostol, the optimum times of application were 2-3h and 1 day prior to the procedure, respectively. All the prophylactic medical methods were able to alleviate
pain during IUD removal, and vaginal
misoprostol was more effective than
nilestriol. Uterine injury was more common with no treatment and with
nilestriol. Gastrointestinal side-effects such as
nausea and diarrhoea were common with oral
misoprostol and vaginal
misoprostol, respectively. Therefore,
mifepristone or sublingual
misoprostol should be the medical treatments of choice. Oestrogen regimens might be alternatives when
mifepristone or
misoprostol are contraindicated, and there is a need for further study on combined regimens for cervical priming.