Levonorgestrel IUD

MIRENA

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What it isLevonorgestrel intrauterine system (MIRENA, 2000) locally activates progesterone receptors; contraception for up to 8 years and heavy menstrual bleeding.

Why this oneIts heavy-menstrual-bleeding indication (2009) and up to 8 years of contraception distinguish it from lower-dose levonorgestrel systems.

What limits itIrregular bleeding is expected early; insertion can cause perforation or expulsion, and pregnancy with one in place may be ectopic.

FDA-approved for

contraception (intrauterine) (2000)
heavy menstrual bleeding (2009)

FDA label

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FDA dosing	Population	Start	Target	Max
Prevention of pregnancy (intrauterine contraception)	Females of reproductive potential	One intrauterine system (52 mg LNG) inserted; releases ~21 mcg/day after 24 days	Single device	Remove/replace by end of the 8th year
Treatment of heavy menstrual bleeding (in women using it for contraception)	Females of reproductive potential	One intrauterine system (52 mg LNG) inserted	Single device	Replace by end of the 5th year if continued treatment needed

Renal Undefined (no formal studies)

Hepatic Undefined (no formal studies; acute liver disease or liver tumor is a contraindication)

Contraception: replace by end of 8th year; heavy menstrual bleeding: replace by end of 5th year

Instructions

Inserted by a trained healthcare provider using strict aseptic technique
Uterus should sound to a depth of 6 to 10 cm
Re-examine 4 to 6 weeks after insertion, then yearly
Remove by applying gentle traction on threads with forceps

Contraindications

Pregnancy or suspicion of pregnancy; cannot be used for post-coital (emergency) contraception
Congenital or acquired uterine anomaly including fibroids that distorts the uterine cavity
Acute pelvic inflammatory disease (PID) or a history of PID unless there has been a subsequent intrauterine pregnancy
Postpartum endometritis or infected abortion in the past 3 months
Known or suspected uterine or cervical malignancy
Known or suspected breast cancer or other progestin-sensitive cancer, now or in the past
Uterine bleeding of unknown etiology
Untreated acute cervicitis or vaginitis, including bacterial vaginosis or other lower genital tract infections until infection is controlled
Acute liver disease or liver tumor (benign or malignant)
Conditions associated with increased susceptibility to pelvic infections
A previously inserted intrauterine device (IUD) that has not been removed

Cautions

Ectopic pregnancy risk
Intrauterine pregnancy risks (septic abortion, sepsis, preterm labor)
Group A streptococcal sepsis following insertion
Pelvic infection/PID
Uterine perforation (increased with lactation/postpartum insertion)
Partial or complete expulsion
Ovarian cysts
Bleeding pattern alterations
Breast cancer (progestin-sensitive)

Adverse reactions

Alterations of menstrual bleeding patterns
Abdominal/pelvic pain
Amenorrhea
Headache/migraine
Genital discharge
Vulvovaginitis

Pregnancy Contraindicated in pregnancy; may cause adverse pregnancy outcomes (ectopic pregnancy, miscarriage, sepsis, preterm labor/delivery). Remove if pregnancy occurs.

Lactation Levonorgestrel present in human milk (~0.1% of maternal dose); no reported adverse effects in breastfed infants with progestin-only contraceptives; isolated reports of decreased milk production.

NO BOXED WARNINGS

Principal riskEmergency use is less effective at higher body weight