Which intrauterine device—levonorgestrel‑releasing system (e.g., Mirena, Kyleena, Liletta, Skyla) or copper device (Paragard)—is most appropriate for specific complaints such as heavy menstrual bleeding, dysmenorrhea, desire for hormonal cycle suppression, need for a non‑hormonal option, or emergency contraception?

IUD Selection by Clinical Indication

For heavy menstrual bleeding, choose a levonorgestrel-releasing IUD (LNG-IUD) such as Mirena (52 mg) or Liletta (52 mg), which reduce menstrual blood loss by more than 90% within 6 months and are FDA-approved for this indication. 1, 2

Heavy Menstrual Bleeding (HMB)

The LNG-IUD is the clear winner for HMB management:

• Liletta (52 mg LNG-IUD) is FDA-approved specifically for treating HMB for up to 5 years in patients who also want contraception 1
• Blood loss reduction is dramatic: median decrease of 97.6% by 6 months, with 81.8% of users achieving treatment success (blood loss <80 mL and ≥50% reduction from baseline) 2
• This efficacy holds regardless of BMI or parity—nulliparous and obese women respond equally well 2
• The lower-dose Kyleena (19.5 mg) also shows high satisfaction for HMB (96.2% satisfied with bleeding quantity at 1 year), though it lacks FDA approval for this indication 3

Avoid copper IUD (Paragard) for HMB—its main side effect is increased menstrual bleeding that persists even with long-term use 4

Dysmenorrhea

Choose an LNG-IUD over copper IUD for dysmenorrhea. 5, 6

• LNG-IUDs reduce dysmenorrhea faster and more effectively than copper IUDs by decreasing endometrial prostaglandin synthesis 5
• Both IUD types eventually reduce dysmenorrhea over 6 months, but Mirena works earlier and more completely 5
• LNG-IUDs are particularly effective for dysmenorrhea associated with endometriosis, adenomyosis, or fibroids 6
• The copper IUD may actually worsen cramping initially 4

Hormonal Cycle Suppression

Select higher-dose LNG-IUDs (Mirena 52 mg or Liletta 52 mg) for maximal cycle suppression.

• These devices commonly induce oligomenorrhea or amenorrhea as intended effects 4
• Bleeding patterns become progressively lighter, with many users achieving amenorrhea over time 7
• Lower-dose options (Kyleena 19.5 mg, Skyla) provide less cycle suppression

Non-Hormonal Contraception

Paragard (copper T 380A) is the only non-hormonal IUD option, effective for 10 years. 8

Use when:

• Patient refuses or cannot tolerate hormones
• History of hormone-sensitive cancers (breast cancer) contraindicates LNG-IUDs 9, 1
• Patient desires natural menstrual cycles

Trade-off: Expect increased menstrual bleeding and cramping, especially in the first months 4

Emergency Contraception

Paragard is the only IUD approved for emergency contraception. 8

• Can be inserted up to 5 days after unprotected intercourse
• Provides ongoing contraception for 10 years
• LNG-IUDs are contraindicated if pregnancy suspected 9, 1

Device-Specific Considerations

Mirena (52 mg LNG)

• Highest dose, maximal bleeding reduction
• FDA-approved for HMB
• 8-year contraceptive efficacy (though HMB indication only 5 years)

Liletta (52 mg LNG)

• Equivalent to Mirena in dose and efficacy 1
• FDA-approved for HMB for 5 years
• 8-year contraceptive efficacy
• Often lower cost

Kyleena (19.5 mg LNG)

• Smaller frame, easier insertion in nulliparous women 9
• 5-year duration
• Less amenorrhea than higher-dose devices
• Not FDA-approved for HMB but shows good satisfaction 3

Paragard (Copper T 380A)

• 10-year duration (longest)
• Hormone-free
• Emergency contraception option
• Expect heavier, more painful periods 8, 4

Managing Bleeding Irregularities

When patients experience bothersome bleeding with any IUD 7:

For copper IUD users with spotting or heavy bleeding:

• NSAIDs for 5-7 days (first-line)

For LNG-IUD users:

• NSAIDs for 5-7 days
• Reassurance that bleeding typically improves over 3-6 months

Common pitfall: Removing an LNG-IUD prematurely for irregular bleeding in the first 3-6 months. Counsel patients that irregular bleeding is expected initially and typically resolves, with eventual oligomenorrhea or amenorrhea being common and beneficial outcomes.

Contraindications Common to All IUDs

Do not insert if 9, 1, 8:

• Pregnancy or suspected pregnancy
• Acute PID or PID history without subsequent intrauterine pregnancy
• Postpartum endometritis or septic abortion within 3 months
• Known/suspected uterine or cervical malignancy
• Uterine anomaly distorting the cavity
• Unexplained vaginal bleeding (evaluate first)

Additional LNG-IUD contraindications:

• Breast cancer or hormone-sensitive malignancy
• Acute liver disease or liver tumor

Additional Paragard contraindication:

• Wilson's disease or copper allergy