What should be checked for when Mirena (levonorgestrel-releasing intrauterine system) is prescribed for the first time to a patient?

Essential Assessments Before Prescribing Mirena (Levonorgestrel IUD)

Before prescribing Mirena (levonorgestrel-releasing intrauterine system) for the first time, clinicians must perform a bimanual examination and cervical inspection to ensure appropriate placement and rule out contraindications. 1

Medical History Assessment

• Pregnancy status: Determine if the patient is pregnant using criteria in Table 1 1:

  • ≤7 days after start of normal menses
  • No intercourse since last normal menses
  • Consistent use of reliable contraception
  • ≤7 days after spontaneous/induced abortion
  • ≤4 weeks postpartum
  • Fully/nearly fully breastfeeding

• Contraindications: Screen for conditions that would make IUD placement unsafe 1:

  • Current purulent cervicitis
  • Active gonorrhea or chlamydia infection
  • Current pelvic inflammatory disease (PID)
  • Current pelvic infections
  • Pregnancy
  • Unexplained vaginal bleeding

• Medical conditions: Assess for conditions that might affect IUD use 1:

  • History of thromboembolic disease
  • Uncontrolled hypertension
  • Liver disease or tumors
  • Breast cancer or other hormone-sensitive cancers

Physical Examination

• Mandatory examination 1:

  • Bimanual pelvic examination (Class A - essential)
  • Cervical inspection before insertion

• STI screening 1:

  • If patient has risk factors for STIs and hasn't been recently screened
  • Testing for gonorrhea and chlamydia can be performed on the day of insertion
  • IUD placement should not be delayed while waiting for results unless symptoms of infection are present

Patient Counseling

• Efficacy: Inform patient that Mirena has a 0.2% failure rate with both typical and perfect use 1

• Duration of use: Advise that Mirena is effective for up to 7-8 years for contraception 2

• Expected side effects 1, 3:

  • Bleeding pattern changes (decreased bleeding, spotting, or amenorrhea)
  • Potential cramping after insertion
  • Possibility of expulsion (more common in women with heavy bleeding) 4

• Non-contraceptive benefits 1, 5:

  • Treatment for abnormal uterine bleeding (80% decrease in menstrual blood loss at 4 months)
  • Improvement in hemoglobin levels (average 7.8% increase by 4 months)

Follow-up Plan

• Individualize follow-up based on the patient's needs and risk of discontinuation 1

• Provide instructions on:

  • How to check for IUD strings
  • When to return if experiencing problems (severe pain, abnormal bleeding, fever)
  • Using backup contraception (condoms) for 7 days if inserted >5 days after menses start 1

Common Pitfalls to Avoid

1. Requiring unnecessary tests that create barriers to care 1:

   • Cervical cytology
   • Breast examination
   • Screening for diabetes, dyslipidemia, or liver disease
   • Thrombophilia testing

2. Delaying IUD insertion unnecessarily:

   • IUD can be placed immediately if reasonably certain patient is not pregnant
   • STI testing can be performed on day of insertion; treatment can be provided later without IUD removal if patient improves 1

3. Not discussing dual method use with condoms for STI protection 1

4. Failing to counsel about expected bleeding changes, which is a common reason for discontinuation 4