Can a Mirena (levonorgestrel) IUD and Depo (medroxyprogesterone) shot be used together to control intrauterine bleeding?

Managing Intrauterine Bleeding: Combining Mirena IUD with Depo Shot

The levonorgestrel intrauterine system (Mirena IUD) alone is the preferred first-line treatment for controlling intrauterine bleeding, and adding Depo-Provera (medroxyprogesterone acetate) injection is generally not recommended due to redundant mechanisms and potential for increased side effects.

Efficacy of Mirena IUD for Bleeding Control

The Mirena IUD is highly effective as a standalone treatment for abnormal uterine bleeding:

• Causes an 80% decrease in median menstrual blood loss at 4 months, 95% decrease by 1 year, and 100% decrease (amenorrhea) by 2 years 1
• Approximately 44-50% of women experience amenorrhea by 6 months of use, which remains stable through 24 months 2
• The American College of Radiology recommends the levonorgestrel-releasing intrauterine system (LNG-IUS) as an excellent option for women with abnormal uterine bleeding 3, 4
• Provides significant improvement in hemoglobin levels (7.8% increase from baseline within 4 months) 1

Why Adding Depo-Provera Is Not Typically Recommended

• Both Mirena and Depo-Provera work through similar progestogenic mechanisms
• The Society of Family Planning guidelines recommend IUDs or implantable contraceptives as first-line options for most women 3
• Long-acting reversible contraception (LARC) methods like the Mirena IUD have been shown to be superior to other contraceptive methods with higher 12-month adherence rates (86% vs. 55%) 3
• Combining two progestin-based methods may increase side effects without providing significant additional benefit for bleeding control

Potential Exceptions to Consider

In rare cases where a combination might be considered:

• Persistent heavy bleeding despite 3-6 months of Mirena use
• Situations where immediate bleeding control is needed while waiting for Mirena to take full effect
• Cases where additional contraceptive backup is temporarily needed

Management Algorithm

1. First-line treatment: Insert Mirena IUD

   • Expect gradual reduction in bleeding over 3-6 months
   • Provide reassurance that unscheduled spotting or light bleeding is common during the first 3-6 months 4

2. If bleeding persists after 3-6 months:

   • Verify proper IUD placement via ultrasound
   • Rule out other causes of bleeding (fibroids, polyps, malignancy)
   • Consider adding non-hormonal treatments like tranexamic acid or NSAIDs during heavy bleeding episodes 4

3. Only consider adding Depo-Provera if:

   • Mirena alone has failed after 6 months
   • Patient understands potential increased side effects
   • Patient requires immediate bleeding control while waiting for Mirena's full effect

Important Considerations and Cautions

• Backup contraception is not needed when using Mirena IUD alone (failure rate <1%) 4
• When switching from another method to Mirena, backup contraception may be needed for 7 days if insertion occurs >7 days after starting menses 3
• Common side effects of Mirena include irregular bleeding patterns initially, which typically improve over time 2
• Adding Depo-Provera may increase risk of amenorrhea, weight gain, and mood changes

Conclusion

The Mirena IUD is highly effective as a standalone treatment for controlling intrauterine bleeding, with most women experiencing significant reduction in bleeding within 3-6 months and many achieving amenorrhea by 1-2 years. Adding Depo-Provera is generally unnecessary and may increase side effects without providing significant additional benefit.