How to manage constipation while using Mirena (levonorgestrel)

Managing Constipation While Using Mirena (Levonorgestrel)

For patients experiencing constipation while using Mirena (levonorgestrel), polyethylene glycol (PEG) is recommended as the first-line pharmacological treatment due to its proven efficacy in increasing bowel movements and providing symptom relief. 1

Initial Management Approach

• Begin with lifestyle modifications as the foundation of treatment:

  • Increase fluid intake, especially for those with low baseline fluid consumption 1
  • Gradually increase dietary fiber intake to at least 20-25g daily 1, 2
  • Encourage regular physical activity within patient's capabilities 1
  • Ensure proper toileting habits, including responding promptly to the urge to defecate 1

• For mild constipation, start with fiber supplementation:

  • Psyllium is recommended as it has the best evidence among fiber supplements 1
  • Begin with low doses and gradually increase to avoid flatulence and bloating 1, 2
  • Take fiber supplements with 8-10 ounces of fluid 1

Pharmacological Management Algorithm

First-Line Treatment

• Polyethylene glycol (PEG) 17g mixed in 8 ounces of water once or twice daily 1, 3
  • PEG increases complete spontaneous bowel movements by approximately 2.9 per week compared to placebo 1
  • Response to PEG has been shown to be durable over 6 months 1
  • Side effects may include abdominal distension, loose stool, flatulence, and nausea 1

Second-Line Options (if PEG alone is insufficient)

• Add a stimulant laxative such as bisacodyl (10-15mg daily) or senna 1, 3
• Consider combination therapy with PEG plus a stimulant laxative for more severe cases 1, 3

For Persistent Constipation

• Consider adding a prokinetic agent (e.g., metoclopramide 10-20mg PO four times daily) 3
• For severe cases, newer agents like lubiprostone or linaclotide may be considered if other treatments fail 1, 4

Monitoring and Assessment

• Aim for one non-forced bowel movement every 1-2 days 3
• Use validated assessment tools when possible to monitor constipation severity and treatment response 1
• Monitor for potential complications such as:
  • Abdominal distension 1
  • Fecal impaction 4
  • Bowel obstruction (rare but serious) 1

Important Considerations

• Constipation is a common side effect of many medications, including hormonal treatments like levonorgestrel 5
• Avoid long-term use of magnesium-based laxatives due to potential toxicity 4
• Stool softeners alone (like docusate sodium) are generally less effective than osmotic laxatives and should not be used as monotherapy 3
• If constipation persists despite appropriate management, consider evaluation for other causes of constipation such as defecatory disorders or slow transit constipation 1, 6

When to Seek Further Evaluation

• If constipation is accompanied by alarm symptoms such as blood in stool, weight loss, or severe abdominal pain 1
• If constipation is severe and unresponsive to the above management strategies 1
• If there is sudden change in bowel habits 1

Remember that early intervention with appropriate treatment can prevent progression to more severe constipation and improve quality of life for patients using Mirena who experience this side effect.