When should the Kyleena (levonorgestrel-releasing intrauterine device (IUD)) be removed?

When Should Kyleena Be Removed?

Kyleena should be removed after 5 years of use, as this is the FDA-approved duration of effectiveness for this specific levonorgestrel-releasing IUD formulation.

Routine Removal Timeline

• Kyleena is approved for 5 years of continuous use and should be removed at or before this timepoint to maintain contraceptive efficacy 1
• The device releases 14 mcg of levonorgestrel per 24 hours, distinguishing it from the 20 mcg formulation (Mirena) which has different duration specifications 1
• If continued contraception is desired after 5 years, a new device can be inserted immediately after removal of the expired device 1

Immediate Removal Indications

Pregnancy

• Remove immediately if pregnancy is confirmed and strings are visible 2, 3
• Evaluate for ectopic pregnancy first before attempting removal 2
• Leaving the IUD in place during pregnancy increases risks of spontaneous abortion (including life-threatening septic abortion) and preterm delivery 2
• Removal reduces these risks, though not to baseline levels of pregnancy without an IUD 2

Device Malposition

• Remove as soon as possible if the IUD is located in the cervix rather than the uterine cavity, as this causes reduced contraceptive efficacy, pain, abnormal bleeding, and infection risk 4
• Remove promptly if the device has perforated or embedded into the myometrium, especially if symptomatic with pelvic pain 5, 6
• Do not replace on the same day after removing a perforated/embedded device; wait 4-6 weeks for myometrial healing 5

Pelvic Inflammatory Disease (PID)

• The IUD does not need immediate removal when PID is diagnosed 2, 3
• Initiate appropriate antibiotic treatment and reassess in 24-48 hours 2
• Remove the IUD only if no clinical improvement occurs after 48 hours of antibiotics or if the woman desires discontinuation 2
• If removing for PID, do so after antibiotics have been started to minimize bacterial spread 2

Patient Request or Intolerable Side Effects

• Remove if the patient desires discontinuation for any reason, including unacceptable bleeding patterns or other side effects 2
• Common levonorgestrel-IUD side effects that may prompt removal include persistent irregular bleeding, amenorrhea (if unacceptable to patient), headaches, depression, or decreased libido 1
• Counsel on alternative contraceptive methods and offer emergency contraception if appropriate 2

Special Clinical Scenarios

Cancer Diagnoses

• Remove before treatment for cervical or endometrial cancer, though the device likely needs removal at time of definitive treatment 2
• For current breast cancer, the LNG-IUD is contraindicated (Category 4) and should be removed 2
• For past breast cancer with no evidence of disease for 5 years, use is Category 3 (risks generally outweigh benefits) 2

Gestational Trophoblastic Disease

• Do not insert or continue use with persistently elevated β-hCG levels or malignant disease (Category 4) 2

Common Pitfalls to Avoid

• Do not delay removal beyond 5 years assuming continued effectiveness—contraceptive failure rates increase after the approved duration 1
• Do not remove the IUD before evaluation of unexplained vaginal bleeding; the device can remain while diagnostic workup proceeds 2
• Do not assume perforation requires emergency surgery—approximately 30% of perforations are asymptomatic and surgical findings are typically minimal, though laparoscopic removal is still recommended 6
• Do not routinely remove for amenorrhea—this affects approximately 50% of users by 2 years and requires only reassurance unless unacceptable to the patient 2

Post-Removal Fertility

• Fertility returns rapidly after IUD removal, with cumulative pregnancy rates of 61.5% at 3 months, 87.9% at 6 months, and 92.3% at 12 months 7
• Mean interval from removal to conception is approximately 4.4 months 7
• IUD use does not impair subsequent fertility 7