Can a patient use Nextstellis (drospirenone and estetrol) if they already have a Mirena (levonorgestrel) IUD (intrauterine device)?

Combining Nextstellis with Mirena IUD

Yes, a patient can use Nextstellis (estetrol/drospirenone) while having a Mirena IUD in place, though this combination provides redundant contraceptive protection and is generally unnecessary from a contraceptive standpoint alone.

Clinical Rationale

Contraceptive Redundancy

• Both methods are highly effective contraceptives independently: Mirena has a failure rate of less than 1% over 5-7 years 1, while Nextstellis demonstrates a Pearl Index of 0.44-0.47 pregnancies per 100 woman-years 2, 3
• Using both methods simultaneously provides no meaningful additional contraceptive benefit beyond what the Mirena IUD already offers 1

Potential Therapeutic Indications for Dual Use

When combination therapy may be justified:

• Dysmenorrhea management: If the patient experiences persistent menstrual pain despite the Mirena IUD, adding Nextstellis could provide additional symptom control through continuous or extended hormonal suppression 4
• Breakthrough bleeding control: The CDC recommends that combined hormonal contraceptives can be used in continuous regimens to manage bleeding irregularities, which could theoretically apply even with an IUD in place 4
• Other therapeutic benefits: Nextstellis contains drospirenone, which has antimineralocorticoid and anti-androgenic effects that may benefit conditions like acne or premenstrual symptoms independent of the IUD 3

Safety Considerations

No contraindications to dual use:

• There are no guideline-based contraindications to using combined hormonal contraceptives alongside a levonorgestrel IUD 5
• The mechanisms of action differ: Mirena works primarily through local intrauterine effects and cervical mucus thickening 1, 6, while Nextstellis provides systemic hormonal contraception 2

Important caveats:

• The patient would experience the side effect profile of both methods simultaneously
• Nextstellis carries the typical risks of combined hormonal contraceptives, including a small increased risk of venous thromboembolism (one case reported in phase 3 trials) 2
• Cost considerations: paying for two contraceptive methods when one provides adequate protection

Clinical Decision Algorithm

Proceed with dual therapy if:

1. The patient has a specific therapeutic indication beyond contraception (dysmenorrhea, acne, menstrual regulation)
2. The patient understands the redundancy for contraceptive purposes
3. No contraindications to combined hormonal contraceptives exist (history of VTE, active liver disease, etc.)

Consider alternatives if:

1. The sole purpose is contraception—the Mirena alone is sufficient 1
2. The patient is seeking better bleeding control—first try NSAIDs for 5-7 days or consider a 3-4 day hormone-free interval if already on hormonal contraceptives 4
3. Cost or medication burden is a concern

Common Pitfall to Avoid

• Do not assume the patient needs dual contraception for pregnancy prevention—this represents overtreatment 1. Always clarify the specific indication for adding Nextstellis when a highly effective IUD is already in place.