What alternative contraceptive options are available for a sensitive female patient who cannot tolerate Mirena (levonorgestrel-releasing intrauterine system)?

Alternative Contraceptive Options for Patients Intolerant to Mirena

The copper IUD is the most appropriate first-line alternative for a patient who cannot tolerate Mirena, offering equally effective hormone-free contraception with no systemic hormonal side effects. 1, 2

Primary Recommendation: Copper IUD

The copper IUD provides several distinct advantages for sensitive patients:

• Highly effective contraception with failure rates less than 1% per year, comparable to Mirena and effective for 10-12 years 2, 3
• Completely hormone-free, eliminating all systemic progestin effects that may have caused intolerance to Mirena 2, 3
• No increased thrombotic risk, making it ideal for patients with any thrombotic risk factors 1, 2
• Safe for immunocompromised patients and those on immunosuppressive therapy, with no increased infection risk 1, 2
• Immediate return to fertility upon removal with no waiting period 2

Important Caveats for Copper IUD

The copper IUD does have specific side effects that differ from Mirena:

• Increased menstrual bleeding and cramping, particularly during the first several months after insertion 1, 2, 3
• This is the opposite effect of Mirena, which typically reduces bleeding 3, 4
• Small increased infection risk only during the first 20 days post-insertion, not beyond 2, 3

Secondary Hormonal Alternatives

If the patient requires hormonal contraception but cannot tolerate the levonorgestrel IUD specifically, consider these options in order of effectiveness:

Etonogestrel Subdermal Implant (Nexplanon)

• Highest contraceptive efficacy among reversible methods, effective for 3 years 2, 5
• Different progestin (etonogestrel vs. levonorgestrel) may be better tolerated if sensitivity was progestin-specific 5
• Minimal to no bone loss, unlike depot medroxyprogesterone 2
• Common pitfall: May interact with efavirenz-based antiretroviral therapy, reducing efficacy 1

Progestin-Only Pills

• Lower efficacy than IUDs or implants, requiring strict daily adherence 1, 2
• No increased VTE risk, appropriate for patients with thrombotic contraindications 1
• May be better tolerated than Mirena if local uterine effects (not systemic progestin) caused intolerance 1
• Important limitation: Effectiveness depends entirely on consistent daily use 1

Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera)

• Typical failure rate approximately 6%, administered every 12 weeks 2
• Black box warning for decreased bone density with prolonged use 1, 2
• Not recommended for patients with thrombotic risk factors or those at risk for osteoporosis 1
• Should be avoided in patients on chronic glucocorticoids or with underlying bone disease 1

Contraindicated Options

Combined hormonal contraceptives (pills, patches, rings) should be avoided in patients with:

• History of thrombosis or thrombotic risk factors 1
• Positive antiphospholipid antibodies 1
• Active SLE with moderate-severe disease activity 1
• Age >35 years who smoke 6
• Uncontrolled hypertension 6

The VTE risk with combined hormonal contraceptives is 36 times higher than baseline, with odds ratios ranging from 2.2 to 6.6 depending on progestin type 1

Clinical Decision Algorithm

Step 1: Determine the specific reason for Mirena intolerance:

• If hormonal side effects (acne, mood changes, headaches): Consider copper IUD 2, 3
• If local uterine effects (cramping, spotting): Consider etonogestrel implant or progestin-only pills 2, 5
• If device-related discomfort: Consider progestin implant or oral methods 2

Step 2: Assess contraindications:

• Thrombotic risk factors present: Copper IUD, progestin-only pills, or etonogestrel implant 1, 2
• Osteoporosis risk or chronic steroid use: Avoid DMPA 1, 2
• Heavy menstrual bleeding: Avoid copper IUD, consider etonogestrel implant 2, 3

Step 3: Consider patient preferences:

• Desire for hormone-free option: Copper IUD only 2
• Need for menstrual suppression: Etonogestrel implant 5
• Preference for oral method: Progestin-only pills 1