What are the steps for inserting a Mirena (levonorgestrel-releasing intrauterine system) in a female patient of reproductive age seeking contraception or treatment for heavy menstrual bleeding?

Steps for Mirena (Levonorgestrel-Releasing Intrauterine System) Insertion

Pre-Insertion Requirements

Before inserting the Mirena IUD, perform a bimanual examination and cervical inspection, and confirm the patient is not pregnant using standard criteria. 1, 2

Essential Pre-Procedure Steps:

• Measure blood pressure if the patient has any cardiovascular risk factors, though this is not required for IUD placement specifically 1

• Screen for sexually transmitted infections if risk factors are present (multiple partners, new partner, partner with STI), but do not delay insertion to await results unless purulent cervicitis is visible 1, 2

• Confirm non-pregnancy status - the Mirena can be inserted at any time during the menstrual cycle if you are reasonably certain the patient is not pregnant 2

• Rule out anatomical abnormalities that would distort the uterine cavity, as these are absolute contraindications (Category 4) to IUD insertion 3

• Assess for uterine fibroids - while not a contraindication, women with fibroids have higher expulsion rates (11% vs 0-3%), though this may still be acceptable 3

Timing of Insertion

• The levonorgestrel IUD can be inserted at any time if pregnancy is reasonably excluded 2

• Backup contraception is needed for 7 days only if inserted more than 7 days after menses starts 4, 2

Contraindications to Check

Absolute Contraindications (Category 4):

• Current pelvic inflammatory disease - treat with antibiotics first, though the IUD can remain if already in place 3

• Current purulent cervicitis, chlamydia, or gonorrhea - treat the STI first before insertion 3

• Distorted uterine cavity from congenital or acquired abnormalities incompatible with IUD insertion 3

• Current cervical or endometrial cancer awaiting treatment - concern exists about increased infection and bleeding risk at insertion 3

Relative Contraindications:

• Past PID without subsequent pregnancy is Category 2 (benefits generally outweigh risks) 3

• Current breast cancer is Category 4 for hormonal methods, though concerns may be less with LNG-IUD than combined oral contraceptives due to primarily local effects 3

Patient Counseling Before Insertion

• Counsel about expected bleeding patterns - unscheduled spotting or bleeding is common during the first 3-6 months and generally decreases with continued use 4, 2

• Explain that amenorrhea is common after prolonged use and is not harmful, does not require treatment, and does not indicate pregnancy 4

• Discuss the 71-95% reduction in menstrual blood loss that typically occurs, making it comparable in effectiveness to endometrial ablation for heavy menstrual bleeding 3, 4

• Emphasize condom use for STI protection, as the IUD does not protect against sexually transmitted infections 4

Managing Post-Insertion Breakthrough Bleeding

• Prescribe NSAIDs for 5-7 days as first-line treatment for breakthrough bleeding episodes in the first 3-6 months 4, 2

• Consider short-term hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days if bleeding persists beyond 6 months 2

• Before treating persistent bleeding, rule out pregnancy, STIs, medication interactions, or new pathologic uterine conditions (polyps, fibroids) 4

Key Clinical Advantages

• The LNG-IUS provides superior adherence compared to oral contraceptives, with 12-month continuation rates of 86% versus 55% for pills 2

• Contraceptive failure rates are dramatically lower - 0.27 for LARC methods versus 4.55 for oral pills 2

• Systemic progesterone absorption is minimal - the main effect is at the endometrial level, making it safer than systemic hormonal options in women with cardiovascular concerns 3