What are the differences between Mirena (levonorgestrel), Liletta (levonorgestrel), Kyleena (levonorgestrel), Skyla (levonorgestrel), and Paragard (copper IUD) for a woman considering an intrauterine device (IUD) for long-term contraception?

IUD Comparison: Mirena, Liletta, Kyleena, Skyla, and Paragard

All five IUDs are highly effective long-acting reversible contraceptives with failure rates <1%, but your choice depends primarily on desired duration of use, whether you want hormonal benefits (reduced bleeding/cramping) versus hormone-free contraception, and device size considerations for nulliparous women. 1

Contraceptive Efficacy and Duration

All five devices provide excellent contraceptive protection:

• Mirena (52mg levonorgestrel): 0.1% failure rate, FDA-approved for 5 years but effective up to 7 years 1, 2
• Liletta (52mg levonorgestrel): 0.1% failure rate, FDA-approved for 5 years with data supporting up to 7 years 1
• Kyleena (19.5mg levonorgestrel): 0.1% failure rate, FDA-approved for 5 years 1
• Skyla (13.5mg levonorgestrel): 0.1% failure rate, FDA-approved for 3 years 1
• Paragard (copper): 0.8% failure rate, FDA-approved for 10 years with data supporting 12 years 1, 3

Clinical Decision Algorithm

For Contraception Alone:

Nulliparous women or those preferring smaller devices:

• Choose Kyleena (5 years) or Skyla (3 years) due to smaller inserter size 1

Parous women or those accepting standard inserter:

• Choose Mirena/Liletta (5-7 years) or Paragard (10-12 years) 1

For Heavy Menstrual Bleeding Treatment:

Only Mirena and Liletta are FDA-approved for treating heavy menstrual bleeding 1. These provide 20-60% reduction in menstrual blood loss after 3-6 months 1.

For Dysmenorrhea:

Any levonorgestrel IUD (Mirena, Liletta, Kyleena, Skyla) provides significant symptom improvement 1. Avoid Paragard if dysmenorrhea is a concern, as it may worsen cramping 1.

For Hormone-Free Contraception:

Choose Paragard if you want completely hormone-free contraception with no systemic hormonal effects 3. This is ideal for women with contraindications to hormones or history of venous thromboembolism 3.

Bleeding Pattern Differences

Levonorgestrel IUDs (Mirena, Liletta, Kyleena, Skyla):

• Initial 2-3 months: Irregular spotting is common 1
• After 3-6 months: Progressive reduction in bleeding with 20-60% decrease in menstrual blood loss 1
• Long-term: Many women experience amenorrhea (20-60% depending on dose) 2
• Management: NSAIDs for 5-7 days during bleeding episodes if needed 1

Copper IUD (Paragard):

• Initial 3-6 months: Unscheduled spotting, light bleeding, heavy or prolonged bleeding 1
• Long-term: Increased menstrual bleeding and cramping may continue indefinitely 1, 3
• Management: NSAIDs for 5-7 days; tranexamic acid for persistent heavy bleeding 4, 1

Device Specifications

Size Considerations:

Smaller devices (Kyleena, Skyla):

• Easier insertion in nulliparous women 1
• Lower hormone dose means less amenorrhea but still effective contraception 5

Standard devices (Mirena, Liletta, Paragard):

• Higher hormone dose (Mirena/Liletta) provides better menstrual suppression 2
• Paragard is completely hormone-free 3

Safety Profile and Risks

All IUDs:

• Pelvic infection risk: Small increased risk only during first 20-21 days after insertion 1, 2
• Expulsion rate: 5-10% within 5 years 6
• Uterine perforation: 0.6-16 per 1000 insertions 6
• Ectopic pregnancy: If pregnancy occurs with IUD in place, approximately 1 in 20 is ectopic 6

Levonorgestrel IUDs Specific:

• No increased risk of venous thromboembolism 3
• Possible hormonal side effects: headache, acne, breast tension, functional ovarian cysts 6
• Safe for immunocompromised patients including HIV 2, 3

Copper IUD Specific:

• No hormonal side effects 3
• Increased menstrual bleeding and cramping, especially first several months 3
• Can be used as emergency contraception with <1% failure rate when inserted within 5 days of unprotected intercourse 3, 7

Critical Pitfalls to Avoid

Do not dismiss new-onset heavy bleeding without evaluation after the initial 3-6 month adjustment period—rule out IUD displacement, pregnancy, STIs, or new uterine pathology 1. Check for visible strings and obtain pelvic ultrasound if strings are not visible 2.

Bleeding pattern changes do not correlate with contraceptive failure—the mechanism of contraception remains independent of bleeding patterns 2. Provide reassurance that irregular bleeding is common and does not indicate device failure 2.

Do not routinely prescribe prophylactic antibiotics at insertion except in populations with high prevalence of sexually transmitted diseases 6, 8.

Special Populations

Nulliparous Women:

All IUDs are safe and do not cause tubal infertility 2, 3. Consider smaller devices (Kyleena, Skyla) for easier insertion 1.

Postpartum Women:

Insertion is safe at ≥4 weeks after delivery 1. Immediate postpartum insertion is also safe and effective 2.

Women with Cardiovascular Risk Factors:

Copper IUD or levonorgestrel IUD are first-line choices for women with history of deep venous thrombosis, pulmonary embolism, or coronary events, as they have no estrogen-associated risks 3, 6.