How long after removal of a Mirena (levonorgestrel-releasing intrauterine device (IUD)) does menstruation typically resume in a female patient of reproductive age?

Return of Menstruation After Mirena Removal

Menstruation typically resumes immediately after Mirena removal, with most women returning to their baseline menstrual pattern within 1-3 months, though fertility and ovulation can return within days of removal.

Immediate Return to Fertility

• The CDC explicitly states that waiting for the next menstrual period is unnecessary after IUD discontinuation, indicating the uterus is physiologically ready for pregnancy right away 1
• Removal can be performed at any time during the menstrual cycle without concern for timing 1
• Women can conceive immediately after removal, as the contraceptive effect ceases once the device is removed 1

Expected Timeline for Menstrual Return

First Few Months Post-Removal

• Most women experience return of their pre-Mirena menstrual pattern within 1-3 months after removal, though this varies based on individual bleeding patterns during use 2, 3
• Women who had amenorrhea while using Mirena (approximately 44-50% of users after 6-12 months of use) may take slightly longer to resume regular menses 3
• Ovulation can resume very quickly—research shows that even with the device in place, some women ovulate, indicating rapid return of ovarian function once removed 2

Important Considerations About Mirena's Effects

• During Mirena use, approximately 50% of women develop amenorrhea by 12-24 months, while others experience oligomenorrhea or spotting 3
• The levonorgestrel effect is local and systemic levels drop rapidly after removal (mean plasma concentrations were 260 pg/ml during first 3 months of use and 129 pg/ml after one year) 2
• Once removed, the hormonal suppression of the endometrium reverses, allowing normal menstrual cycling to resume 2

Fertility After Removal

• Historical data shows no significant delay in conception after IUD removal when controlling for age and pelvic inflammatory disease history 4
• Women have successfully conceived through natural conception immediately after Mirena removal 5
• Age and history of pelvic inflammatory disease are the primary factors affecting time to conception, not the IUD itself 4

Clinical Pitfalls to Avoid

• Do not counsel patients that they need to wait for a menstrual period before attempting conception—this is unnecessary 1
• Active infection is a contraindication for IUD removal and should be treated first 1
• In rare cases (primarily reported in nulliparous women), endometrial dysfunction or uterine synechiae may occur, though this is uncommon 5
• If menses do not return within 3 months or if the patient had amenorrhea prior to Mirena insertion, evaluate for other causes of amenorrhea using standard workup