A hormonal intrauterine device (IUD), also known as an intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel into the uterus. It is used for birth control, heavy menstrual periods, and to prevent excessive build of the lining of the uterus in those on estrogen replacement therapy. It is one of the most effective forms of birth control with a one-year failure rate around 0.2%. The device is placed in the uterus and lasts three to eight years. Fertility often returns quickly following removal. Side effects include irregular periods, benign ovarian cysts, pelvic pain, and depression. Rarely uterine perforation may occur. Use is not recommended during pregnancy but is safe with breastfeeding. The IUD with progestogen is a type of long-acting reversible birth control. It works by thickening the mucus at the opening of the cervix, stopping the buildup of the lining of the uterus, and occasionally preventing ovulation. The IUD with levonorgestrel was first approved for medical use in 1990 in Finland and in the United States in 2000. It is on the World Health Organization's List of Essential Medicines.
Medical uses
The hormonal IUD is an extremely effective method of birth control, and a 2021 study demonstrated that it may be used for emergency contraception. In addition to birth control, the hormonal IUD is used for prevention and treatment of:
Heavy menstrual periods Endometriosis and chronic pelvic pain Adenomyosis and dysmenorrhea Anemia Endometrial hyperplasia (especially in pre-menopausal people who wish to maintain fertility in the treatment of endometrial hyperplasia) In some cases, use of a hormonal IUD may prevent a need for a hysterectomy. Advantages:
Considered one of the most effective forms of reversible birth control Can be used while breastfeeding (see also nursing mothers) No preparations needed before sex, though routine checking of the device strings by patient and physician is advised to ensure proper placement remains intact 90% of users who wish to become pregnant do so within 24 months of removal. May experience lighter periods (some users stop having periods completely, see also amenorrhea) Effective for up to three to eight years (depending on the IUD) Disadvantages:
Irregular periods and spotting between periods often occurs after insertion This usually improves after three to six months. Moderate to severe discomfort may be experienced during insertion procedure, including uterine cramping and back pain. Other potential adverse effects and risks
Effectiveness After insertion, Mirena is effective at preventing pregnancy for up to eight years. Kyleena is approved for five years and Skyla is approved for three years. The hormonal IUD is a long-acting reversible contraceptive, and is considered one of the most effective forms of birth control. The first year failure rate for the hormonal IUD is 0.1-0.2% and the five-year failure rate is 0.7-0.9%. These rates are comparable to tubal sterilization, but unlike sterilization the effects of the hormonal IUD are reversible. The hormonal IUD is considered to be more effective than other common forms of reversible contraception, such as the birth control pill, because it requires little action by the user after insertion. The effectiveness of other forms of birth control is mitigated (decreased) by the users themselves. If medication regimens for contraception are not followed precisely, the method becomes less effective. IUDs require no daily, weekly, or monthly regimen, so their typical use failure rate is therefore the same as their perfect use failure rate. In a 10-year study, the levonorgestrel IUD was found to be as effective as oral medicines (tranexamic acid, mefenamic acid, combined oestrogen–progestogen or progesterone alone) for heavy periods; the same proportion of study participants had not had surgery for heavy bleeding and had similar improvements in their quality of life. In people with complete bicornuate uterus and in need of contraception, two IUDs are generally applied (one in each horn) due to lack of evidence of efficacy with only one IUD. Evidence is lacking regarding progestogen IUD usage for menorrhagia in bicornuate uterus, but a case report showed good effect with a single IUD for this purpose.
Breastfeeding Progestogen-only contraceptives such as an IUD are not believed to affect milk supply or infant growth. However, a study in the Mirena application for FDA approval found a lower continuation of breastfeeding at 75 days in hormonal IUD users (44%) versus copper IUD users (79%). When using Mirena, about 0.1% of the maternal dose of levonorgestrel can be transferred via milk to the nursed infant. A six-year study of breastfed infants whose mothers used a levonorgestrel-only method of birth control found the infants had increased risk of respiratory infections and eye infections, though a lower risk of neurological conditions, compared to infants whose mothers used a copper IUD. No longer-term studies have been performed to assess the long-term effects on infants of levonorgestrel in breast milk. There are conflicting recommendations about use of Mirena while breastfeeding. The U.S. CDC does not recommend any hormonal method as a first choice of contraceptive for nursing mothers, although progestin-only methods, such as Mirena, may be used with close follow-up or when the benefits outweigh the risks. The World Health Organization recommends against immediate postpartum insertion, citing increased expulsion rates. It also reports concerns about potential effects on the infant's liver and brain development in the first six weeks postpartum. However, it recommends offering Mirena as a contraceptive option beginning at six weeks postpartum even to nursing women. Planned Parenthood offers Mirena as a contraceptive option for those who are breastfeeding beginning at four weeks postpartum.
Contraindications A hormonal IUD should not be used by people who:
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