The Mirena Intrauterine System

1. The Mirena Intrauterine System Max Brinsmead PhD FRANZCOG 2 Gungas Rd Nimbin NSW 2450 April 2007

2. The Ideal Contraceptive is: • 100% effective • Not dependent on patient compliance • Reversible • Free of side effects • Safe

3. The Mirena Intrauterine System: • Is the closest we have ever come to the ideal contraceptive • It also offers the advantage of having the positive benefits that arise from continuous progestogen exposure

5. Indications for Mirena • Contraception • Menorrhagia • Endometriosis • Anovulatory uterine bleeding • Fibroids • Adenomyosis • Pelvic Congestion Syndrome • Pelvic Pain – no cause found • Premenstrual Syndrome • Menstrual migraine • Leucorrhoea • Postmenopausal Progestin Therapy • Endometrial hyperplasia • Polycystic Ovary Syndrome

6. So what is the Mirena? • An T-shaped intrauterine device that contains 52 mg of levonorgestrel in its stem • Releases 14 ug/day over 5 years • This is equivalent to taking a Microlut (minipill) every second or third day • But the hormone is concentrated within the uterus & serum levels are 4 times lower than after oral ingestion

7. How does the Mirena Work? • Thickens cevical mucous and prevents sperm (and maybe bacterial) penetration • Prevents fertilisation by its effect on the fallopian tubes and sperm function • Thins the endometrium and causes a mild foreign body reaction • Inhibits ovulation in about 1 woman in six

8. What about side effects? • Prolonged and irregular bleeding • 20% in first 3 months of use • Only 3% after 6 months • 15% develop amenorrhoea • Expulsion – rare after correct fundal insertion • Uterine perforation – rare • Androgenic effects – headache, weight gain, mastalgia, acne (1-2%) • Ovarian cysts – in up to 15% of users but usually asymptomatic • Risk of ectopic pregnancy • Pelvic infection

9. Who cannot use a Mirena? • Absolute contraindications: • Pregnancy • Active PID • Undiagnosed abnormal uterine bleeding • Liver tumour • Relative contraindications: • Nulliparity • Within 6 weeks of term pregnancy • Cervicitis, history of ectopic or PID • Congenital or acquired uterine abnormality • Lactation OK – only 0.1% of the Levonorgestrel goes into breast milk

10. 4 Years of Using the Mirena IUS A Personal Practice Audit

11. Patient Characteristics • 98 Patients • 101 Insertions • 3 re insertions: 2 after expulsion, 1 for ALO • Average age 39.6 years • Average parity 2.4 • Nulliparous 7

12. Indications for Mirena • Only 30 were for contraception only • 35 were primarily for menorrhagia • 11 were for menorrhagia and contraception • 11 were primarily for endometriosis • 2 for NOS pelvic pain

13. Pelvic Pathology • Normal uterus in 69 patients • 14 with fibroids and uterus >10w size • 11 with endometriosis • 7 with nonspecific uterine enlargement 2X • 5 with adenomyosis

14. Outcomes • Satisfactory result 73/98 = 75% • Unsatisfactory result 13/98 = 13% • Follow up incomplete 12/98 = 12%

15. Unsatisfactory Outcomes • Troublesome bleeding - 4 to hysterectomy - 2 waiting • Expulsions - 1 to hysterectomy - 1 to COC - 2 others DNA • Weight gain, dysphoria, bloating - 3 patients

16. Other Issues • 2 expulsions – reinserted and satisfactory • 3 with bleeding weeks or months after insertion - settled c oral Primolut 5mg BD • 2 patients with troublesome bleeding and fibroids but they persist • 2 patients with depression (postnatal) • 2 with ALO on Pap smear • 1 with acute PID after 26m – GBS • 1 patient with decreased libido • 1 post insertion syncope and near miss MVA

17. Conclusions • Mirena is not only a useful contraceptive agent... • It is a reasonable alternative to hysterectomy and endometrial ablation • It can be successfully used used in patients with benign pathology e.g. fibroids, adenomyosis & endometriosis • Most patients with pelvic pain had complete resolution of that symptom

18. Comments from Patients • “No periods to speak of at all” • “Fantastic” • “Changed my life” • “Best thing I ever did”