Levonorgestrel intrauterine device

What is the levonorgestrel releasing intrauterine device?

An intrauterine device (IUD) is a small T-shaped piece of smooth plastic, which is inserted into the uterus (womb).

Hormonal IUDs release a type of progestogen hormone called levonorgestrel (LNG). You may be familiar with Mirena® but there many other types available in the UK. LNG-IUDs are currently available in three doses of levonorgestrel: 52mg, 19.5 mg and 13.5 mg.

The progestogen hormone works directly on the lining of the womb to make it thinner and reducing menstrual bleeding or even stopping it all together.

A 52 mg LNG-IUD can also be used for contraception, as part of hormone replacement therapy or
to treat endometrial hyperplasia.

There are threads attached to the stem of all LNG-IUDs and these are used to check the position
and to remove device when required

What is the LNG-IUD used for and how long can I use it?

Contraception

LNG-IUDs are widely used as reliable, long-acting reversible forms of contraception. Typically, fewer than one in every 100 LNG-IUD users will get pregnant each year.

The 52 mg LNG-IUD can protect against pregnancy for eight years if you are under 45 years old at the time of insertion, after which it will need removing and replacing.

If you are 45 years or older at the time of insertion the 52mg LNG-IUD can protect against pregnancy until the age of 55 years, after which contraception is no longer required.

The 13.5 mg LNG-IUD can be used for contraception for three years and the 19.5 mg LNG-IUD lasts five years.

Reducing heavy menstrual bleeding (problematic monthly periods)

The LNG-IUD is a very effective treatment for heavy and painful periods. It can reduce the amount of blood lost over a year by 90%.

The LNG-IUD can provide relief for heavy periods for up to eight years but sometimes the bleeding worsens again after five or six years, and the device may need to changed at this point.

Hormone Replacement Therapy (HRT)

A 52mg LNG-IUD can be used with oestrogen as a tablet, patch, gel or spray for up to five years to provide relief from peri-menopausal and menopausal symptoms. We recommend choosing LNG-IUD as part of HRT if you have heavy periods or still need contraception.

Treatment of endometrial hyperplasia

Endometrial hyperplasia is a condition where the lining of the womb (endometrium) is overgrown or thickened. Studies have shown that 52 mg LNG-IUD is an effective treatment for endometrial hyperplasia.

Is the LNG-IUD suitable for me?

Abnormal bleeding such as bleeding after the menopause, unscheduled bleeding on HRT, bleeding after sex or in between periods needs to be investigated before a device can be fitted.

LNG-IUD may not be suitable if you

• Might be pregnant
• Have a current sexually transmitted infection such as chlamydia that has not been treated
• Have an abnormally shaped uterus
• Have the cavity of the uterus that is distorted by fibroids
• You have current breast cancer or breast cancer in the past

LNG-IUD is suitable even if you:

• Have a raised body mass index (BMI)
• Are aged 16 to 25 years of age
• Have never been pregnant
• Have only had delivered by caesarean section
• Take enzyme-inducing medications e.g., carbamazepine, rifampicin

What happens when the LNG-IUD is fitted?

LNG-IUD can be fitted in outpatient clinics, at some GP practices or in sexual health services.

Before the fitting procedure

You may want to take some simple painkillers like paracetamol and/or ibuprofen an hour before your appointment.

Contraception prior to fitting

LNG-IUD cannot be fitted it you are pregnant or at risk of pregnancy. You must use contraception carefully before the device is fitted unless you are post-menopausal or over 55 years of age.

• If fitted during the first seven days of your menstrual cycle the device will work for contraception immediately.
• If your LNG-IUD is fitted at any other time in your cycle, you will need to use additional contraception (condoms or continue your current contraception) for seven days.
• If you are having your device changed you must use condoms for seven days prior to the replacement.

Pain relief

Most women experience mild-moderate pain or discomfort, but the majority find the procedure acceptable. Analgesia options include local anaesthetic spray or injections and inhaled analgesia, i.e., Entonox (has and air) and Penthrox®.

Please discuss pain relief options with your clinician.

You should remember that you are in control of what happens at the fitting procedure, and you can ask for the procedure to be stopped at any time.

At the fitting procedure

A speculum is used to allow us to see the cervix (similar to cervical screening test). The cervix is grasped gently and a thin device is passed into the uterus to measure the uterine cavity.

The LNGIUD will set to your uterine length and gently passed through the cervix into the uterine cavity.

The fitting itself only takes five to ten minutes but please allow 30 minutes for the entire appointment.

After the fitting procedure

Cramping discomfort and light bleeding are common after the procedure. Some patients can experience light headedness and can, rarely, faint after the procedure. Please discuss any previous fainting episodes before your procedure so we are aware. We will allow you adequate time to recovery after your procedure.

You may wish to take some over-the-counter pain relief for a few days to reduce the discomfort.

We will show you how to feel for the threads, and we recommend checking the threads four weeks after insertion and at regular intervals if you are using the LNG-IUD for contraception.

You will be given a card stating when the device should be removed or replaced, and your GP will be informed of the type of device fitted.

Are there any side effects?

Irregular spotting and menstrual bleeding are common in the first three to six months after fitting. The bleeding tends to be more prolonged if your bleeding was very heavy before.

What are the potential complications or risks?

On occasions it is not possible for us to fit LNG-IUD due to a narrowing of the cervix or severe pain.

It is often possible to fit a smaller device in this situation or the fitting can be performed under general anaesthetic.

There is a small risk of pelvic infection in the first three weeks after fitting (<1%). We recommend having STI testing at the time of fitting if you have had a recent change in sexual partner to reduce this risk and if you develop any unusual vaginal discharge or severe pelvic pain you should seek medical attention.

There is a risk of damaging the cervix or uterus at the time of fitting – this is called a perforation. It happens at 2 in every 1000 fits (0.2%). The risks are significantly higher if you have recently given birth or are breastfeeding.

LNG-IUD can occasionally fall out (expulsion) or move position. This is most likely to occur within the first three months of fitting and happens at 1 in 20 fits (5%). If you are worried that you cannot feel your threads or they are longer in length, you should use condoms for contraception and seek advice.

LNG-IUD are very reliable, but pregnancy can occur and there is a higher chance of a pregnancy forming outside the uterus – ectopic pregnancy. If you feel pregnant and have a positive pregnancy test you must seek medical advice urgently.

Sometimes the threads that are used to remove the device become tangled around the device and at not visible at the cervix. This makes removal slightly trickier, and you may need a referral to a specialist for the device to be removed.

Studies have shown that there may be a small increased risk of breast cancer in users of progestogen containing contraception. However, these risks may need to balance against the benefits which include reduced risks of womb cancer and symptom control.

What will happen to my menstrual periods?

LNG-IUD can cause irregular menstrual bleeding in the first six months after insertion. Bleeding should settle down with time and we encourage everyone to persist as the long-term benefits are well worth this inconvenient phase.

After fitting of a 52 mg device 20-30 % of patients will have no bleeding at all – this is not dangerous, and many women enjoy this bonus of LNG-IUD. LNG-IUD for treatment of hyperplasia

It is important that you attend for follow up when a 52mg LNG-IUD is used for treatment of endometrial hyperplasia as there is a small chance this can progress into endometrial cancer.

You will be seen at six and 12 months and you will be offered an endometrial biopsy to check that the treatment is working and the hyperplasia is resolving.

How is the LNG-IUD removed?

LNG-IUD is easily removed by a trained doctor or nurse with minimal discomfort. We examine the cervix in a similar way to a cervical screening test and the threads of the device are pulled gently to remove the device.

Research

There is a large research team at the Royal Victoria Infirmary who often work with Newcastle University.

Our consultant team is actively involved in research and may ask you to take part in research studies. Whilst we are very grateful for those who choose to participate, we understand that some may wish to decline, and we would like to emphasise that this will not affect your care.

Any questions?

If you would like to discuss LNG-IUD or the contents of this leaflet in more detail, please speak to your hospital specialist or contact your GP or local sexual health service.

You may find the following websites helpful when deciding whether LNG-IUD is right for you.

If you have any concerns after fitting?

If you have any concerns after having an IUD fitted, you can contact the Women’s Health Unit or the Gynaecology Ward for telephone advice.

What if I cannot attend my appointment?

If you are unable to attend your appointment, please call our waiting list officer with 48 hours’ notice in Women’s Services for your appointment to be rescheduled.

For further information

PALS (Patient Advice and Liaison Service) for help, advice and information about NHS services.
You can contact them on freephone 0800 032 02 02, email [email protected]

Useful website

If you would like further information about health conditions and treatment options, you may wish to have a look at the NHS website at www.nhs.uk

If you would like to find accessibility information for our hospitals, please visit www.accessable.co.uk