Dr Diana Mansour MBBCh FRCOG MFFP

Abstract | CV

From first Mirena to consecutive use

Dr. Diana Mansour FRCOG MFFP,
Consultant in Community Gynaecology,
Head of Contraception and Sexual Health Services, 
Newcastle upon Tyne, United Kingdom.

The levonorgestrel intrauterine system (LNG-IUS) has been hailed as one of the greatest advances, in the field of contraception, since the introduction of the Pill. It has been available in the United Kingdom since May 1995 with more than 300,000 women in Britain and over 2 million women worldwide having used the LNG-IUS. Mirena is also one of the contraceptive methods of choice for women following childbirth whether they are breast-feeding or not. 

Women have chosen the LNG-IUS not only because it is a highly effective yet reversible, contraceptive method but because women report a decrease in dysmenorrhoea and lighter menses. Studies show objective blood loss, in women suffering from menorrhagia, reduced by 86% after 3 months and 97% after 12 months (1). As women in their late thirties and forties often report an increase in their menstrual loss along with dysmenorrhoea (2) this non-contraceptive benefit is most welcomed. It also has the flexibility of being used as the progestogen component for HRT (3).

The LNG-IUS is a T shaped device with the vertical stem containing 52 mg. of levonorgestrel surrounded by a silastic capsule (4). This allows a steady, local release of 20mg levonorgestrel per day, over five years, giving few systemic side-effects. Unlike copper intrauterine devices (IUDs) the LNG-IUS should be changed every five years, even if a woman is over the age of 40 years.

The LNG-IUS is licensed to provide contraception for five years and exerts its contraceptive action firstly, by altering the cervical mucus and utero-tubal fluid which inhibits sperm migration. Secondly the LNG-IUS causes the uterine endometrium to atrophy by making the uterine mucosa thin, the stroma swollen, the endometrial glands atrophic and the epithelial cells inactive (5). The LNG-IUS may also suppress ovulation in one third of cycles and possibly reduce the pre-ovulatory luteinising hormone surge.

In cases of an accidental pregnancy with a LNG-IUS in situ, removal of the system (if possible) is advised and termination of pregnancy should be considered. The local exposure of the developing fetus to levonorgestrel delivered by this intrauterine system theoretically may lead to problems such as virilisation of a female fetus. There are a small number of cases reported where the LNG-IUS could not be removed, however and no adverse affects were found in the subsequent children. 

It is important that all medical practitioners providing an IUD/LNG-IUS service should have received formal tuition in IUD/LNG-IUS insertion, removal and management of common IUD/LNG-IUS problems. Careful patient selection will ensure contraceptive acceptability and long term continuance. 

It is recommended that the LNG-IUS be inserted within the first 7 days of the menstrual cycle although not during the days of heaviest loss when expulsion is more likely. No further extra contraceptive precautions are necessary. If a copper IUD is already in place or the women is taking a hormonal method of contraception, insertion can take place at any time during the cycle. It is important to remember that unlike copper IUDs the LNG-IUS has not been shown to be an effective post-coital contraceptive method.

There is now evidence to suggest that copper IUDs and the LNG-IUS can be inserted immediately after a miscarriage or first trimester termination of pregnancy without an increase in side-effects (6). The manufacturers recommend that the insertion of the LNG-IUS should be delayed by about 6 weeks if fitted post-natally or following a second trimester abortion. This ensures the uterus is fully involuted and may reduce the incidence of problematic prolonged vaginal bleeding. It is advisable to remove copper IUDs and the LNG-IUS at the time of a period. Not only will it be easier at this time but it will also reduce the chance of an iatrogenic unplanned pregnancy 

The LNG-IUS dramatically reduces menstrual blood loss and dysmenorrhoea. However counselling of the potential user is important as the LNG-IUS may cause irregular bleeding especially in the first 3 months. 20% of users experience prolonged bleeding (more than 8 days) in the first month of use however periods become shorter and only 3% of users had prolonged bleeding during the third month (7). The duration and amount of bleeding generally falls during the use of Mirena with 17% of women experiencing amenorrhoea of at least 3 months duration or more in the first year. 

The LNG-IUS may limit the risk of pelvic infection when compared to copper IUDs by thickening the cervical mucus. A European study reported an infection rate, with LNG-IUS of 0.4 per 100 women years at five years, as compared with 3.4 per 100 women years of use for the Nova-T (8). Very low ectopic pregnancy rates have been reported in LNG-IUS users making Mirena suitable for patients with a past history of ectopic pregnancies (0.02 per 100 women years compared to 0.25 for the Nova-T (8).

Very high continuation rates are found in women using the LNG-IUS with one study reporting that 82% of women still using the IUS at three years (9). The LNG-IUS provides highly effective, immediately reversible contraception that can be commenced in the early post-natal period and will last for up to 5 years. The efficacy data suggesting that this system rivals female sterilisation. Reversibility data suggests that a woman’s normal fertility will return within one month of removing the LNG-IUS. 

These messages need to be conveyed to couples requesting long term, effective methods of contraception to space and limit their family size safely in the antenatal and early post-natal period. Mirena can be used safely in women who are breast-feeding (10). Looking to the future, the non-contraceptive benefits of the LNG-IUS may also improve the overall health of women.

REFERENCES

1. Andersson J. K., Rybo G.
Levonorgestrel-releasing Intrauterine Device in the Treatment of Menorrhagia.
Br. J. Obstet Gynaecol 1990, 97; 690-694.

2. Rees M. 
Menstrual problems.
In: Women’s Health (4th edition)
(ed. A McPherson and D. Waller)
Oxford University Press, Oxford, 1997.

3. Suvanto-Luukkonen E., Malinen H., Sundstrom H., Penttinen J., Kauppila A.
Endometrial morphology during hormone replacement therapy with estradiol gel combined to levonorgestrel-releasing intrauterine device or natural progesterone.
Acta Obstet Gynecol Scand 1998;77:758-763.

4. Luukkainen T.
Levonorgestrel-releasing intrauterine device.
Annals New York Academy of Science 1991, 626; 43-49.

5. Silverberg S.G., Haukkamaa M., Arko H., Nilsson C.G., Luukkainen T.
Endometrial morphology during long-term use of levonorgestrel-releasing intrauterine devices.
Int J Gynecol Pathol 1986, 5; 235-241.

6. WHO Task Force in IUDs.
Clinical Trial of 3 IUDs Inserted Following Termination Of Pregnancy and Spontaneous Miscarriage.
Stud Fam Plann, 1983 14; 109-114.

7. Schering A.G.
Mirena Product Monograph,
Third Edition, 1997

8. Andersson K., Odlind V., Rybo G.
Levonorgestrel-releasing and Copper-releasing (Nova-T) IUDs During Five Years of
Use: a Randomised Comparative Trial.
Contraception 1994, 49; 56-72.

9. Backman T., Huhtala S., Tuominen J., Luoto R., Erkkola R., Blom T., Rauramo I., 
Koskenvuo M.
Sixty thousand woman-years of experience on Mirena: results from a postmarketing survey in Finland.
Presentation, 5th Congress European Society of Contraception, Prague, June, 1998.

10. Kennedy KI, Short RV, Tully MR.
Premature introduction of progestin-only contraceptive methods during lactation.
Contraception 1997, 55;347-350.

CV

PRESENT APPOINTMENT:

Consultant in Community Gynaecology and Reproductive Health Care and Head of Service, Contraception and Sexual Health, Newcastle Primary Care Trust, Newcastle upon Tyne.
Honorary Lecturer, University of Newcastle. 

FACULTY POSTS:

Regional Advisor/Assessor for the Faculty of Family Planning and Reproductive Health Care (FFPRHC) of the Royal College of Obstetricians and Gynaecologists (2001-)
Examiner for FFPRHC (2002-)
Chairman of the Menopause Special Skills Module of FFPRHC/BMS (2002-)
Honorary Secretary for the FFPRHC (1997-2001).
Company Director for the FFPRHC (1997-2001).
Chairman of the Postgraduate Education Committee for FFPRHC (1997-2001).
Member of the Audit Committee of FFPRHC (1993-1997)
Member of the Clinical and Scientific Committee of FFPRHC (1995-1997)

PAST APPOINTMENTS:

Deputy Medical Director/Senior Registrar/Lecturer in Family Planning and Reproductive Health Care, Margaret Pyke Family Planning Centre, London.
First accredited subspecialty trainee in Community Gynaecology and Reproductive Health Care of RCOG.
General Practice Vocational Training scheme, South Wales.

QUALIFICATIONS:

MBBCH, Welsh National School of Medicine, Cardiff 1982
MRCOG, London 1989
MFFP, London 1993
Sub-speciality Accreditation in Community Gynaecology and Reproductive Health Care, RCOG, 1995
FRCOG, London 2001

SOCIETIES:

Member of the Royal College of Obstetricians and Gynaecologists.
Founder Member of the Faculty of Family Planning and Reproductive Health Care.
Member of the North East Society of Family Planning Doctors.
Member of the British Menopause Society.
Member of the Society for the Advancement of Contraception.
Associate Member of the Institute of Psychosexual Medicine.
Member of the European Society of Contraception.

MEDICAL INTERESTS:

Long term methods of Contraception.
Menopause and Hormone Replacement Therapy.
Education and Teaching.

CURRENT RESEARCH:

i) Clinical Performance of the New Levonorgestrel Intrauterine System (Mirena)Inserter. 
ii) Use of misoprostol prior to insertion of intrauterine contraceptives in nulliparous women
iii) Contraceptive usage in women seeking repeat abortions
iv) Sexual health needs of Asian women
v) A randomised placebo controlled study of HRT in women with a previous history of early breast cancer.

PRINCIPAL PUBLICATIONS:

Over 60 scientific papers/publications on medical topics including vaginal infection, pre term delivery and post term delivery, contraception and the menopause. Advisory Consultant for several books and Contributor to a number of other medical books.

LECTURES:

Invited lecturer to post-graduate audiences and undergraduate clinical students.