Birth Control in 2015: Making the Right Choice (Part 3)

Combination Hormonal and Mechanical—Mirena®, Skyla® and Liletta™

IMG_8246The Mirena IUD was first the first hormone-releasing IUD approved by the FDA in 2000.  It is a small, T-shaped plastic device that secretes a small amount of a synthetic progestin called levonorgestrel.  Since there is no estrogen released by the Mirena it is perfect for women who are concerned about the side effects of estrogen—women with clotting disorders or have medical conditions such as hypertension, obesity, cardiovascular disease and diabetes.  The Mirena IUD does not generally stop ovulation.  Instead it works by altering the cervical mucus so that it becomes almost impenetrable by sperm.  It also causes the uterine lining (endometrium) to become thin further decreasing the survival of sperm.

The Mirena IUD is an example of long-acting-reversible contraceptive (LARC).  It provides contraception for up to 5 years.  A second example of a hormone releasing IUD is the Skyla® which was approved by the FDA in 2013.  The Skyla® emits a smaller amount of progestin for 3 years and may be better suited for adolescents who have a slightly smaller uterus than a woman who has already carried a pregnancy to term.  In mid-2015 the Liletta IUD was approved by the FDA.  Liletta is another hormone releasing IUD similar to the Mirena and Skyla.

The Mirena, Skyla and Liletta IUDs have some important advantages.

  1. It is spontaneous and eliminates the need to interrupt sex for contraception.
  2. It is one of the most reliable methods of contraception available.  It is not only spontaneous, but once it’s implanted you don’t have to remember to take a pill or change vaginal rings or patches.
  3. It is good for up to 5 years.
  4. It has a pleasant side effect for many women—it causes your menstrual periods to lighten and occasionally even stop entirely.  Although some women are concerned that this isn’t “natural” the fact is that it doesn’t negatively affect your future fertility.
  5. Along with causing your periods to be lighter or stop altogether it decreases menstrual cramps for most women.
  6. It decreases the likelihood of uterine (endometrial) cancer.
  7. It can be used while breast feeding.
  8. It is immediately reversible.  If you wish to start a family just have the IUD removed, wait for a normal period or two and then start trying.

There are women who should avoid the use of the Mirena or similar IUDs.  These include

  1. Women who had had or have breast cancer.
  2. Women with known liver disease.
  3. Women with fibroids that distort the uterine cavity.
  4. Women who have unexplained vaginal bleeding.
  5. Women with a history of pelvic inflammatory disease.
  6. Women at high risk for a sexually transmitted disease.

FREQUENTLY ASKED QUESTIONS ABOUT HORMONE-CONTAINING INTRAUTERINE DEVICES (IUDs)

  1. What are the differences between the Mirena, the Skyla and the Liletta IUDs?
How long it lasts Amount of levonorgestrel released per day
Mirena 5 years 20 mcg/day
Skyla 3 years 14 mcg/day
Liletta 3 years* 16-19 mcg/day

*This is the current FDA approval. It is expected to increase over the next few years and likely will be equivalent to the Mirena IUD.

  1. Is the insertion of the IUD painful? The insertion of an IUD can be painful, particularly in younger women who have never carried a pregnancy or in older women. The pain varies from a mild to, sometimes, intolerable cramps. However, it doesn’t need to be painful. We offer intravenous sedation for women who request it.
  1. Are these devices covered by medical insurance?
    The answer is –with few exceptions—yes. Even high deductible plans cover the use of a Mirena IUD.
  1. How effective is the IUD at preventing pregnancy? The IUD is nearly 99% effective in protecting against a pregnancy. It does not protect against a tubal pregnancy, however.
  1. I’ve heard that the IUD can perforate the uterus during insertion. Is that something to be concerned about? Any potential complication is something to be concerned about. However, the risk of uterine perforation is extremely low. One study conducted in Europe found 61 perforation out of over 61,000 women studied. That’s an extremely low number. We try and minimize even that remote risk by performing the IUD insertion under ultrasound guidance. IUD perforation appears to occur more often when they are inserted in the first few months after childbirth, during lactation or in a very retroverted (“tipped”) uterus.
  1. Some of my friends have said that IUDs can migrate through the uterus. Is that true? Although the IUD may be able to migrate it is more likely that an injury is caused at the time of the insertion—possibly even a uterine perforation. My own opinion is that there is insufficient information in the scientific literature, at this point, to state that a properly placed IUD in a normal uterus has the capacity to migrate through its wall into the abdominal cavity. We have observed many IUD “migrate” downward and even become expelled—but this action does not damage the uterus or the internal organs.
  1. Will IUDs protect against an ectopic pregnancy? It’s very important to remember that no IUD will protect against an ectopic or tubal pregnancy.
  1. What can I expect if I choose to have an IUD inserted? Once we’ve agreed that this method of contraception is right for you, we’ll schedule an appointment for an insertion. It is unnecessary to “time” the insertion with your menstrual cycle—it can be done at any time. Some physicians prefer that you have your period at the time but truth is that it can be inserted at any time. You can decide whether or not you wish to have it performed with intravenous sedation. If you choose I.V. sedation then we’ll ask you to bring someone that will drive you to and from your appointment and stay here with you while you are recovering.Just before the IUD is inserted we perform an ultrasound examination to quickly scan your uterus and ovaries. Afterwards your device will be inserted under ultrasound guidance to minimize the risk of uterine perforation. Lastly, we perform a vaginal ultrasound to be certain that it’s in the proper position. This all takes about 5 minutes from start to finish, after which you’ll rest in the room until you’re ready to go.
  1. Finally, we’ll send you home with a prescription for antibiotics and ask you to schedule a follow-up visit in 2 weeks just to make sure the IUD is still in its proper location.