1. Lecture 3
MIRENA
Its role in Menorrhagia
Dr. Jyoti Bhaskar
“Save
Uterus
Campaign”
Lecture Series
(1 to 4 )

2. MIRENA
Its role in Menorrhagia
Dr. Jyoti Bhaskar
Dr. Sharda Jain
Dr. Jyoti Agarwal

3. Mirena (LNG IUS)
is a
Magic Stick

4. What is Mirena - LNG IUS
• Progestin releasing
intrauterine system
• T shaped polyethylene
frame
• Contains 52 mg
levonorgestrel
• Releases 20 µg LNG daily

5. Mirena : local mode of action
Prevents endometrial
proliferation
• Thickens cervical
mucus
• Inhibits sperm motility
Serum Levels are 4 times lower than
after oral ingestion

6. Benefits of local action
No significant change in
•
•
•
•
•
•
Blood pressure
Lipid profile
Coagulation factors
Carbohydrate metabolism
Liver function
Bone mineral density

7. Mirena has an additional advantage
of providing reversible contraception.
Menorrhagia
Contraception

8. Efficacy of LNG IUS in
Idiopathic Menorrhagia

9. Bleeding pattern in the first 5-year period
Ammenorhea
26%
Infrequent
3.7%
Regular
70.3%
Rönnerdag M, Odlind V. Acta Obstet Gynecol Scand 1999;78:716–21

10. Comparison of Rx Modalities
Progesterone or LNG IUS
LNG IUS reduces menstrual blood loss
more
effectively and has a higher likelihood of
treatment success than oral medroxyprogesterone
acetate.
Obstet Gynecol. 2010

11. Effectiveness and Cost-Effectiveness of Levonorgestrel- Containing
Intrauterine System in Primary Care against Standard Treatment for
Menorrhagia (ECLIPSE) Trial
Improvements in MMAS scores were significantly greater
(lesser score= more severity)
Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J for the ECLIPSE Trial Collaborative Group N Engl J Med 2013;368:128-37
Daily routine work, social and family life, and psychological and physical well-being
11

12. LNG IUS versus Hysterectomy
When patients were given the option of mirena
a significant percentage of women cancelled
their hysterectomy
Pekka Lähteenmäki et al. 1998 316: 1122 (6)
12

13. Finnish trial
(multicentric RCT 236 pts)
• Mirena improves the quality of life as
effectively as surgical treatment at 1 year.
• Women ranked their satisfaction with a
mean score of 7 / 10.
• Less than 5% of women required subsequent
operative treatment
• Mirena is more cost effective than
hysterectomy in the short term

14. Mirena is as effective as
endometrial ablation in reducing
heavy menstrual bleeding
• In sept 2009 , the US FDA approved
mirena as a treatment for heavy menstrual
bleeding
Obstet gynecol 2009;1104-1116

15. Emerging new
indications for use
of mirena

16. ENDOMETRIOSIS
ADENOMYOSIS

17. Mirena provides long term relief
of chronic pelvic pain
Obstet gynecol 2012;119:519-526

18. FIBROIDS
Significant reduction in
both the uterine volume and

19. Endometrial Hyperplasia
• Beneficial effects are observed by1
year.
• Treatment should be reliably
monitored through regular 6-montly
outpatient follow up
Eur J Obstet Gynecol Reprod Biol. 2008

20. Early-stage Endometrial Carcinoma
May have a role in selected patients
willing to preserve fertility
• Endometrial protection for women on tamoxifen
• Women With Clotting Disorders Or Under Anti
Thrombotic Treatment
Conservative treatment of early endometrial
cancer: preliminary results of a pilot study.
Gynecol Oncol. 2011; 120(1):43-6

21. Are there any drugs that interact with
mirena ?
• Women using mirena
may be reassured that
• No drugs are known
to interact with
mirena
• Can be used safely
with ATT
• No effect on BMD
Not to be used as Emergency Contraceptive

22. PRACTICAL TIPS
TO SUCCESS

23. COUNSELLING
Is it not very costly as
compared to oral
medication?
Doctor, I am spotting
daily? What do I do?
I have not had periods
since 6 months? Am I
in menopause?

24. Counselling- Three problems !!!
• Spotting after insertion
• Amenorrhea in 25 % of women
• Price

25. Irregular Bleeding or spotting
• May last for 4-6 months
COC or Progesterone is used to tide over
this period
• GnRHa can also be used
Acceptance depends on good
pre insertion counselling

26. COST EFFECTIVENESS
LNG IUS
• Cost- Rs 8205/• Insertion cost – Rs.
2000 - 5000
Covered by Insurance
ORAL
PROGESTERONE
1 mnth – Rs. 3000
6 months Rs. 18000
1 Yr
Rs. 36000
No insurance

27. How long ?
NICE GUIDELINES :
If inserted > 45 yrs of
age and has complete amenorrhea may
continue to use it until menopause.
It can be removed at mid 50s as long as it controls the
bleeding
HRT
Change it after 4 years “licenced”
Contraception
< 45years…..5 years
> 45 years ….7 years

28. Sonographic Evaluation

29. My Journey with LNG- IUS
Oman to Republic of Ireland to India
2001 -- 2010 --- 2013

30. My Journey with LNG IUS
• 2 – 4 cases of Hysterectomy/month
• 4-5 cases of Hysteroscopy/D&C/
Mirena Insertion per theatre
• 2-4 cases of Mirena Insertion / week
in OPD for contraception.
Cost of Mirena- 120 euros
Paid by patient

31. My Journey with LNG IUS
• Inserted in unmarried girls, morbidly
obese, DM , HT patients.
• Women with Fibroids, adenomyosis,
endometriosis, complex hyperplasia.
• Not used in HRT patients.

32. Lifecare Experience
with
MIRENA in
Heavy Bleeding

33. Used in 41 cases
INCLUDING FIBROIDS AND ENDOMETRIOSIS
• It can replace the need of hysterectomy in
50 % of cases.
• Especially useful when future fertility is
desired
Expulsion in 3
(UBT , hysterectomy , reinsertion )

34. Mirena
Positive Side
• Effective after 4 month
• Major Surgery is saved – Mortality
- Morbidity
Cost Effective

35. UBT v/s Mirena
Great
Great
Great
4th Month
Jaan Nikaal
Deta Hai
Really
troublesome
But one should TRY