LNG IUSROLE IN AUB DR. JYOTI BHASKAR Dr Sharda Jain

1. INSERTION OF MIRENA :
PRACTICAL TIPS
Dr Sharda Jain
…Caring hearts, healing hands

3. INCREASED ANXIETY increses
PERCEPTION OF PAIN
• Higher levels of anxiety in women may worsen
perceived pain
• Pre-placement COUNSELING to reduce anxiety &
removal of mirena

4. PREINSERTION STRATEGIES
Various evidence based and non-evidence based pharmacological strategies are used
to improve ease of placement.
4
Pre-placement
cervical priming
with misoprostol
Pre-placement
oral analgesia with
NSAIDs
Pre-placement local
anesthesia
Includes different
formulations:
1. Gels, injections
and sprays and
2. Different
techniques for
administration:
Intracervical and
paracervical
Post-placement -
NSAIDs

5. INDIAN EXPERT GROUP CONSENSUS
Pre-placement considerations

6. SCHEDULING OF THE PLACEMENT PROCEDURE
Mirena insertin during periods
• IUC placement is not restricted to during
menses
• Placement can be performed at any point in
the menstrual cycle.
• However, the placement procedure may be
slightly easier during or at the end of menses
when the cervix is more dilated

7. PRE-PLACEMENT PAP SCREENING
• Pre-placement Pap screening is not evidence
based
• Absence of a Pap smear should not be a
barrier to provision of IUC.

8. CERVICAL PRIMING
• IUC placement can be performed without the
need for cervical priming in the majority women
• Use of misoprostol for the sole purpose of
reducing placement-related pain is not evidence
based
• Vaginal administration of misoprostol 4-8 hours
before IUC placement is preferable to sublingual
• More effective, less uterine cramping

9. PRE-PLACEMENT ORAL ANALGESIA
• Although not evidence-based, administration
of an NSAID such as ibuprofen 400-600 mg or
1000 mg of paracetamol, 1-2 hours before
placement may
• Increase women’s confidence
• Have a placebo effect with regard to minimizing pain associated with placement
• An NSAID should always be given if
misoprostol is used, to minimize misoprostol-
induced uterine cramping

10. Indian Expert Group Consensus
Uterine sounding and IUC placement

11. ASSESSING THE POSITION OF
THE UTERUS
• Good visualization is important
• Uterine sounding is a good practice.

12. CLEANSING THE CERVIX
• Cleaning the cervix is Not Evidence-based, but some
providers believe it is
• Good defensive practice
• Reassuring to women

13. Steps to be taken in difficult
insertions
If the uterus is sharply anteverted or retroverted and sounding or
placement of the insertion tube (canulation) is difficult, the following
techniques may be useful:
Use an
ultrasound to
guide further
attempts
Place the
tenaculum on
the posterior
Place a pillow or
other material
under the hips to
change the angle
of the pelvis
Apply
suprapubic
pressure

14. PARACERVICAL BLOCK – ANAESTHETIC AGENTS
• 1% lignocaine is adequate; <10 ml is not toxic, even
if it is mistakenly administered into the vasculature
• The woman should be informed that mild ringing in
the ears and/or tingling or numbness of the tongue
or lips may occur, and that this is of no concern
• Avoid concomitant use of adrenaline
• The risk of adrenaline-induced tachycardia, which can be distressing for the woman,
outweighs the benefit

15. MANAGEMENT OF PAIN
• VERBAL ANESTHESIA and distraction
techniques is best.
• Intracervical injection of local anesthetic gel
• May make cannulation of the cervical canal more comfortable, but there is limited
clinical evidence
• Injectable local anesthesia
• No randomized studies have evaluated the impact of pre-placement intracervical or
paracervical block on pain associated with IUC placement
• However, complications and pain can be difficult to predict, therefore injectable
local anesthesia should be kept to hand for reactive use in the instance of a women
experiencing pain during the procedure

16. Indian Expert Group Consensus
Post-placement troubleshooting

17. Bleeding
Irregular bleeding for ≤ 6 months since
placement AND/OR bleeding less than
heaviest period
Before placement of LNG IUS, counsel on the expected bleeding pattern
Irregular bleeding for ≥ 6 months since
placement AND/OR bleeding less than
heaviest period
1. Counselling
Reassure about
bleeding pattern
and gradual
decrease in the
incidences of
spotting/irregular
bleeding
2. Adjuvant therapies
Offer options to manage
bleeding if bothersome:
a) First line: COCs (30 mcg
EE with
LNG/GTD/DRSP)
b) Second Line:
Ormeloxifene (60 mg
twice weekly)
Pregnancy
Test
Gynecological exam
Positive test Negative Test
1) Infection
2) Cervical
lesion
Ultrasound
Treat
accordingly
No apparent cause Malposition
Offer options to manage bleeding:
Ormeloxifene/COCs/Estrogen
1) Consider removal
2) Consider placement under
ultrasound guidance;
either immediately in the
same sitting or in 2-3 weeks
if patient is still motivated
to use IUS.
If continues to be
bothersome