It depends on the type of IUD. A copper IUD should be removed 12 months after the last menstrual period for someone aged over 50, after two years if they are under 50, or at 55 when a natural loss of fertility can be assumed.
If the 52 mg levonorgestrel IUD (the Mirena) is inserted at age 45 or above, it can remain in place for contraception up to age 55. If a woman wants to stop using the IUD before age 55, if she is over 50 and has not had any bleeding you can check an FSH level. If the FSH level is over 30, she is probably menopausal and will not ovulate again, so you can wait another 12 months then remove the IUD. If the FSH level is less than 30, it is recommended to leave the IUD in place and repeat the FSH level in another year’s time.
If somebody is using a 52 mg levonorgestrel IUD for control of heavy menstrual bleeding and not for contraception, it can remain in place for as long as needed to manage periods, regardless of the age at which it was put in.
The Kyleena, the 19.5 mg levonorgestrel IUD, can only be used for five years regardless of the age it is put in.
We should always be encouraging women to get their IUD removed when it is no longer needed for contraception or management of their heavy menstrual bleeding because it does carry a risk of infection in postmenopausal women.
– Answered by Dr Rebecca South – Women’s Health General Practitioner, Clinical Lead at Inner West Women’s Health
The right IUD is the right IUD for the person in front of you. Only the Mirena is licensed for both contraception and menstrual management. The Kyleena is not licensed for menstrual management and is less likely to give you amenorrhoea than the Mirena.
The Kyleena releases a lower dose of levonorgestrel into the uterus (19.5 mg over five years compared to 52 mg over the same period with the Mirena), leading to different bleeding patterns. With the Mirena, most women will experience a profound reduction in their menstrual bleeding, around 90%, whereas with the Kyleena most women in my experience will still continue to get a bit of a bleed. It is usually quite a bit lighter, but it might be a bit longer.
The Mirena may be preferable in the context of significant dysmenorrhoea, known endometriosis, or during perimenopause to provide continuous contraception until it is no longer required. There is also the option of using a Mirena as the progesterone component of hormonal therapy for up to five years.
The Kyleena is slightly smaller, both in stem length and arm width. This means the diameter of the insertion tube is smaller: 3.8 mm versus 4.4 mm. Both devices are generally very well-tolerated being put in, but discomfort scores may be lower inserting the Kyleena than the Mirena.
Studies have also suggested the Kyleena may be easier to insert, which can make it a good option for someone who is concerned about insertion or has had a painful insertion in the past. As an inserter, I have occasionally been able to get a Kyleena in when I was unable to get a Mirena in. The person may have chosen a Mirena but I have not been able to achieve that due to difficulties getting through the internal os, but I can actually insert a Kyleena after counselling and getting their consent to change.
“It’s important to let people know that efficacy with the 19.5 mg levonorgestrel is a little bit lower but it is still between 99.4% and 99.7% effective, while Mirena is 99.95%.”
There has been significant interest about whether the Kyleena’s lower hormonal dose would mean fewer hormonal side-effects such as acne, mood changes and libido reduction. However, there is currently no good data to show that.
Some women may simply prefer the lowest hormone option.
– Answered by Dr Rebecca South and Dr Sara Whitburn – General Practitioner and Medical Educator, Sexual Health Victoria.
The Mirena is currently licensed in Australia for contraception for five years, but family planning organisations recently moved to support the use of Mirena for contraception for six years when inserted in women under 45 years of age. This extended use is off label but is supported by evidence.
Studies have shown that the rate of pregnancies occurring in the sixth and seventh years are very similar to the fifth year. That is, very small numbers of pregnancies occur in those six to seven years. They also looked at how much levonorgestrel is released in those six to seven years and it was almost the same.
Guidelines from the Faculty of Sexual and Reproductive Health in the UK and the US FDA have recently approved use of the Mirena for contraception for eight years.
In Australia, Bayer has made a submission to extend the licenced use, but this will probably take some time. Off label extended use for contraception for those over 45 years of age has been standard practice for many years. When inserted after the age of 45, the Mirena can stay in place until age 55 for the purpose of contraception if required.
A Mirena can also be used as the progesterone component of MHT for endometrial protection in those requiring management of menopausal symptoms for five years only. If ongoing MHT is required and contraception is still needed, the Mirena can be changed every five years.
If it was inserted after 45 years of age, it can stay for 10 years for contraception, and another method of combined MHT can be added. This may be sequential or continuous depending on the patient, but it must contain adequate progesterone for endometrial protection.
Given all these complexities, it’s important to explain to clients that it is used for different durations for different purposes, and to document when you put a Mirena in and what people are using it for.
– Answered by Dr Sarah Callister – General Practitioner; Senior Medical Educator and Medical Officer, Family Planning Australia and Dr Sara Whitburn – General Practitioner and Medical Educator, Sexual Health Victoria.
Acne and hirsutism are common PCOS symptoms and are due to the higher circulating levels of androgens produced by ovaries where there are multiple hormonally-active follicles. Unlike the COCP, hormonal IUDs like Mirena and Kyleena do not reliably stop ovulation, though their local effect within the uterus tends to suppress regular bleeding. Women with PCOS who are using hormonal IUDs therefore produce exactly the same excess androgens as they would in any reproductive cycle – with exactly the same potential problems. Androgenic symptoms may be even more obvious if the woman has recently changed from something like a COCP since the COCP has a suppressive effect on androgen levels.
Explanation is the first step in management – and then to provide the woman with choices. If she wants to go back on something like the oral contraceptive pill that is a quite reasonable thing to do. However, if she loves her hormonal IUD then it is possible to target the androgenic symptoms specifically, with something like spironolactone, usually at a dose of 50mgs daily. Cyproterone acetate was an alternative in the past, but since the current lowest available dose is 50mgs it is impossible to cut the tablets to get down to the 2-3mgs required for this condition.
– Answered by Dr Terri Foran – Sexual Health Physician; Conjoint Senior Lecturer, School of Women’s and Children’s Health, UNSW.
The short answer is ‘not very’. This is because though the woman may not be bleeding or be able to easily recognise the stages of her cycle, she is still producing exactly the same hormones as she would if the Mirena was not in place.
There are a few strategies in PMS management which have some evidence to support their use. These include the use of 600-1200 mg of calcium daily, the daily use of a herb called Vitex Agnus-Castus (VAC), or the use of an oral contraceptive pill or contraceptive implant which suppresses the normal hormonal fluctuations occurring in a reproductive cycle and provides more stable hormone levels. Another option which is backed by good evidence is the use of an SSRI. These are often used at doses significantly lower than would normally be used to treat depression and in some women it may be necessary to only use the SSRI in the latter half of the cycle rather than daily.
One problem is that women with PMS are often more sensitive to synthetic hormones generally. You can sometimes take someone who gets quite severe symptoms for half of their cycle to someone who gets troublesome but less severe symptoms for the whole of their cycle on the chosen COCP. That is not a great trade as far as I’m concerned, and it may take several attempts before the best COCP preparation is found – if ever. It is also possible to combine a COCP and an SSRI as a dual treatment strategy.
– Answered by Dr Terri Foran
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