# Mirena Insertion

## Overview

This module describes how to insert a Mirena, a hormonal intrauterine contraceptive device.

## Indications

1. Contraception for up to 7 years

2. Treatment of heavy menstrual bleeding for up to 5 years

## Contraindications

1. Current pregnancy
   Current pregnancy

   Mirena can not be used as emergency contraception.

2. Any anomaly causing distortion of the uterine cavity

3. Current pelvic inflammatory disease, prior pelvic inflammatory disease without subsequent intrauterine pregnancy, or increased susceptibility to pelvic infections

4. Postpartum endometritis or infected abortion in the past 3 months

5. Known or suspected malignancies of the uterus, cervix, breast, or other progestin-sensitive cancer

6. Undiagnosed abnormal uterine bleeding

7. Untreated lower genital tract infections

8. Hepatic conditions
   Hepatic conditions

   Acute liver disease or liver masses

9. A previously inserted unremoved intrauterine device

10. Hypersensitivity to any component of the product

## Patient information & consent

Patients should be fully counselled about their contraceptive options. Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You have chosen the Mirena intrauterine device for family planning. The Mirena is a very small device which is stored in a thin tube. I will place the tube through your cervix into your womb, where the wings will pop out to keep it in place, and I will remove the tube.”

### What can my patient expect?

“Some patients do not find this painful, but other patients get moderate to severe pain during insertion. Afterwards, you can get cramping and minor spotting for a few days, but bleeding should be minimal. You or your sexual partner will not feel the Mirena in your womb.”

### What is my patient’s role?

“Tell me if you have any illnesses, symptoms of

sexually transmitted infections

sexually transmitted infections

Symptoms include abnormal vaginal discharge, pelvic pain, and abnormal vaginal bleeding.

or allergies. Tell me if the pain becomes too much, or you need a break before we go ahead. If at any point you feel you do not want to continue with the procedure, tell me and I’ll stop immediately. Let me know if you feel faint. Afterwards, you will need to return one month from now, and thereafter yearly, for an examination to check that the Mirena is still in place.”

## Preparation

Prepare a trolley with equipment. A female chaperone should be present.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile and sterile gloves

2. Alcohol-based hand rub

3. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another.

4. Swabs/cotton balls

5. Sterile pack

6. Sterile tenaculum

7. Sterile

   uterine sound
   uterine sound

   to determine uterine depth

8. Sterile speculum & lubricant

9. Sterile curved scissors

10. Ring forceps

11. Mirena in sterile package
    Mirena in sterile package

## Site & Positioning

The patient should be positioned in

dorsal lithotomy

dorsal lithotomy

. A bimanual examination using non-sterile gloves should be performed to determine uterine position and size.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open a sterile pack and create a sterile field. Open sterile equipment onto the field, leaving the Mirena, open, in its packaging beside the field. Fill the well with cleaning solution and open gauze/cotton wool into the well. Squeeze lubricant onto the blades of the speculum.

3. Perform hand hygiene and don sterile gloves.

4. Insert the lubricated speculum into the vagina.

5. Clean the cervix using soaked cotton balls and the ring forceps.

6. Apply the tenaculum to the

   anterior cervix
   anterior cervix

   Apply to the posterior cervix if retroverted uterus is present.

   (12 o’clock position) and apply gentle traction to straighten the uterus.

7. Insert the uterine sound carefully, avoiding perforation, and note the

   depth
   depth

   Depth of 6-10 cm is required.

   of the uterus. Remove the sound.

8. Slide the thumb slider of the insertion device all the way forward and hold it there.

9. Set the flange so the front edge is at the marking corresponding to the depth of the uterus.

10. Insert the device
    Insert the device

    through the cervix up to 1.5-2 cm from the flange.

11. Slide the thumb slider

    back to the mark
    back to the mark

    indicating the depth of the uterus. Wait 10 seconds for the arms to open.

12. Advance the device
    Advance the device

    until the flange touches the cervix and you feel resistance; this seats the Mirena in the fundus.

13. Slide the thumb slider all the way back and hold it there while you

    withdraw
    withdraw

    the insertion device fully.

14. Release the tenaculum.

15. Cut the threads perpendicularly 3 cm from the cervical os

    without applying tension
    without applying tension

    Applying tension risks moving the Mirena out of position.

    .

16. Withdraw the speculum.

17. Dispose of medical waste safely.

18. Document the procedure, including the IUD serial number.

## Troubleshooting

The cervical os is too tightly closed to pass the Mirena.

You may need a set of graduated cervical dilators to dilate the cervix before insertion.

I want to manage IUD insertion and post-insertion pain.

There is no evidence that using a cervical block, misoprostol, or NSAIDs reduces insertion pain, but a cervical block may reduce tenaculum application pain, and NSAIDs may reduce cramping post-insertion. Procedural sedation may be necessary in patients experiencing severe insertion pain.

## Risks

1. Vasovagal response

2. Tenaculum site & cervical bleeding

3. Pelvic inflammatory disease

4. Group A streptococcal infection

5. Uterine perforation

6. Complications of Mirena use

## References

1. Mirena Prescribing Information. Whippany, NJ: Bayer HealthCare Pharmaceuticals. Aug 2021.

2. American College of Obstetricians and Gynecologists. LARC Video Series.