What to Expect from the Mirena IUD for Endo and Adeno
By Dr Graham Tronc
Can a Mirena IUD be part of your treatment plan to manage endometriosis and/or adenomyosis? How about two? While Mirenas aren’t for everybody, many with endo and/or adeno find them extremely helpful for symptom management, including pelvic pain and heavy bleeding. In this blog Dr Graham Tronc discusses the use of one Mirena or two, with or without other medications, and what to expect before and after insertion.
Want to know more about the experience of having two Mirenas? You can read Dannielle’s experience here.
Over the last two years I have inserted over 700 Mirenas, so I think I know the device pretty well.
Mirenas don’t suit everyone, but by following a few simple rules, they are a great aid to suppression of both endometriosis and/or adenomyosis.
The “rules” I use may be different to those of other Gynaecologists, so please discuss your situation with your own Doctor.
Unless a woman has had a vaginal birth, and specifically wants the Mirena inserted awake, I suggest a brief general anaesthetic. This avoids the pain of actual insertion, but more importantly, allows me to assess the uterine cavity prior to insertion AND to check the position after insertion (with a hysteroscope).
I won’t put a Mirena in until I know what is causing heavy bleeding (and pain). This means, that for the insertion of the first Mirena, the patient must have had a laparoscopy, to ascertain the site and the stage of endometriosis AND to check for adenomyosis.
Although unlikely to occur, expulsion can happen and over the last two years, I have had three patients expel their devices. If this happens a second time, I will not put in another.
The patient must be made fully aware of the settling in period. I tell my patients that they can expect intermittent crampy and nuisance type spot bleeding for 3-4 months.
I also suggest the oral contraception pill be taken on a back to back basis, even though the Mirena is a contraceptive device. Why? 7% of women with a Mirena will develop a larger than normal egg follicle (4-6 cm) rather than the normal 2 cm. This can cause pain in its own right. I suggest Normin-1 or Brevinor 1, taken back to back (ie no sugar pills). Taking the pill back to back also helps the Mirenas settle in a little more quickly.
I do tell my patients that Progesterones slow down the normal gastrointestinal movement of the gut and this can lead to bloating and constipation. Movicol three sachets at night all at once until things get moving is a good remedy. So is rhubarb (look up the recipe).
What about 2 Mirenas? Many women see me having already had one Mirena saying “it didn’t work”. There are a couple of reasons a Mirena may not control menstrual bleeding. The most common reason is that the Mirena was put in to treat/control bleeding presumably caused only by endometriosis; where in fact, there could also be a diagnosis of adenomyosis to be made. In other words, the “target tissue” for the Mirena, which always has the same amount of Progesterone in them, is just too much for the single dose to deal with. Many with adenomyosis find that just one Mirena doesn’t pack enough progesterone punch to deal with their condition, hence the use of two may be warranted.
Before putting two Mirenas in, I do always confirm adenomyosis (by laparoscopy myself) or with an ultrasound scan or MRI if the patient has already had a laparoscopy with excisional surgery and I still use the pill, back to back.
Zoladex, in conjunction with 2 Mirenas is another option but I try to leave this for cases where the pill and two Mirenas fails to control the bleeding.
Two Mirenas are generally not well tolerated in the patient who is in her teens because the uterine cavity is not as large generally. One Mirena, the pill and extra oral Progesterone is what I use here.
In summary, Mirenas work well and are generally well tolerated, but do need time to settle in. This need to settle in should always be fully discussed with the patient before insertion.
Dr Graham Tronc
Endometriosis and Adenomyosis Specialist
(Author of “ENDOMETRIOSIS 101 - FOR THE Significant Other”)
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