Levonorgestrel (IUD)

• It is used to prevent pregnancy.
• It is used to treat heavy bleeding during monthly periods (menstruation).

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
• Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight.
• Chest pain or pressure.
• Dizziness.
• Belly pain.
• Pelvic pain.
• Vaginal bleeding that is not normal.
• Vaginal itching or discharge.
• Fever or chills.
• A lump in the breast or breast soreness.
• Cannot feel string.
• Device comes out.
• Painful sex.
• Very bad headache.
• Any unexplained bruising or bleeding.
• Yellow skin or eyes.
• Mood changes.
• Low mood (depression).
• Genital sores.

• LNG
• LNg 20

• Contraceptive
• Progestin

Pregnancy may be prevented through several mechanisms: Thickening of cervical mucus, which inhibits sperm passage through the uterus and sperm survival; inhibition of ovulation, from a negative feedback mechanism on the hypothalamus, leading to reduced secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH); altering the endometrium, which may affect implantation. Levonorgestrel is not effective once the implantation process has begun.

Distribution

Vd: ~1.8 L/kg

Metabolism

Hepatic via CYP3A4; forms inactive metabolites

Excretion

Urine (~45%); feces (~32%)

Contraception: Females: Intrauterine device: To be inserted into uterine cavity.

Kyleena: Initially releases levonorgestrel ~17.5 mcg per day, then rate subsequently decreases; mean release rate over 5 years is levonorgestrel ~9 mcg per day. Do not leave device in place for >5 years.

Liletta: Releases levonorgestrel ~15.6 mcg per day over 3 years. Do not leave device in place for >3 years.

Mirena: Initially releases levonorgestrel 20 mcg per day, then rate subsequently decreases; mean release rate over 5 years is levonorgestrel ~14 mcg per day. Do not leave device in place for >5 years.

Skyla, Jaydess [Canadian product]: Releases levonorgestrel ~6 mcg per day over 3 years. Do not leave device in place for >3 years.

Initiation of therapy: The device may be inserted at any time in the menstrual cycle once it is determined that the woman is not pregnant; immediately postpartum; or immediately after first or second trimester spontaneous or induced abortion. Back-up contraception is not needed if insertion is within 7 days of onset of menstruation. If insertion occurs >7 days after menstrual bleeding started, an additional form of contraception must be used for 7 days unless the woman abstains from sexual intercourse. Additional contraception is not needed if IUD is placed at the time of surgical abortion. Do not administer immediately following a septic abortion (Curtis 2016a).

Manufacturer recommendations: Following pregnancy or a second trimester abortion or miscarriage, insertion of the device should not take place for at least 6 weeks or until involution of the uterus is complete.

Continuation of contraception: When it is time to replace, device may be removed and replaced with a new device immediately, and at any time during menstrual cycle as long as the woman is not pregnant.

Additional contraceptive dosing considerations:

Switching from a different contraceptive to levonorgestrel IUD: The device may be inserted immediately if it is determined that the woman is not pregnant. Unless the woman abstains from sexual intercourse, a backup method of contraception is needed if it has been >7 days since menstrual bleeding has begun. When an additional method of contraception is needed, consider continuing the woman’s previous method for 7 days after insertion (Curtis 2016a).

Switching from a copper IUD: If sexual intercourse occurred after the start of the current cycle, and it has been >5 days since bleeding began, consider administering an emergency contraceptive (Curtis 2016a).

Switching to Liletta or Mirena from an injectable progestin contraceptive: May be inserted at any time. If inserted >13 weeks after the last injection, a barrier method of contraception should be used for 7 days.

Switching to Liletta or Mirena from a contraceptive implant or another intrauterine system: May insert on the same day the implant or device is removed, any time during the menstrual cycle.

Switching to Liletta or Mirena from a hormonal contraceptive (oral, transdermal, vaginal): May be inserted anytime, including hormone free interval of the previous method. If inserted during active use of the previous method, continue previous method for 7 days after insertion or until the end of the current treatment cycle.

Switching from levonorgestrel IUD to a different contraceptive: If the patient wishes to change to a different method of birth control, may remove the device during the first 7 days of menstrual cycle and begin the new therapy. If the device is not removed during the first 7 days of menstruation (or if the patient has irregular menstrual cycles or amenorrhea) and wants to start a different method of birth control, start the new method at least 7 days prior to device removal, otherwise, a back-up barrier contraceptive should be used for 7 days after the device is removed unless the woman abstains from vaginal intercourse.

Heavy menstrual bleeding: Females: Intrauterine device (Mirena): Refer to dosing for contraception

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied); use of the intrauterine device is contraindicated with active hepatic disease or hepatic tumor.

Use during pregnancy or a suspected pregnancy is contraindicated. Pregnancy should be ruled out prior to insertion. Women who become pregnant with an IUD in place risk septic abortion; septicemia, septic shock, and death may occur. Removal of the device is recommended; however, removal or manipulation of IUD or probing of the uterus may result in pregnancy loss. In addition, if pregnancy occurs with an IUD in place, the likelihood of ectopic pregnancy is increased; miscarriage, sepsis, premature labor, and premature delivery may occur if pregnancy is continued. Following pregnancy or a second trimester abortion or miscarriage, the manufacturer recommends that insertion of the device should not take place for at least 6 weeks or until involution of the uterus is complete. The device may be inserted immediately following a first trimester abortion. Following removal of the device, ~71% to 87% of women who wished to conceive became pregnant within 12 months.