Currently, the hormonal intrauterine device (IUD) "Mirena" is widely used.
"Mirena" is a levonorgestrel-releasing system made of polyethylene and having a T-shape. The length of the Mirena is 32 mm. Around the vertical shaft is a cylindrical container filled with levonorgestrel (52 mg), which exerts a stronger effect on the endometrium than progesterone. The container is covered with a special membrane providing continuous release of levonorgestrel in the amount of 20 μg / day. "Mirena" combines high contraceptive effectiveness and therapeutic properties of hormonal contraceptives (COCs and subcutaneous implants) with amenities and long-acting IUDs.
The term "Mirena" is 5 years, although the contraceptive effect persists for 7 years.
The mechanism of action of "Mirena" is based on a combination of mechanisms of action of intrauterine contraceptive and levonorgestrel.
- IUD suppresses the functional activity of the endometrium: inhibits the proliferation of the endometrium, causes endometrial gland atrophy, pseudodecidual stromal transformation, and vascular changes, which prevents implantation.
- There is a change in the physico-chemical properties of cervical mucus (viscosity increases), which makes penetration of spermatozoa difficult.
- The motility of spermatozoa in the uterine cavity and fallopian tubes decreases.
- Reliable contraceptive effect.
- High safety (local action of the hormone minimizes its systemic effect).
- Reversibility of contraceptive effect (pregnancy is possible already in the first month after the removal of the "Mirena", but more often fertility is restored 6-24 months after the end of the action of the drug).
- Lack of communication with sexual intercourse and the need for self-control.
- Reduction of menstrual blood loss in most patients.
- It can be used in breastfeeding, since Mirena does not affect the quality and quantity of breast milk, as well as the growth and development of the child.
- Therapeutic effect in idiopathic menorrhagia.
- The ability to use small uterine myomas.
Indications for the use of "Mirena"
It is recommended first of all to give birth to women of different ages who have one sexual partner and who need long-term and reliable contraception. Especially shown to women with profuse and painful menstruation. In a number of cases, Mirena can be used in nulliparous women who have one partner and who need reliable long-term contraception, as well as with a therapeutic purpose. It should be emphasized that for the young non-women, Mirena is not the first choice.
Contraindications to the application of "Mirena":
- acute thrombophlebitis or thromboembolic conditions;
- mammary cancer;
- acute hepatitis;
- hepatic cirrhosis in severe form, liver tumors;
- cardiac ischemia;
- general contraindications to the use of the IUD.
It should be noted that there are a number of conditions where, according to the eligibility criteria (ie the benefit of using the method in this case exceeds the theoretical and proven risk), you can use Mirena, but on condition of constant medical observation. The list of such conditions includes hypertension with blood pressure of 160/100 mm Hg. Art. And above, vascular diseases, diabetes, ischemic or stroke history, hyperlipidemia, migraine, liver cirrhosis in mild form, risk factors for cardiovascular disease.
Side effects and complications in the application of "Mirena"
- During the first 3-4 months of using the IUD, levonorgestrel may have a minor systemic effect, which is manifested by mood changes, headache, mastalgia, nausea, acne, which then pass on their own.
- It is possible to develop functional ovarian cysts (in 12% of patients), which, as a rule, regress independently and do not require removal of the IUD.
- Possible violations of the menstrual cycle.
- Acyclic uterine bleeding is considered to be the most frequent side effects when using progestagenic contraception. They occur in the first 3-4 months of using the IUD and are mostly of an ointment. In these cases, it is necessary to conduct differential diagnosis with the expulsion of the IUS, inflammatory diseases of the uterus and / or its appendages, spontaneous abortion, ectopic pregnancy, organic pathology of the uterus. It should be explained to the woman that as the duration of use increases, bloody discharge usually stops, the menstrual cycle stabilizes, menstruation becomes short, uninvigorated and less painful.
- Oligo- and amenorrhea develop in 20% of Mirena's use as a result of local levonorgestrel exposure to the endometrium with the development of its atrophy. If menstruation is absent within 6 weeks after the start of the last period, pregnancy should be excluded. Repeated pregnancy tests for amenorrhea are not necessary (in the absence of other signs of pregnancy). After the extraction of the IUS, the endometrial condition is normalized within 1 month.
- Violations of the menstrual cycle in the form of irregular uterine bleeding.
- The possibility of developing amenorrhea, the cause of which is the local effect of levonorgestrel on the endometrium, and not a violation of the function of the hypothalamus-pituitary-ovary system. However, for women with heavy menstruation and iron deficiency anemia, the development of this condition can be an advantage.
Therapeutic (non-contraceptive) effects of "Mirena"
- Reduction in the intensity of menstrual bleeding and increased levels of hemoglobin and iron in the blood.
- Reduction of pain with dysmenorrhea.
- The ability to use hormone replacement therapy as a component in perimenopause due to a pronounced suppressive effect on the endometrium.
- Alternative to surgical methods of treatment for bleeding.
- Prevention of fibroids and internal endometriosis of the uterus.
- Prophylaxis of hyperplastic processes and endometrial cancer. "Mirena" is recommended to be administered from the 4th to the 6th day of the menstrual cycle. The technique of introducing "Mirena" has some peculiarities due to the need for the use of a special conductor supplied with the device.
Basic principles of monitoring patients using Mirena
- Within 1 month after the introduction of the Mirena, it is necessary to check its threads several times and make sure that the IUD is installed correctly.
- Repeated examinations should be carried out at least once every 6 months.
- It is necessary to teach the patient self-examination, which should be done after each menstruation, - palpation check the position of the strands of the IUD. If they were not found, transvaginal ultrasound scanning is necessary.
- It should be explained to the patient that with a fever, lower abdominal pain, abnormal discharge from the genital tract, a change in the nature or delay in menstruation, you should consult your doctor as soon as possible.
The hormone-containing vaginal contraceptive ring "NovaRing"
The "NovaRing" ring is a fundamentally new method of contraception, based on the vaginal way of introducing hormones. Its diameter is 54 mm. Per day, 15 μg of EE and 120 μg of etonogestrel, the active metabolite of desogestrel, are released from it, providing high contraceptive efficacy. The vaginal route of administration has significant advantages: first, a stable hormonal background, i. E. Stable concentration of hormones in the blood; secondly, the absence of a primary passage through the liver and gastrointestinal tract. This makes it possible to use the same daily doses of hormones that are easier to tolerate by the body with the same efficiency. Thus, the systemic effect on the woman's body is minimal. In addition, NovaRing does not affect the body weight due to the minimum dose and the stable level of hormones in the blood. The main mechanism of action of NovaRing, as well as COC, is suppression of ovulation. In addition, it increases the viscosity of cervical mucus.
For 1 menstrual cycle, one ring is needed. The woman herself introduces and removes NovaRing. It is administered from the 1st to the 5th day of the menstrual cycle, and for 3 weeks the ring is in the vagina. Then it is removed, a 7-day break is made and the next ring is inserted. During the first 7 days of using the vaginal ring, a condom should be used. In subsequent cycles, there is no need for additional use of any contraception.
- Discomfort in the vagina.
- Irregular spotting.
- Sensations of engorgement of mammary glands.
- Pregnancy or suspicion of it.
- Bleeding from the genital tract of an unknown etiology.
- Diabetic angiopathy.
- Severe diseases and liver tumors.
- Hormone-dependent tumors of the reproductive system (including in history).
- Migraine with focal neurological symptoms.
- Conditions that make it difficult to use the vaginal ring are cystocele, rectocele, uterine prolapse, cervical prolapse, bladder hernia, rectal hernia, severe chronic constipation.