Levonorgestrel 19.5 mg IUD

The levonorgestrel 19.5 mg intrauterine device is a small-frame hormonal device that releases levonorgestrel into the uterine cavity for 5 years of contraception. It was designed for easier insertion through a narrower inserter and gives less bleeding suppression than the 52 mg device, so more patients keep a monthly bleed.

Design and release. The frame measures 28 mm by 30 mm and the inserter tube is 3.8 mm in diameter. A silver ring near the top of the stem allows identification on ultrasound and X-ray. Release is about 17.5 micrograms daily at first and falls to about 7 micrograms daily by 5 years.

Mechanism. Cervical mucus thickening and endometrial suppression; ovulation is preserved in most cycles.

Effectiveness. About 2 pregnancies per 1,000 women in the first year, and about 15 per 1,000 over 5 years.

Onset, duration and return to fertility. Immediate protection when inserted within 7 days of menses start. Duration 5 years. Fertility returns immediately on removal.

Bleeding profile. About 12 in 100 users are amenorrhoeic at 1 year and about 23 in 100 by 5 years.

Ideal candidates. Nulliparous patients, adolescents and those with a narrow cervix or anxiety about insertion who want 5 years of hormonal intrauterine contraception and prefer to keep some bleeding.

Not the device of choice. Heavy menstrual bleeding treatment and endometrial protection with oestrogen therapy; use the 52 mg device for these.

Examination and investigations. Bimanual and speculum examination; pregnancy exclusion; STI testing where risk is increased.

Eligibility. The categories match the levonorgestrel 52 mg device. Current breast cancer is category 4. Acute deep vein thrombosis or pulmonary embolism, decompensated cirrhosis, hepatocellular adenoma or hepatoma, and lupus with positive or unknown antiphospholipid antibodies are category 3. Breastfeeding within 48 hours of delivery is category 2. Postpartum 48 hours to 4 weeks is category 3.

Interactions. No clinically significant reduction in effectiveness with enzyme inducers.

Counselling points. Irregular bleeding is likely for 3 to 6 months. Most patients continue to bleed, usually lighter. No STI or HIV protection. Removal on request.

Regimen line. Levonorgestrel 19.5 mg intrauterine device, releasing about 17.5 micrograms daily at first.

• Transcervical insertion through a 3.8 mm inserter.
• Start within 7 days of menses start with no backup, or at any other time if reasonably certain not pregnant with backup for 7 days.
• Insert within 48 hours or from 4 weeks postpartum, or immediately after abortion.
• Replace at 5 years; no missed-use rule.
• No adjustment for weight, kidney disease or enzyme inducers.
• Avoid initiation in severe liver disease and liver tumours.

Switching. From another hormonal method used correctly, insert at any time with no backup. From a copper device after day 7 of the cycle, advise condoms or abstinence for 7 days before the exchange and backup for 7 days after it.

Follow up. Review at 3 to 6 weeks. Confirm the silver ring position on ultrasound if threads are absent.

Replacement. Replace at 5 years. A patient who wants heavier bleeding control at replacement can change to a 52 mg device.

Expected effects. Irregular spotting early, then lighter regular or infrequent bleeding. Acne, breast tenderness, headache and functional ovarian cysts occur, usually mild.

Unscheduled bleeding. Exclude pregnancy, STI and malposition. Give mefenamic acid 500 mg orally three times daily for 5 days or ibuprofen 400 mg orally three times daily with food for 5 days (maximum 2.4 g daily).

Device complications. Expulsion, perforation (about 1 to 2 for every 1,000 insertions) and infection in the first 20 days.

Pregnancy. Rare; a high proportion of failures are ectopic. Arrange ultrasound for any positive test or new pelvic pain.

Referral and escalation. Refer for suspected perforation, ectopic pregnancy, device not seen on ultrasound, or complex adnexal mass.