Levonorgestrel 52 mg IUD

The levonorgestrel 52 mg intrauterine device is a T-shaped polyethylene frame carrying a reservoir of 52 mg levonorgestrel that releases the progestogen directly into the uterine cavity for 5 years of contraception. It is the most effective reversible hormonal method, has the strongest effect on menstrual blood loss of any intrauterine device, and gives low systemic hormone exposure.

Design and release. The frame measures 32 mm by 32 mm. Release starts at about 20 micrograms daily and falls to about half that by 5 years. Plasma levonorgestrel stays low, so systemic progestogenic effects are fewer than with oral or implanted progestogens.

Mechanism. Thickened cervical mucus blocks sperm entry; endometrial suppression and altered uterotubal fluid impair sperm function. Ovulation continues in most cycles after the first year.

Effectiveness. About 2 pregnancies per 1,000 women in the first year with both perfect and typical use.

Onset, duration and return to fertility. Protection is immediate when inserted within 7 days of menses start; otherwise after 7 days. Duration is 5 years. Fertility returns immediately on removal.

Noncontraceptive benefits. Reduces heavy menstrual bleeding and dysmenorrhoea, improves anaemia, reduces pain from endometriosis and adenomyosis, and protects the endometrium during oestrogen therapy.

Ideal candidates. Patients who want long-term contraception with lighter menses, including those with heavy menstrual bleeding, dysmenorrhoea, endometriosis, adenomyosis, iron deficiency anaemia or sickle cell disease, and those with oestrogen contraindications.

History and examination. Menstrual and STI history, breast history, liver and thrombotic history. Bimanual and speculum examination before insertion.

Eligibility points specific to the levonorgestrel device.

• Category 1: heavy or prolonged menstrual bleeding (initiation), endometriosis, severe dysmenorrhoea, anaemia including sickle cell disease and thalassaemia; non-breastfeeding patients within 48 hours of delivery; enzyme-inducing medicines.
• Category 2: breastfeeding within 48 hours of delivery; past deep vein thrombosis or pulmonary embolism, or current disease established on anticoagulation; systemic lupus erythematosus without antiphospholipid antibodies; migraine with or without aura at initiation; benign focal nodular hyperplasia of the liver; ischaemic heart disease at initiation; worsening bleeding during use (continuation).
• Category 3: acute deep vein thrombosis or pulmonary embolism; severe decompensated cirrhosis; hepatocellular adenoma or hepatoma; systemic lupus erythematosus with positive or unknown antiphospholipid antibodies; ischaemic heart disease developing during use (continuation); migraine with aura worsening during use (continuation); breast cancer in the past with no evidence of disease for 5 years.
• Category 4: current breast cancer, plus all device-related category 4 conditions (pregnancy, unexplained bleeding before evaluation, current pelvic infection, puerperal sepsis, pelvic tuberculosis, cavity distortion).

Interactions. Rifampicin, rifabutin, enzyme-inducing antiseizure medicines, efavirenz and ritonavir-boosted regimens do not reduce contraceptive effectiveness because the action is local.

Counselling points. Irregular spotting is common for 3 to 6 months; about 1 in 5 patients have amenorrhoea by 1 year, which is safe. Explain that hormonal side effects are usually mild and transient, the device does not protect against STIs or HIV, and removal is available on request.

Regimen line. Levonorgestrel 52 mg intrauterine device, releasing about 20 micrograms daily at first; transcervical insertion.

• 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.
• Within 48 hours or from 4 weeks postpartum.
• Immediately after abortion, with no backup if within 7 days.
• Replace at 5 years; no missed-use rule.
• No clinically significant interactions; no adjustment for weight, kidney disease or enzyme inducers.
• Avoid initiation in severe decompensated cirrhosis and liver tumours.

Switching.

• From combined or progestin-only pills, an implant or an injectable used correctly: insert at any time, no backup. From an injectable, insert by the date the next injection is due.
• From a copper device: within 7 days of menses start, exchange directly with no backup. Later in the cycle, advise condoms or abstinence for 7 days before the exchange and backup for 7 days after it, or keep the copper device until the next menses.

Endometrial protection. With oestrogen therapy for menopausal symptoms, the device provides progestogenic endometrial protection; replace at 5 years when used for this purpose.

Follow up. Review at 3 to 6 weeks. Check threads, bleeding pattern and blood pressure, and review symptoms at later visits only if problems arise.

Perimenopause. If inserted at 45 years or older and the patient becomes amenorrhoeic, the device can stay until contraception is no longer needed. Contraception can stop once 12 consecutive months have passed without menses.

Expected effects. Irregular spotting or light bleeding for 3 to 6 months, then reduced bleeding or amenorrhoea. Breast tenderness, headache, acne and mood change are usually mild and settle within months.

Unscheduled bleeding. Exclude pregnancy, STI, cervical lesions and malposition. Options:

• 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).
• If eligible for oestrogen, a combined oral contraceptive containing 30 micrograms ethinylestradiol taken daily for up to 3 months.

Functional ovarian cysts. More common than with copper devices; usually asymptomatic and resolve within 2 to 3 months. Repeat ultrasound at 6 to 12 weeks if persistent; refer cysts over 5 cm or complex features.

Device complications. Expulsion about 1 in 20 in the first year, more with heavy menstrual bleeding and adenomyosis. Perforation about 1 to 2 for every 1,000 insertions, more in breastfeeding patients. Pelvic infection risk is confined mainly to the first 20 days.

Pregnancy. Rare, but up to half of pregnancies that occur are ectopic. Request ultrasound promptly for a positive test, missed menses after a regular pattern, or pelvic pain.

Referral and escalation. Refer for suspected perforation, ectopic pregnancy, new breast lump, jaundice, complex ovarian mass, or severe headache with focal neurological signs.