This section of the IUD Toolkit presents the latest information on service delivery for the LNG-IUS IUD as of January 2009.

See also: Method Characteristics of the LNG-IUS | Client Attitudes and Behaviors Regarding the LNG-IUS | How Organizations and Providers Can Obtain the LNG-IUS | Bibliography

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Who Can Use the LNG-IUS?

• Almost all women can use the LNG-IUS, including young women (under 20 years old) and older women (over 40 years old), women who are postpartum or postabortion, nulliparous women, nulligravid women, women who have had an ectopic pregnancy or a previous case of PID, women with HIV, or women who have AIDS and are doing clinically well on antiretrovirals (WHO, 2004a).
• In addition, the LNG-IUS can be used as a treatment option for patients with menorrhagia and possibly several other health conditions (see Non-Contraceptive Health Benefits).
• There are only a few conditions for which WHO recommends that the LNG-IUS should not be used (WHO Medical Eligibility Criteria, Category 4), the common ones being pregnancy; postpartum or postabortion sepsis; and current purulent cervicitis, PID, or chlamydial or gonorrheal infection. Less common conditions for which the LNG-IUS should not be used include cervical, endometrial or breast cancer; distorted uterine cavity; pelvic tuberculosis; malignant trophoblastic disease; and unexplained vaginal bleeding believed to reflect a serious underlying condition. There are also a few conditions in which the LNG-IUS should not be inserted unless other methods are not available or not acceptable to the woman (Category 3). These conditions—all of which are rare in women of reproductive age—include acute deep venous thrombosis, certain types of liver tumors, and severe cirrhosis. Not all of the conditions listed are contraindications for copper-containing IUDs; it is the hormonal content which makes the LNG-IUS inappropriate for patients with illnesses such as breast cancer and liver disease (WHO, 2004a).

Use of LNG-IUS by Women Who Are Breastfeeding

• Use of the LNG-IUS by lactating mothers during the postpartum period does not negatively impact breastfeeding or the healthy development of breastfed babies (Shaamash, 2005). Levels of levonorgestrel in the breast milk of mothers using the LNG-IUS are extremely low. WHO guidelines indicate that breastfeeding mothers can initiate use of the LNG-IUS starting as early as 4 weeks postpartum (WHO, 2008).

Use of LNG-IUS by Women at "Increased Risk" of STIs

• The LNG-IUS can generally be inserted in women who might be judged as having an “increased risk” of STIs solely because of certain epidemiologic or socio-demographic characteristics (Category 2) (WHO, 2004a). Some examples of these characteristics include age (young), marital status (unmarried), level of education (low), or area of residence (e.g., a region where prevalence of STIs is high).
• LNG-IUS insertion is not generally recommended if a woman has a high individual likelihood of exposure to chlamydia or gonorrhea (e.g., she or her partner has multiple partners), unless current gonorrhea and chlamydia (cervical infection) can be reliably ruled out prior to insertion. This is because the risks of initiating use in the presence of cervical infection (i.e., the risk of developing pelvic infection following insertion) will generally outweigh the benefits (Category 3). However, if a woman already has an LNG-IUS inserted and later becomes at higher risk of STI exposure, she can generally continue using the LNG-IUS (Category 2) (WHO, 2004a).

Use of LNG-IUS in the Presence of Chlamydia or Gonorrhea

• The LNG-IUS should not be inserted in the presence of current purulent cervicitis, or chlamydial or gonorrheal infection (WHO, 2004a). If a woman who already has an LNG-IUS in place presents with current purulent cervicitis or chlamydial or gonorrheal infection, she should be treated for these STIs with appropriate antibiotics, but there is no need to remove the LNG-IUS (WHO, 2004a).

Use of LNG-IUS by Women with HIV Infection

• The LNG-IUS can generally be inserted and used by women at high risk of HIV or by HIV-infected women if other STIs, such as gonorrhea and chlamydia, can be reliably ruled out prior to insertion. The LNG-IUS can also be inserted in women with AIDS who are doing clinically well on antiretroviral (ARV) therapy. Women with AIDS should be closely monitored for signs of PID. Women with HIV who develop AIDS while using the LNG-IUS do not have to have the LNG-IUS removed, even if they are not on ARV therapy (WHO, 2004a).

Counseling

• Women who receive counseling at the time of insertion about possible side effects associated with the LNG-IUS have higher levels of user satisfaction, regardless of whether they subsequently experience those symptoms. The strongest association between increased user satisfaction and information received through advanced counseling exists when women were told about the possibility of decreased menstrual bleeding or amenorrhea due to the LNG-IUS (Backman et al., 2002; Davie et al., 1996). Health care providers should provide detailed information about possible side effects, especially about menstrual changes that patients could experience (Jensen, 2005).

Insertion Techniques

• The insertion technique for the LNG-IUS is different from techniques required for the TCu-380A and other IUD devices and requires additional training. In a recent study, the majority of clinicians reported perceiving that insertion of the LNG-IUS was easier than insertion of the TCu-380A. Also, clinicians with no prior experience with the LNG-IUS were able to insert the device successfully 95 percent of the time after only 1 attempt; less than 1 percent were unsuccessful after 2 attempts. The study also showed that 68 percent of patients felt either no pain or mild pain during insertion (Jensen, 2008).

Timing of insertion

• The LNG-IUS can be inserted in the first 7 days of the menstrual cycle, or at any other time in the menstrual cycle, as long as the provider is reasonably sure that the client is not pregnant (WHO, 2004a). A pregnancy checklist based on criteria endorsed by WHO has been shown to be an effective tool for determining if a woman is not pregnant (Stanback et al., 1999).
• A woman does not need to wait until she is menstruating to have the LNG-IUS inserted (WHO, 2004b).

Postpartum Insertion 

• The LNG-IUS can be inserted any time within 48 hours after birth if a woman is not planning to breastfeed. (The provider must have special training in postpartum insertion of the LNG-IUS.) Women who are breastfeeding should not have an IUD inserted immediately postpartum due to concerns that the newborn liver is not mature enough to metabolize progestin ingested with breast milk. After 48 hours, regardless of breastfeeding status, it is recommended that insertion be delayed for at least 4 weeks postpartum, at which point the uterus returns to its normal size. Breastfeeding mothers can initiate use of the LNG-IUS starting at 4 weeks postpartum; after this point, use of the LNG-IUS will not negatively impact the healthy development of breastfed babies (WHO, 2008). There are no data on expulsion of the LNG-IUS following immediate postplacental insertion (within 10 minutes after removal of the placenta following childbirth) or early postpartum insertion (between 10 minutes and 48 hours after delivery). However, a 2003 review of articles on immediate postplacental insertion of the copper IUD indicates that this approach is safe and effective, although spontaneous expulsion is more likely than with interval insertion (performed at least 4 weeks after delivery) (Grimes et al., 2003). Subsequent studies also demonstrated that expulsion rates were higher after both immediate postplacental and early postpartum insertion compared with insertion 6 weeks or more postpartum (Grimes et al., 2007; Eroglu et al., 2006; WHO, 2004a; WHO, 2008).

Postabortion Insertion

• The LNG-IUS can also be safely inserted immediately after a first- or second-trimester abortion (spontaneous or induced) if no infection is present. Expulsion rates are higher when inserted immediately after a second-trimester abortion than following a first-trimester abortion (WHO, 2004a).

Cost Considerations

• The LNG-IUS is not widely available in many developing countries because of its high cost (Mansour, 2007). Its commodity cost is significantly greater than the TCu-380A because no generic version is currently available. Therefore, the LNG-IUS may be most appropriate for women with concerns about excessive menstrual bleeding or pain (Grimes, 2007).
• The price listed by the U.S. Agency for International Development (USAID) for the TCu-380A is US$1.64, according to the 2007 International Drug Price Indicator Guide (MSH, 2007). USAID does not supply the LNG-IUS, so a comparable cost is not available. The manufacturer makes Mirena available at a public-sector price of US$40 (Schwanenflugel, 2005). The International Contraceptive Access (ICA) Foundation provides some quantities of the product for free and at subsidized rates.
• In the United States and other developed countries, IUDs—including the LNG-IUS—are the most cost-effective form of reversible contraception (Trussell et al., 2008; Trussell et al., 1995; Chiou et al., 2003; French et al., 2000).