These highlights do not include all the information needed to use MIRENA safely and effectively. See full prescribing information for MIRENA. MIRENA (levonorgestrel-releasing intrauterine system) Initial U.S. Approval: 2000 | Mirena [Bayer HealthCare Pharmaceuticals Inc.] | BioPortfolio

17:46 EST 26th January 2019 | BioPortfolio
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The system should be replaced after 5 years if continued use is desired.

Mirena contains 52 mg of levonorgestrel (LNG). Initially, LNG is released at a rate of approximately 20 mcg/day. This rate decreases progressively to half that value after 5 years.

Mirena must be removed by the end of the fifth year and can be replaced at the time of removal with a new Mirena if continued contraceptive protection is desired.

Mirena is supplied within an inserter in a sterile package (see Figure 1) that must not be opened until required for insertion [see Description (11.2)]. Do not use if the seal of the sterile package is broken or appears compromised. Use strict aseptic techniques throughout the insertion procedure [see Warnings and Precautions (5.3)].

Table : When to Insert Mirena
Starting Mirena in women not currently using hormonal or intrauterine contraception Mirena can be inserted any time the provider can be reasonably certain the woman is not pregnant. Consider the possibility of ovulation and conception prior to initiation of this product [see Contraindications (4)]. If Mirena is inserted during the first seven days of the menstrual cycle or immediately after a first trimester abortion, back up contraception is not needed. If Mirena is not inserted during the first seven days of the menstrual cycle, a barrier method of contraception should be used or the patient should abstain from vaginal intercourse for seven days to prevent pregnancy.
Switching to Mirena from an oral, transdermal or vaginal hormonal contraceptive Mirena may be inserted at any time, including during the hormone-free interval of the previous method. If inserted during active use of the previous method, continue that method for 7 days after Mirena insertion or until the end of the current treatment cycle. If the woman was using continuous hormonal contraception, discontinue that method seven days after Mirena insertion.
Switching to Mirena from an injectable progestin contraceptive Mirena may be inserted at any time; a back-up method of contraception (such as condoms or spermicide) should also be used for 7 days if Mirena is inserted more than 3 months (13 weeks) after the last injection.
Switching to Mirena from a contraceptive implant or another IUS Insert Mirena on the same day the implant or IUS is removed. Mirena may be inserted at any time during the menstrual cycle.
Inserting Mirena after abortion or miscarriage
First-trimester Mirena may be inserted immediately after a first-trimester abortion or miscarriage.
Second-trimester Do not insert Mirena until a minimum of 6 weeks after second trimester abortion or miscarriage, or until the uterus is fully involuted. If involution is delayed, wait until involution is complete before insertion [see Warnings and Precautions (5.6, 5.7)]. If the woman has not yet had a period, consider the possibility of ovulation and conception occurring prior to insertion of Mirena. [See Contraindications (4), Warnings and Precautions (5.2), and FDA-Approved Patient Labeling.] Mirena can be inserted any time the provider can be reasonably certain the woman is not pregnant. If Mirena is not inserted during the first 7 days of the menstrual cycle, a back-up method of contraception should be used or the patient should abstain from vaginal intercourse for 7 days to prevent pregnancy.
Inserting Mirena after Childbirth Do not insert Mirena until a minimum of 6 weeks after delivery, or until the uterus is fully involuted. If involution is delayed, wait until involution is complete before insertion [see Warnings and Precautions (5.6, 5.7)]. If the woman has not yet had a period, consider the possibility of ovulation and conception occurring prior to insertion of Mirena. [See Contraindications (4), Warnings and Precautions (5.2), and FDA-Approved Patient Labeling.] Mirena can be inserted any time the provider can be reasonably certain the woman is not pregnant. If Mirena is not inserted during the first 7 days of the menstrual cycle, a back-up method of contraception should be used or the patient should abstain from vaginal intercourse for 7 days to prevent pregnancy. There is an increased risk of perforation in lactating women. [See Warnings and Precautions (5.7).]

Proceed with insertion only after completing the above steps and ascertaining that the patient is appropriate for Mirena. Ensure use of aseptic technique throughout the entire procedure.

Do not force the inserter. If necessary, dilate the cervical canal.

While holding the inserter steady, move the slider down to the mark to release the arms of Mirena (Figure 5). Wait 10 seconds for the horizontal arms to open completely.

Mirena insertion is now complete. Prescribe analgesics, if indicated. Keep a copy of the Consent Form with lot number for your records.

Mirena is a LNG-releasing IUS consisting of a T-shaped polyethylene frame with a steroid reservoir containing a total of 52 mg LNG.

The use of Mirena is contraindicated when one or more of the following conditions exist:

Evaluate women for ectopic pregnancy if they become pregnant with Mirena in place because the likelihood of a pregnancy being ectopic is increased with Mirena. Up to half of pregnancies that occur with Mirena in place are likely to be ectopic. Also consider the possibility of ectopic pregnancy in the case of lower abdominal pain, especially in association with missed periods or if an amenorrheic woman starts bleeding.

The incidence of ectopic pregnancy in clinical trials with Mirena, which excluded women with a history of ectopic pregnancy, was approximately 0.1% per year. The risk of ectopic pregnancy, in women who have a history of ectopic pregnancy and use Mirena is unknown. Women with a previous history of ectopic pregnancy, tubal surgery or pelvic infection carry a higher risk of ectopic pregnancy. Ectopic pregnancy may result in loss of fertility.

If pregnancy occurs while using Mirena, remove Mirena because leaving it in place may increase the risk of spontaneous abortion and preterm labor. Removal of Mirena or probing of the uterus may also result in spontaneous abortion. In the event of an intrauterine pregnancy with Mirena, consider the following:

In patients becoming pregnant with an IUD in place, septic abortion - with septicemia, septic shock, and death - may occur.

If a woman becomes pregnant with Mirena in place and if Mirena cannot be removed or the woman chooses not to have it removed, warn her that failure to remove Mirena increases the risk of miscarriage, sepsis, premature labor and premature delivery. Follow her pregnancy closely and advise her to report immediately any symptom that suggests complications of the pregnancy.

When pregnancy continues with Mirena in place, long-term effects on the offspring are unknown. Congenital anomalies in live births have occurred infrequently. No clear trend towards specific anomalies has been observed. Because of the local exposure of the fetus to LNG, the possibility of teratogenicity following exposure to Mirena cannot be completely excluded. Some observational data support a small increased risk of masculinization of the external genitalia of the female fetus following exposure to progestins at doses greater than those currently used for oral contraception. Whether these data apply to Mirena is unknown.

Severe infection or sepsis, including Group A streptococcal sepsis (GAS), have been reported following insertion of Mirena. In some cases, severe pain occurred within hours of insertion followed by sepsis within days. Because death from GAS is more likely if treatment is delayed, it is important to be aware of these rare but serious infections. Aseptic technique during insertion of Mirena is essential in order to minimize serious infections such as GAS.

Mirena is contraindicated in the presence of known or suspected PID or in women with a history of PID unless there has been a subsequent intrauterine pregnancy [see Contraindications ( 4)]. IUDs have been associated with an increased risk of PID, most likely due to organisms being introduced into the uterus during insertion. In clinical trials, total combined upper genital infections were reported in 3.5% of Mirena users. More specifically, endometritis was reported in 2.1%, PID in 0.6%, and all other upper genital infections in ≤0.5% of women overall. These infections occurred more frequently within the first year. In a clinical trial with other IUDs and a clinical trial with an IUD similar to Mirena, the highest rate occurred within the first month after insertion.

Promptly examine users with complaints of lower abdominal or pelvic pain, odorous discharge, unexplained bleeding, fever, genital lesions or sores. Remove Mirena in cases of recurrent endometritis or PID, or if an acute pelvic infection is severe or does not respond to treatment.

PID is often associated with a sexually transmitted infection, and Mirena does not protect against sexually transmitted infection. The risk of PID is greater for women who have multiple sexual partners, and also for women whose sexual partner(s) have multiple sexual partners. Women who have had PID are at increased risk for a recurrence or re-infection. In particular, ascertain whether the woman is at increased risk of infection (for example, leukemia, acquired immune deficiency syndrome [AIDS], IV drug abuse).

PID may be asymptomatic but still result in tubal damage and its sequelae.

Following a diagnosis of PID, or suspected PID, bacteriologic specimens should be obtained and antibiotic therapy should be initiated promptly. Removal of Mirena after initiation of antibiotic therapy is usually appropriate. Guidelines for PID treatment are available from the Centers for Disease Control (CDC), Atlanta, Georgia.

Actinomycosis has been associated with IUDs. Symptomatic women should have Mirena removed and should receive antibiotics. The significance of actinomyces-like organisms on Pap smear in an asymptomatic IUD user is unknown, and so this finding alone does not always require Mirena removal and treatment. When possible, confirm a Pap smear diagnosis with cultures.

Mirena can alter the bleeding pattern and result in spotting, irregular bleeding, heavy bleeding, oligomenorrhea and amenorrhea. During the first three to six months of Mirena use, the number of bleeding and spotting days may be increased and bleeding patterns may be irregular. Thereafter the number of bleeding and spotting days usually decreases but bleeding may remain irregular. If bleeding irregularities develop during prolonged treatment, appropriate diagnostic measures should be taken to rule out endometrial pathology.

Amenorrhea develops in approximately 20% of Mirena users by one year. The possibility of pregnancy should be considered if menstruation does not occur within six weeks of the onset of previous menstruation. Once pregnancy has been excluded, repeated pregnancy tests are generally not necessary in amenorrheic women unless indicated, for example, by other signs of pregnancy or by pelvic pain [see Clinical Studies ( 14.1)].

In most women with heavy menstrual bleeding, the number of bleeding and spotting days may also increase during the initial months of therapy but usually decrease with continued use; the volume of blood loss per cycle progressively becomes reduced [see Clinical Studies ( 14.2)].

Perforation (total or partial, including penetration/embedment of Mirena in the uterine wall or cervix) may occur most often during insertion, although the perforation may not be detected until sometime later. Perforation may reduce contraceptive efficacy and result in pregnancy. The incidence of perforation during clinical trials, which excluded breast-feeding women, was < 0.1%.

If perforation occurs, locate and remove Mirena. Surgery may be required. Delayed detection or removal of Mirena in case of perforation may result in migration outside the uterine cavity, adhesions, peritonitis, intestinal perforations, intestinal obstruction, abscesses and erosion of adjacent viscera.

The risk of perforation may be increased if Mirena is inserted when the uterus is fixed retroverted or not completely involuted. Delay Mirena insertion a minimum of six weeks or until involution is complete following a delivery or a second trimester abortion.

A large postmarketing safety study conducted in Europe over a 1-year observational period reported that lactation at the time of insertion of an IUD/IUS was associated with an increased risk of perforation. For Mirena users, the incidence of uterine perforation was reported as 6.3 per 1,000 insertions for lactating women, compared to 1.0 per 1,000 insertions for non-lactating women.

Partial or complete expulsion of Mirena may occur resulting in the loss of contraceptive protection. Expulsion may be associated with symptoms of bleeding or pain, or it may be asymptomatic and go unnoticed. Mirena typically decreases menstrual bleeding over time; therefore, an increase of menstrual bleeding may be indicative of an expulsion. The risk of expulsion may be increased when the uterus is not completely involuted. In clinical trials, a 4.5% expulsion rate was reported over the 5-year study duration.

Delay Mirena insertion a minimum of six weeks or until uterine involution is complete following a delivery or a second trimester abortion. Remove a partially expelled Mirena. If expulsion has occurred, a new Mirena can be inserted any time the provider can be reasonably certain the woman is not pregnant..

Because the contraceptive effect of Mirena is mainly due to its local effects within the uterus, ovulatory cycles with follicular rupture usually occur in women of fertile age using Mirena. Sometime atresia of the follicle is delayed and the follicle may continue to grow. Ovarian cysts have been reported in approximately 8% of women using Mirena. Most of these cysts are asymptomatic, although some may be accompanied by pelvic pain or dyspareunia.

In most cases the ovarian cysts disappear spontaneously during two to three months observation. Evaluate persistent ovarian cysts. Surgical intervention is not usually required.

Women who currently have or have had breast cancer, or have a suspicion of breast cancer, should not use hormonal contraception because some breast cancers are hormone-sensitive [see Contraindications ( 4)].

Spontaneous reports of breast cancer have been received during postmarketing experience with Mirena. Observational studies of the risk of breast cancer with use of a LNG-releasing IUS do not provide conclusive evidence of increased risk.

Use Mirena with caution after careful assessment if any of the following conditions exist, and consider removal of the system if any of them arise during use:

In addition, consider removing Mirena if any of the following conditions arise during use [see Contraindications ( 4)]:

If the threads are not visible or are significantly shortened they may have broken or retracted into the cervical canal or uterus. Consider the possibility that the system may have been displaced (for example, expelled or perforated the uterus) [see Warnings and Precautions (5.6, 5.7)]. Exclude pregnancy and verify the location of Mirena, for example, by sonography, X-ray, or by gentle exploration of the cervical canal with a suitable instrument. If Mirena is displaced, remove it. A new Mirena may be inserted at that time or during the next menses if it is certain that conception has not occurred. If Mirena is in place with no evidence of perforation, no intervention is indicated.

The following serious or otherwise important adverse reactions are discussed in elsewhere in the labeling:

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The data provided reflect the experience with the use of Mirena in the adequate and well-controlled studies as well as in the supportive and uncontrolled studies for contraception and heavy menstrual bleeding (n=5,091). The data cover more than 12,101 women-years of exposure, mainly in the contraception studies (11,761 women-years). The frequencies of reported adverse drug reactions represent crude incidences.

The most common adverse reactions (≥10% users) are alterations of menstrual bleeding patterns [including unscheduled uterine bleeding (31.9%), decreased uterine bleeding (23.4%), increased scheduled uterine bleeding (11.9%), and female genital tract bleeding (3.5%)], abdominal/pelvic pain (22.6%), amenorrhea (18.4%), headache/migraine (16.3%), genital discharge (14.9%), and vulvovaginitis (10.5%). Adverse reactions reported in ≥ 5% of users are shown in Table 1.

Other adverse reactions occurring in <5% of subjects include alopecia, (partial and complete) device expulsion, hirsutism, nausea, and PID/endometritis.

Table : Adverse Reactions ≥ 5% Reported in Clinical Trials with Mirena
System Organ Class Adverse Reactions % (N= 5,091)
Reproductive system and breast disorders alteration of menstrual bleeding pattern, including: unscheduled uterine bleeding decreased uterine bleeding increased scheduled uterine bleeding female genital tract bleeding 31.9 23.4 11.9 3.5
amenorrhea 18.4
genital discharge 14.9
vulvovaginitis 10.5
breast pain 8.5
benign ovarian cyst and associated complications 7.5
dysmenorrhea 6.4
Gastrointestinal disorders abdominal/pelvic pain 22.6
Nervous system disorders headache/migraine 16.3
Musculoskeletal and connective tissue disorders back pain 7.9
Skin and subcutaneous
tissue disorders
acne 6.8
Psychiatric disorders depression/depressive mood 6.4

The following adverse reactions have been identified during post approval use of Mirena. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

No drug-drug interaction studies have been conducted with Mirena.

Drugs or herbal products that induce enzymes, including CYP3A4, that metabolize progestins may decrease the serum concentrations of progestins.

Some drugs or herbal products that may decrease the serum concentration of LNG include:

Significant changes (increase or decrease) in the serum concentrations of the progestin have been noted in some cases of co-administration with HIV protease inhibitors or with non-nucleoside reverse transcriptase inhibitors. CYP3A4 inhibitors such as itraconazole or ketoconazole may increase plasma hormone levels.

Consult the labeling of all concurrently used drugs to obtain further information about interactions with Mirena or the potential for enzyme alterations.

The use of Mirena is contraindicated in pregnancy or with a suspected pregnancy because there is no need for pregnancy prevention in a woman who is already pregnant and Mirena may cause adverse pregnancy outcomes [see Contraindications ( 4 ), Warnings and Precautions ( 5.1 , 5.2 )]. If a woman becomes pregnant with Mirena in place, the likelihood of ectopic pregnancy is increased and there is an increased risk of miscarriage, sepsis, premature labor, and premature delivery. Remove Mirena, if possible, if pregnancy occurs in a woman using Mirena. If Mirena cannot be removed, follow the pregnancy closely [see Warnings and Precautions ( 5.1 , 5.2 )].

Studies report no adverse effects on fetal and infant development associated with long-term use of contraceptive doses of oral progestins in a pregnant woman. However, there have been reported cases of masculinization of the external genitalia of the female fetus following exposure to progestins at doses greater than those currently used for oral contraception.

Published studies report the presence of LNG in human milk. Small amounts of progestins (approximately 0.1% of the total maternal doses) were detected in the breast milk of nursing mothers who used Mirena, resulting in exposure of LNG to the breastfed infants. There are no reports of adverse effects in breastfed infants with maternal use of progestin-only contraceptives. Isolated cases of decreased milk production have been reported with Mirena. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Mirena and any potential adverse effects on the breastfed child from Mirena or from the underlying maternal condition.

Safety and efficacy of Mirena have been established in women of reproductive age. Efficacy is expected to be the same for postpubertal females under the age of 18 as for users 18 years and older. Use of this product before menarche is not indicated.

Mirena has not been studied in women over age 65 and is not approved for use in this population.

No studies were conducted to evaluate the effect of hepatic disease on the disposition of LNG released from Mirena [see Contraindications ( 4)].

No studies were conducted to evaluate the effect of renal disease on the disposition of LNG released from Mirena.

Mirena (levonorgestrel-releasing intrauterine system) contains 52 mg of LNG, a progestin, and is intended to provide an initial release rate of approximately 20 mcg/day of LNG.

Levonorgestrel USP, (-)-13-Ethyl-17-hydroxy-18,19-dinor-17α-pregn-4-en-20-yn-3-one, the active ingredient in Mirena, has a molecular weight of 312.4, a molecular formula of CHO, and the following structural formula:

Mirena consists of a T-shaped polyethylene frame (T-body) with a steroid reservoir (hormone elastomer core) around the vertical stem. The reservoir consists of a white or almost white cylinder, made of a mixture of levonorgestrel and silicone (polydimethylsiloxane), containing a total of 52 mg levonorgestrel. The reservoir is covered by a semi-opaque silicone (polydimethylsiloxane) membrane. The T-body is 32 mm in both the horizontal and vertical directions. The polyethylene of the T-body is compounded with barium sulfate, which makes it radiopaque. A monofilament brown polyethylene removal thread is attached to a loop at the end of the vertical stem of the T-body. The polyethylene of the removal thread contains iron oxide as a colorant (see Figure 10).

The components of Mirena, including its packaging, are not manufactured using natural rubber latex.

Mirena is packaged sterile within an inserter. The inserter (Figure 11), which is used for insertion of Mirena into the uterine cavity, consists of a symmetric two-sided body and slider that are integrated with flange, lock, pre-bent insertion tube and plunger. The outer diameter of the insertion tube is 4.4 mm. The vertical stem of Mirena is loaded in the insertion tube at the tip of the inserter. The arms are pre-aligned in the horizontal position. The removal threads are contained within the insertion tube and handle. Once Mirena has been placed, the inserter is discarded.

Figure 11 Diagram of Inserter

The local mechanism by which continuously released LNG enhances contraceptive effectiveness of Mirena has not been conclusively demonstrated. Studies of Mirena and similar LNG IUS prototypes have suggested several mechanisms that prevent pregnancy: thickening of cervical mucus preventing passage of sperm into the uterus, inhibition of sperm capacitation or survival, and alteration of the endometrium.

Mirena has mainly local progestogenic effects in the uterine cavity. The high local levels of LNG lead to morphological changes including stromal pseudodecidualization, glandular atrophy, a leukocytic infiltration and a decrease in glandular and stromal mitoses.

Ovulation is inhibited in some women using Mirena. In a 1-year study, approximately 45% of menstrual cycles were ovulatory, and in another study after 4 years, 75% of cycles were ovulatory.

Low doses of LNG are administered into the uterine cavity with the Mirena intrauterine delivery system. The initial release rate is approximately 20 mcg/day over the first 3 months tested (day 0 to day 90). It is reduced to approximately 18 mcg/day after 1 year and then decreases progressively to approximately 10 mcg/day after 5 years.

A stable serum concentration, without peaks and troughs, of LNG of 150–200 pg/mL occurs after the first few weeks following insertion of Mirena. LNG concentrations after long-term use of 12, 24, and 60 months were 180±66 pg/mL, 192±140 pg/mL, and 159±59 pg/mL, respectively.

The apparent volume of distribution of LNG is reported to be approximately 1.8 L/kg. It is about 97.5 to 99% protein-bound, principally to sex hormone binding globulin (SHBG) and, to a lesser extent, serum albumin.

Following absorption, LNG is conjugated at the 17β-OH position to form sulfate conjugates and, to a lesser extent, glucuronide conjugates in serum. Significant amounts of conjugated and unconjugated 3α, 5β- tetrahydrolevonorgestrel are also present in serum, along with much smaller amounts of 3α, 5α-tetrahydrolevonorgestrel and 16β-hydroxylevonorgestrel. LNG and its phase I metabolites are excreted primarily as glucuronide conjugates. Metabolic clearance rates may differ among individuals by several-fold, and this may account in part for wide individual variations in LNG concentrations seen in individuals using LNG–containing contraceptive products. In vitro studies have demonstrated that oxidative metabolism of LNG is catalyzed by CYP enzymes, especially CYP3A4.

About 45% of LNG and its metabolites are excreted in the urine and about 32% are excreted in feces, mostly as glucuronide conjugates. The elimination half-life of LNG after daily oral doses is approximately 17 hours.

Pediatric: Safety and efficacy of Mirena have been established in women of reproductive age. Use of this product before menarche is not indicated.

Geriatric: Mirena has not been studied in women over age 65 and is not currently approved for use in this population.

Race: No studies have evaluated the effect of race on pharmacokinetics of Mirena.

Hepatic Impairment: No studies were conducted to evaluate the effect of hepatic disease on the disposition of Mirena.

Renal Impairment: No formal studies were conducted to evaluate the effect of renal disease on the disposition of Mirena.

No drug-drug interaction studies were conducted with Mirena [see Drug Interactions ( 7)].

[See Warnings and Precautions (5.9)]

Mirena has been studied for safety and efficacy in two large clinical trials in Finland and Sweden. In study sites having verifiable data and informed consent, 1,169 women 18 to 35 years of age at enrollment used Mirena for up to 5 years, for a total of 45,000 women-months of exposure. Of these, 5.6% (66) were nulliparous women. Subjects had previously been pregnant, had no history of ectopic pregnancy, had no history of pelvic inflammatory disease over the preceding 12 months, were predominantly Caucasian, and over 70% of the participants had previously used IUDs (intrauterine devices). The reported 12-month pregnancy rates were less than or equal to 0.2 per 100 women (0.2%) and the cumulative 5-year pregnancy rate was approximately 0.7 per 100 women (0.7%).

About 80% of women wishing to become pregnant conceived within 12 months after removal of Mirena.

The efficacy of Mirena in the treatment of heavy menstrual bleeding was studied in a randomized, open-label, active-control, parallel-group trial comparing Mirena (n=79) to an approved therapy, medroxyprogesterone acetate (MPA) (n=81), over 6 cycles. The subjects included reproductive-aged women in good health, with no contraindications to the drug products and with confirmed heavy menstrual bleeding (≥ 80 mL menstrual blood loss [MBL]) determined using the alkaline hematin method. Excluded were women with organic or systemic conditions that may cause heavy uterine bleeding (except small fibroids, with total volume not > 5 mL). Treatment with Mirena showed a statistically significantly greater reduction in MBL (see Figure 12) and a statistically significantly greater number of subjects with successful treatment (see Figure 13). Successful treatment was defined as proportion of subjects with (1) end-of-study MBL < 80 mL and (2) a ≥ 50% decrease in MBL from baseline to end-of-study.

Figure 13 Proportion of Subjects with Successful Treatment

Farley T M M, Rosenberg M J, Rowe P J, Chen J, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992; 339:785-788.

Nilsson CG, Haukkamaa M, Vierola H, Luukkainen T. Tissue concentrations of LNG in women using a LNG-releasing IUD. Clinical Endocrinol 1982;17:529-536.

Mirena (levonorgestrel-releasing intrauterine system), containing a total of 52 mg LNG, is available in a carton of one sterile unit NDC# 50419-423-01.

Mirena is supplied sterile. Mirena is sterilized with ethylene oxide. Do not resterilize. For single use only. Do not use if the inner package is damaged or open. Insert before the end of the month shown on the label.

Store at 25°C (77°F); with excursions permitted between 15–30°C (59–86°F) [see USP Controlled Room Temperature].

Advise the patient to read the FDA-approved patient labeling (Patient Information)

Complete the Follow-up Reminder Card and give to the patient.

FDA-Approved Patient Labeling

Patient Information

Mirena (mur-ā-nah)

(levonorgestrel-releasing intrauterine system)

Mirena does not protect against HIV infection (AIDS) and other sexually transmitted infections (STIs).

Read this Patient Information carefully before you decide if Mirena is right for you. This information does not take the place of talking with your gynecologist or other healthcare provider who specializes in women’s health. If you have any questions about Mirena, ask your healthcare provider. You should also learn about other birth control methods to choose the one that is best for you.

What is Mirena?

Mirena is a small flexible plastic T-shaped system that slowly releases a progestin hormone called levonorgestrel that is often used in birth control pills. Because Mirena releases levonorgestrel into your uterus, only small amounts of the hormone enter your blood. Mirena does not contain estrogen.

Two thin threads are attached to the stem of Mirena. The threads are the only part of Mirena you can feel when Mirena is in your uterus; however, unlike a tampon string, the threads do not extend outside your body.

What if I need birth control for more than 5 years?

Mirena must be removed after 5 years. Your healthcare provider can place a new Mirena during the same office visit if you choose to continue using Mirena.

What if I want to stop using Mirena?

Mirena is intended for long-term use but you can stop using Mirena at any time by asking your healthcare provider to remove it. You could become pregnant as soon as Mirena is removed, so you should use another method of birth control if you do not want to become pregnant.

What if I change my mind about birth control and want to become pregnant in less than 5 years?

Your healthcare provider can remove Mirena at any time. You may become pregnant as soon as Mirena is removed. About 8 out of 10 women who want to become pregnant will become pregnant sometime in the first year after Mirena is removed.

How does Mirena work?

Mirena may work in several ways including thickening cervical mucus, inhibiting sperm movement, reducing sperm survival, and thinning the lining of your uterus. It is not known exactly how these actions work together to prevent pregnancy.

Mirena can cause your menstrual bleeding to be less by thinning the lining of the uterus.

How well does Mirena work for contraception?

The following chart shows the chance of getting pregnant for women who use different methods of birth control. Each box on the chart contains a list of birth control methods that are similar in effectiveness. The most effective methods are at the top of the chart. The box on the bottom of the chart shows the chance of getting pregnant for women who do not use birth control and are trying to get pregnant.

Mirena, an intrauterine device (IUD), is in the box at the top of the chart.

How well does Mirena work for heavy menstrual bleeding?

In the clinical trial performed in women with heavy menstrual bleeding and treated with Mirena, almost 9 out of 10 were treated successfully and their blood loss was reduced by more than half.

Who might use Mirena?

You might choose Mirena if you:

Who should not use Mirena?

Do not use Mirena if you:

Before having Mirena placed, tell your healthcare provider if you:

How is Mirena placed?

Mirena is placed by your healthcare provider during an in-office visit.

First, your healthcare provider will examine your pelvis to find the exact position of your uterus. Your healthcare provider will then clean your vagina and cervix with an antiseptic solution, and slide a slim plastic tube containing Mirena into your uterus. Your healthcare provider will then remove the plastic tube, and leave Mirena in your uterus. Your healthcare provider will cut the threads to the right length. Placement takes only a few minutes.

You may experience pain, bleeding or dizziness during and after placement. If your symptoms do not pass within 30 minutes after placement, Mirena may not have been placed correctly. Your healthcare provider will examine you to see if Mirena needs to be removed or replaced.

Should I check that Mirena is in place?

Yes, you should check that Mirena is in proper position by feeling the removal threads. It is a good habit to do this once a month. Your healthcare provider should tell you how to check that Mirena is in place. First, wash your hands with soap and water. You can check by reaching up to the top of your vagina with clean fingers to feel the removal threads. Do not pull on the threads. If you feel more than just the threads or if you cannot feel the threads, Mirena may not be in the right position and may not prevent pregnancy. Use non-hormonal back-up birth control (such as condoms and spermicide) and ask your healthcare provider to check that Mirena is still in the right place.

How soon after placement of Mirena should I return to my healthcare provider?

Call your healthcare provider if you have any questions or concerns (see "When should I call my healthcare provider"). Otherwise, you should return to your healthcare provider for a follow-up visit 4 to 6 weeks after Mirena is placed to make sure that Mirena is in the right position.

Can I use tampons with Mirena?

Tampons may be used with Mirena.

What if I become pregnant while using Mirena?

Call your healthcare provider right away if you think you are pregnant. If you get pregnant while using Mirena, you may have an ectopic pregnancy. This means that the pregnancy is not in the uterus. Unusual vaginal bleeding or abdominal pain may be a sign of ectopic pregnancy.

Ectopic pregnancy is a medical emergency that often requires surgery. Ectopic pregnancy can cause internal bleeding, infertility, and even death.

There are also risks if you get pregnant while using Mirena and the pregnancy is in the uterus. Severe infection, miscarriage, premature delivery, and even death can occur with pregnancies that continue with an intrauterine device (IUD). Because of this, your healthcare provider may try to remove Mirena, even though removing it may cause a miscarriage. If Mirena cannot be removed, talk with your healthcare provider about the benefits and risks of continuing the pregnancy.

If you continue your pregnancy, see your healthcare provider regularly. Call your healthcare provider right away if you get flu-like symptoms, fever, chills, cramping, pain, bleeding, vaginal discharge, or fluid leaking from your vagina. These may be signs of infection.

It is not known if Mirena can cause long-term effects on the fetus if it stays in place during a pregnancy.

How will Mirena change my periods?

For the first 3 to 6 months, your period may become irregular and the number of bleeding days may increase. You may also have frequent spotting or light bleeding. Some women have heavy bleeding during this time. After you have used Mirena for a while, the number of bleeding and spotting days is likely to lessen. There is a small chance that your periods will stop altogether.

In some women with heavy bleeding, the total blood loss per cycle progressively decreases with continued use. The number of spotting and bleeding days may initially increase but then typically decreases in the months that follow.

Is it safe to breastfeed while using Mirena?

You may use Mirena when you are breastfeeding if more than six weeks have passed since you had your baby. If you are breastfeeding, Mirena is not likely to affect the quality or amount of your breast milk or the health of your nursing baby. However, isolated cases of decreased milk production have been reported among women using progestin-only birth control pills. The risk of Mirena becoming attached to (embedded) or going through the wall of the uterus is increased if Mirena is inserted while you are breastfeeding.

Will Mirena interfere with sexual intercourse?

You and your partner should not feel Mirena during intercourse. Mirena is placed in the uterus, not in the vagina. Sometimes your partner feels the threads. If this occurs, talk with your healthcare provider.

What are the possible side effects of using Mirena?

Mirena can cause serious side effects including:

Common side effects of Mirena include:

This is not a complete list of possible side effects with Mirena. For more information, ask your healthcare provider.

Call your doctor for medical advice about side effects. You may report side effects to the manufacturer at 1-888-842-2937, or FDA at 1-800-FDA-1088 or

After Mirena has been placed, when should I call my healthcare provider?

Call your healthcare provider if you have any concerns about Mirena. Be sure to call if you:

General advice about prescription medicines

Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. This leaflet summarizes the most important information about Mirena. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider for information about Mirena that is written for health providers.

For more information, go to or call 1-888-842-2937

This Patient Information has been approved by the U.S. Food and Drug Administration.

This patient information booklet was updated June 2017.

Manufactured for:

Bayer HealthCare Pharmaceuticals Inc.Whippany, NJ 07981

Manufactured in Finland

© 2000, Bayer HealthCare Pharmaceuticals Inc.All rights reserved.

Mirena is small and flexible

Mirena (levonorgestrel-releasing intrauterine system) Carton

NDC 50419-423-01

1 Sterile Unit

NEW contains updated single-handed inserter with no removable threads

IMPORTANT: To be inserted in the uterus by a trained healthcare provider. Mirena cannot be reloaded.. See physician insert for detailed instructions for use.


(levonorgestrel-releasing intrauterine system)

Rx only

— 52 mg levonorgestrel

— 1 sterile unit

— intrauterine use


Bayer HealthCare Pharmaceuticals Inc.

Active Ingredients


Drugs and Medications [0 Results]


Clinical Trials [29 Associated Clinical Trials listed on BioPortfolio]

Pretreatment With Mifepristone Prior to Mirena Insertion

Hypothesis: Pretreatment with mifeprsitone prior to Mirena placement will induce amenorrhea and reduce bleeding irrregularities during the initial months of Mirena use.

Mirena Observational Program

Mirena is used for long-term in Kazakhstan, and in our observational program we would like to study patients distribution per indications of Mirena, and also patient compliance within a ye...

Mirena Extension Trial

The study is performed to assess if Mirena is effective and safe as a birth control method beyond 5 years of use. Further the menstrual blood loss (in women that had Mirena inserted for th...

Mirena Efficiency and Tolerability During the First Year of Use

In this trial the efficacy and safety of Mirena was investigated during the first year of use

Survey on Patient Satisfaction Rate for Mirena Use in Heavy Menstrual Bleeding

The purposes of this study are: - To evaluate patient satisfaction for efficacy and tolerability of heavy menstrual bleeding treatment by Mirena. - To collect italian da...

PubMed Articles [1 Associated PubMed Articles listed on BioPortfolio]

Drug release testing of long-acting intrauterine systems.

Performance evaluation of polydimethylsiloxane (PDMS) based long-acting (e.g. 3-5 years) levonorgestrel (LNG) intrauterine systems (IUSs), such as Mirena®, is challenging due to their complex formu...

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