Placement of Mirena
When a patient consults a healthcare professional at a pre-placement visit about whether or not she is a suitable candidate for Mirena, it is important initially to ensure that she does not fall into one of the categories of women for whom Mirena is contraindicated (see section on contraindications) . Once these have been excluded, the woman should be counselled on the efficacy, risks and side effects associated with using Mirena. She should also have a pelvic and breast examination, as well as a cervical smear. Pregnancy and sexually transmitted diseases should be excluded, and genital infections must be successfully treated1.
In women of fertile age, Mirena is to be placed into the uterine cavity within seven days of the onset of menstruation. Mirena can be replaced by a new system at any time in the cycle. The system can also be placed immediately after first trimester abortion1.
Postpartum placements should be postponed until the uterus is fully involuted, however not earlier than six weeks after delivery. If involution is substantially delayed, consider waiting until 12 weeks postpartum. In case of a difficult placement and/or exceptional pain or bleeding during or after placement, physical examination and ultrasound should be performed immediately to exclude perforation1.
It is recommended that Mirena should only be placed by healthcare professionals who are experienced in Mirena placements and/or have undergone sufficient training for Mirena placement1.
The placement procedure may be associated with some pain and bleeding and it may, in rare cases, also precipitate fainting as a vasovagal reaction, or a seizure in an epileptic patient.
Figure 14: How to insert Mirena2
Preparation for Placement
The following preparatory steps should be performed prior to placement2:
- examine the woman to establish the size and position of the uterus to detect acute cervicitis or other genital contraindications and to exclude pregnancy
- visualize the cervix by means of a speculum and thoroughly cleanse the cervix and vagina with a suitable antiseptic solution
- use an assistant as necessary
- grasp the upper lip of the cervix with a holding forceps. Gentle traction on the holding forceps has been shown to straighten the cervical canal. The forceps should remain in position throughout the placement procedure to maintain gentle traction on the cervix against the pushing force of the placement
- gently move a uterine sound across the uterine cavity to the fundus to determine the direction of the cervical canal and the depth of the uterine cavity (sound measure) and to exclude a uterine septum, synechiae and submucous fibroids. Should the cervical canal be too narrow, dilatation of the canal is recommended and consider the use of analgesics/paracervical block