Dr Diana Mansour transcripts

Transcripts for all Dr Diana Mansour videos

For how long does Mirena provide effective contraception?

Mirena is a very effective method of contraception. It’s licensed to provide its action for five years and the good thing about it is that it’s as effective in the fifth year as it is in the first.

Does Mirena provide health benefits in addition to contraceptive protection?

Mirena provides health benefits, not just contraceptive protection, and the health benefits include a reduction in menstrual loss, so reducing menstrual bleeding and often shortening menstrual bleeding. It also provides endometrial protection. This may be very important if you are using it in the form of hormone replacement therapy with the addition of estrogen.

Is Mirena well tolerated?

Mirena is a well tolerated method of contraception. In fact in one recent study it showed that 90% or more women were still using that method at one year and 65% were using it at five years.
It is important, however, to counsel properly you need to get across that there may be some irregular bleeding, particularly within the first few months. And some women may complain of some hormone side effects such as breast tenderness or bloating within the first few months but this does tend to settle.

Is Mirena a good alternative to sterilization?

Mirena is a good alternative to sterilization, not only is it as effective as female sterilization but of course you’ve got the advantage of being able to change your mind.
In the 21st century we have women who may be separating from their partners who perhaps suddenly in their late 30’s want another child, and if you’ve been sterilized that opportunity may just not be there for you.
Therefore, with Mirena you’ve got the additional health benefits but also you’ve got the reversibility of a highly effective method of contraception.
When women have been sterilized they stop using their hormonal method of contraception, and of course this means that their periods can become heavier and certainly they can become more painful, and they often then come back to a gynecologist requesting help which may mean a hysterectomy or an endometrial ablation. Of course, it would be very much better that they continued using their hormonal method, such as Mirena, which actually makes periods lighter and less painful.

How does Mirena exert its effect on menstruation?

Mirena exerts its effects on menstruation through its local effect within the uterine cavity. Not only does it cause endometrial atrophy but also suppresses endometrial growth.

Why is Mirena suitable for perimenopausal and menopausal women?

Mirena is a very suitable option for perimenopausal and menopausal women - women in this age group still get pregnant. But it also has its local effects for suppressing the endometrium and this may be protective.
For women in this age group they may also get flushes and sweats so with the addition of estrogen you have a method that will actually not only give you contraception but endometrial protection in the form of hormone replacement therapy. And this combination means that you’ve got a bleed free option rather than having to put up with withdrawal bleeds with some of the other HRT options.

Is Mirena a good choice of treatment for women with heavy menstrual bleeding (HMB)?

Mirena is a very good choice of treatment for women with heavy menstrual bleeding. Studies have suggested that you can reduce menstrual blood loss between 79 and 98%.
NICE in the United Kingdom, the National Institute for Health and Clinical Excellence have said it should be considered a first line treatment for women with heavy menstrual bleeding.
It provides a reversible option unlike surgical treatments. And we know that with endometrial ablation around about one in five women may return with a recurrence of their problem and you do not see that with Mirena.

Are there other drugs that can be used for heavy menstrual bleeding (HMB) and how effective are they compared to Mirena?

There are other drugs that can be used for heavy menstrual bleeding and these include non-steroidal anti-inflammatories, oral contraceptives, tranexamic acid and oral progestogens.
For example there has been a study looking at Mirena in women with heavy menstrual bleeding versus those who have been taking mefenamic acid and in those using the Mirena IUS the reduction in blood loss was around about 95% but just 23% for mefenamic acid.
Another study looked at Mirena versus an oral progestogen, medroxyprogesterone acetate, the reduction of blood loss was 85% in the Mirena group but just 22% in the oral progestin group.
Overall Mirena is more effective at treating heavy menstrual bleeding when compared with standard oral contraceptives or tranexamic acid.

Why should women be encouraged to consider LARCs as a form of contraception?

Women should actually look at long acting methods of contraception with new eyes, so often they’re not aware of all the methods that are available and they often feel that it’s not suitable for them.
For example women don’t think they can use intrauterine contraceptives because they’ve not had children and this is just not so. They can use them and they’re very effective, very safe and very acceptable in this group of women.
They may not be aware of the non-contraceptive benefits such as a reduction in menstrual blood loss or reduction in period pain.
Another reason for considering these methods is that you don’t have to remember to take a daily pill or to use a condom or to put a diaphragm in prior to sex.
So it’s a highly effective method of contraception, whereas these things that you have to do on a regular basis you may forget to do and therefore get pregnant.

If women received better counselling/information on LARCs, do you think they would be more likely to choose them in preference to other contraceptive methods?

I think good counselling is really important for women who are choosing a method of contraception, particularly when we’re talking about long acting methods of contraception. They’re often not aware that there are suitable options for them even if they haven’t had children.
For example many women feel that you can’t use an intrauterine contraceptive if you’ve not had a child and this is just not true. They’re also not aware of some of the health benefits not just contraceptive benefits of using these methods.
About 40% of women have period pain and the IUS is a very suitable option for helping women who’ve got period pain.

For whom are LARCs suitable?

Long acting methods of contraception are suitable for almost all women in their reproductive years. There are some contra indications to their use particularly if women have had a hormone dependent cancer of some sort, have high risk of cardiovascular disease or perhaps even had a myocardial infarction or stroke and if they’ve had a venous thrombosis.

How effective are LARCs in comparison to other contraceptive methods (e.g. pill, condom, sterilization) in preventing pregnancy?

Long acting reversible contraceptives are very effective methods, if you actually think of a hierarchy of what is the most effective method of contraception compared to the least effective methods. You would certainly see sterilization at the top of the list along side implants and the levonorgestrel intrauterine system. This is very closely followed by copper IUD’s that have more than 300mm squared of copper, then the IUD that has less than 300mm squared of copper and underneath that would be coming the injectable and then oral contraceptives and finally barrier methods.

Are LARCs a valuable alternative option to sterilization?

Long acting reversible methods of contraception are a very useful alternative to female sterilization. So often women are not aware that the long acting reversible methods are just as effective. They often choose female sterilization when they’ve completed their families thinking this is the most effective option and they have other options to actually choose from.
They don’t realise that they may change their minds and there is a regret factor; around about 1 in 10 women may regret their decision particularly if they’re under the age of 30 when they’re sterilized.
Many of them don’t realise that when they give up their hormonal method of contraception that their normal periods will return and these may be heavier and more painful.
Wouldn’t it have been better that they’d continued with that method particularly if it was a long acting reversible method like Mirena?

How valuable are LARCs as a treatment for idiopathic menorrhagia?

Long acting methods of contraception are very valuable in the treatment of idiopathic menorrhagia. For example with Mirena, the intrauterine system, it actually reduces blood loss by up to 97%. If you actually look at how many women get no periods in the labelling it talks about 20%, different studies would show however that between one in five and one in two women may not get a period.
For progestogen-only injectables you do get a reduction in blood loss but they do have to keep coming back for their injection every 11 to 12 weeks. For the contraceptive implant there may be a small reduction in blood loss but the bleeding can be quite unpredictable over that three year period. And for the copper IUD the bleeding actually increases.
Mirena is the only long acting reversible method of contraception with an indication for the treatment of idiopathic menorrhagia.

Which LARC can be used during estrogen treatment for contraception and prevention of endometrial hyperplasia?

There is only one long acting reversible method of contraception that can be used as a contraceptive and as the progestogen component of hormone replacement therapy when you add in with estrogen to help menopausal symptoms and that particular method is Mirena.
At that time in your life you could think a combined or contraceptive pill as an alternative but of course with advancing age and other cardiovascular risk factors it may not always be a suitable option.

How can counselling help allay fears about side effects?

Counselling can really alleviate fears about long acting contraceptives, I think if women know what to expect they’re quite happy to actually put up with a few months of irregular bleeding or hormonal side effects knowing that these will improve.
They’re also prepared to put up with side effects if they know there are treatment options that may help. And for some women if this really is a problem knowing the doctor or nurse will remove that implant or the intrauterine system or device if that woman so wishes is really important.

What type of questions the healthcare professional might ask?

A healthcare professional may ask if a woman has decided about a particular method of contraception or whether they need to discuss various options. They’ll also want to know whether a woman wants to have future children and how soon she might want to have that child. They’ll need to know a little bit more about her medical history and if she’s had pregnancies in the past - whether she’s used medication that may interfere with that method of contraception, and also when her last cervical smear has taken place. They’ll need to know a little bit more about her relationships and whether she may be at risk of a sexually transmitted infection.
And lastly, they’ll want to know about her family history and whether this may have an effect on her choice for a long-acting contraceptive.

How soon can a woman become pregnant after Mirena is removed?

A woman can become pregnant almost immediately after the intrauterine system is actually removed. There’s data suggesting that up to 96% of women can become pregnant after it’s removed in the first year. It’s certainly comparable to discontinuing other methods of contraception such as an IUD or oral contraceptives.

Are women adequately aware of the different types of LARCs?

Women are not aware of all their contraceptive options particularly when we’re talking about long acting contraceptives. Surveys from Europe and around the world have clearly shown that women are aware of oral contraceptives and condoms and even sterilization, but many of them are not aware of the intrauterine system. In fact, in one recent study, only 45 per cent of women were actually aware of the intrauterine system as a method of contraception.

How could the growth in use of LARCS be further strengthened?

We are fortunate to see that more women are choosing long acting contraceptives. We do need to have healthcare professionals up to date with the information provided to women particularly around non-contraceptive benefits. This would certainly encourage more women to use these methods.
Better publicity and coverage by the media would also be a real advantage to increasing women’s knowledge of these methods.
And finally I think for women they need to have good materials to use, websites to access so they can get a realistic picture of these methods. And perhaps also to be discussed between themselves in chat rooms.

Why is the mode of action if Mirena important?

The mode of action of Mirena is important both for the clinician as well as for the patient. I think for many women they want to know that is little hormone actually getting in to their systemic circulation. And over time this has been shown - when Mirena is first inserted about 20 micrograms of levonorgestrel is released each day and this falls to around about 11micrograms at 5 years.
But there is also a high concentration of levonorgestrel within the uterine cavity and this decreases quite rapidly when you look at tissues the myometrium and then the local blood levels of levonegestrel. So the local high concentration of levonorgestrel will cause endometrial atrophy and actually prevent endometrial proliferation.