
Overview
This module describes how to insert a Mirena, a hormonal intrauterine contraceptive device.
Indications
Contraception for up to 7 years
Treatment of heavy menstrual bleeding for up to 5 years
Contraindications
- Current pregnancyCurrent pregnancy
Mirena can not be used as emergency contraception.
Any anomaly causing distortion of the uterine cavity
Current pelvic inflammatory disease, prior pelvic inflammatory disease without subsequent intrauterine pregnancy, or increased susceptibility to pelvic infections
Postpartum endometritis or infected abortion in the past 3 months
Known or suspected malignancies of the uterus, cervix, breast, or other progestin-sensitive cancer
Undiagnosed abnormal uterine bleeding
Untreated lower genital tract infections
- Hepatic conditionsHepatic conditions
Acute liver disease or liver masses
A previously inserted unremoved intrauterine device
Hypersensitivity to any component of the product
Patient information and consent
Patients should be fully counselled about their contraceptive options. Always verify your patient’s identity and obtain informed consent before proceeding.
How do I explain this procedure?
“You have chosen the Mirena intrauterine device for family planning. The Mirena is a very small device which is stored in a thin tube. I will place the tube through your cervix into your womb, where the wings will pop out to keep it in place, and I will remove the tube.”
What can my patient expect?
“Some patients do not find this painful, but other patients get moderate to severe pain during insertion. Afterwards, you can get cramping and minor spotting for a few days, but bleeding should be minimal. You or your sexual partner will not feel the Mirena in your womb.”
What is my patient’s role?
“Tell me if you have any illnesses, symptoms of
sexually transmitted infections
Symptoms include abnormal vaginal discharge, pelvic pain, and abnormal vaginal bleeding.
or allergies. Tell me if the pain becomes too much, or you need a break before we go ahead. If at any point you feel you do not want to continue with the procedure, tell me and I’ll stop immediately. Let me know if you feel faint. Afterwards, you will need to return one month from now, and thereafter yearly, for an examination to check that the Mirena is still in place.”
Preparation
Prepare a trolley with equipment. A female chaperone should be present.

Documentation
Patient notes
Equipment
Non-sterile and sterile gloves
Alcohol-based hand rub
- Skin disinfectantSkin disinfectant
Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another.
Swabs/cotton balls
Sterile pack
Sterile tenaculum
Sterile
uterine sounduterine soundto determine uterine depth
Sterile speculum & lubricant
Sterile curved scissors
Ring forceps
- Mirena in sterile packageMirena in sterile package
Site & Positioning
The patient should be positioned in
dorsal lithotomy

. A bimanual examination using non-sterile gloves should be performed to determine uterine position and size.
Procedure
Follow medical asepsis with sterile gloves.
Perform hand hygiene.
Open a sterile pack and create a sterile field. Open sterile equipment onto the field, leaving the Mirena, open, in its packaging beside the field. Fill the well with cleaning solution and open gauze/cotton wool into the well. Squeeze lubricant onto the blades of the speculum.
Perform hand hygiene and don sterile gloves.
Insert the lubricated speculum into the vagina.
Clean the cervix using soaked cotton balls and the ring forceps.
Apply the tenaculum to the
anterior cervixanterior cervixApply to the posterior cervix if retroverted uterus is present.
(12 o’clock position) and apply gentle traction to straighten the uterus.
Insert the uterine sound carefully, avoiding perforation, and note the
depthdepthDepth of 6-10 cm is required.
of the uterus. Remove the sound.
Slide the thumb slider of the insertion device all the way forward and hold it there.
Set the flange so the front edge is at the marking corresponding to the depth of the uterus.
- Insert the deviceInsert the device
through the cervix up to 1.5-2 cm from the flange.
Slide the thumb slider
back to the markback to the markindicating the depth of the uterus. Wait 10 seconds for the arms to open.
- Advance the deviceAdvance the device
until the flange touches the cervix and you feel resistance; this seats the Mirena in the fundus.
Slide the thumb slider all the way back and hold it there while you
withdrawwithdrawthe insertion device fully.
Release the tenaculum.
Cut the threads perpendicularly 3 cm from the cervical os
without applying tensionwithout applying tensionApplying tension risks moving the Mirena out of position.
.
Withdraw the speculum.
Dispose of medical waste safely.
Document the procedure, including the IUD serial number.
Troubleshooting
The cervical os is too tightly closed to pass the Mirena.
You may need a set of graduated cervical dilators to dilate the cervix before insertion.
I want to manage IUD insertion and post-insertion pain.
There is no evidence that using a cervical block, misoprostol, or NSAIDs reduces insertion pain, but a cervical block may reduce tenaculum application pain, and NSAIDs may reduce cramping post-insertion. Procedural sedation may be necessary in patients experiencing severe insertion pain.
Risks
Vasovagal response
Tenaculum site & cervical bleeding
Pelvic inflammatory disease
Group A streptococcal infection
Uterine perforation
Complications of Mirena use
References
Mirena Prescribing Information. Whippany, NJ: Bayer HealthCare Pharmaceuticals. Aug 2021.
American College of Obstetricians and Gynecologists. LARC Video Series.