Clinical skills masterclass
MIRENA COILINSERTION A Practical, Evidence-Based Masterclass
From patient selection to safe insertion and follow-up
Irish Mirena SmPC FSRH / CoSRH UKMEC 2025 CDC 2024 NICE NG88
Presented by Dr Ashraf Atia Dwidar
Mirena · LNG-IUS 52 mgT-body 32 × 32 mm · 3D teaching schematic
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⏱ Before the clock starts · KEY: set the scene.
Good morning. I am Dr Ashraf Atia Dwidar. In the next ten to eleven minutes we will walk through Mirena coil insertion from patient selection to follow-up, using the Irish SmPC, the FSRH (now CoSRH) intrauterine contraception guideline, UKMEC 2025 and the CDC 2024 recommendations.
This is Mirena: a 52 mg levonorgestrel system on a 32 by 32 millimetre T-body, with brown removal threads. Note — unlike Kyleena and Jaydess, Mirena has no silver ring.
→ Transition: let's start with the five principles.
Mirena: safe and effective insertion
Five essential principles
1 Correct indication2 Appropriate patient selection3 Preparation and analgesia4 Safe insertion technique5 Complications and follow-up
Fundus
Arms at fundus
LNG reservoir
Cervix
Threads
Schematic coronal view · correct fundal position · not to scale
Evidence 1 Irish Mirena SmPC 2 FSRH/CoSRH IUC 2023 (amended 2025)
⏱ 0:00–0:30 (30 s) · KEY: insertion is a process, not a manoeuvre.
Mirena is a highly effective long-acting reversible contraceptive with important therapeutic uses in gynaecology. Safe insertion is not just passing a device through the cervix: it rests on five principles — the right indication, the right patient, good preparation and analgesia, a gentle and correct technique, and recognising complications with clear follow-up.
The goal is the device sitting at the fundus, as shown here.
→ Transition: first principle — when should we offer it?
When should we offer Mirena?
Contraception
0years
LICENSED remove or replace by 8 years
Idiopathic heavy menstrual bleeding
0years initially
LICENSED if controlled, may continue — replace by 8 years
Endometrial protection with oestrogen HRT
0years
LICENSED replace after 5 years — at any age
GUIDELINE-SUPPORTED not extended HRT protection
MAY BE OFF-LABEL
Evidence 1 Irish SmPC §4.1–4.2 2 FSRH IUC 6 NICE NG88
⏱ 0:30–1:20 (50 s) · KEY: separate licensed use from guideline-supported use.
Mirena contains 52 milligrams of levonorgestrel and has three licensed indications in Ireland.
Contraception: up to eight years.
Idiopathic heavy menstrual bleeding: established effectiveness for five years; if bleeding remains controlled, continued use may be considered, but remove or replace by eight years.
Endometrial protection during systemic oestrogen therapy: replace after five years — and this five-year limit applies at any age.
Beyond the licence, FSRH supports contraceptive use until age 55 when the device was inserted at 45 or older — this does not extend endometrial protection for HRT.
NICE NG88 recommends an LNG-IUS as first-line treatment for heavy menstrual bleeding, including suspected adenomyosis and fibroids under three centimetres that do not distort the cavity; endometriosis-related uses may be off-label.
→ Transition: who should not have it inserted today?
Evidence note: UK SmPC limits HRT protection to 4 years; the Irish SmPC states 5 years — follow the Irish product information.
Medical eligibility: stop, defer or proceed?
Assess eligibility
Work left to right: exclude → defer → investigate → proceedIrish SmPC for product contraindications · UKMEC 2025 for risk categories
1 · DO NOT INSERTSmPC contraindication
Known pregnancy
Current or suspected hormone-sensitive cancer, incl. breast
Cavity distorted by anomaly or fibroids
Acute or severe liver disease, liver tumour
Postpartum / post-abortion sepsis (3 months)
2 · DEFER & TREAToffer bridging contraception
Pregnancy not reasonably excluded
Current PIDUKMEC 4
Symptomatic chlamydia, gonorrhoea or M. genitalium; purulent cervicitisUKMEC 4
Known asymptomatic chlamydia / gonorrhoeaUKMEC 3 · TREAT FIRST
48 h – 4 weeks postpartumUKMEC 3
3 · INVESTIGATE FIRSTbefore insertion
Unexplained bleeding suspicious of serious pathologyUKMEC 4 UNTIL EVALUATED
Suspected cavity distortionASSESS UTERINE ANATOMY
Past breast cancerUKMEC 3 · SPECIALIST ADVICE
Pregnancy reasonably excluded
STI screen if at risk — taken on the dayDO NOT DELAY
Vaginitis incl. BVUKMEC 2
Fibroids without cavity distortionUKMEC 1
Evidence 1 Irish SmPC §4.3 3 UKMEC 2025 2 FSRH IUC 4 CDC SPR 2024
⏱ 1:20–2:10 (50 s) · KEY: four outcomes, not a simple yes/no.
Work through eligibility in a safety-first order — four steps, left to right.
One — exclude the Irish SmPC contraindications: known pregnancy, hormone-sensitive cancer including breast, a cavity distorted by anomaly or fibroids, acute or severe liver disease or liver tumour, and recent postpartum or post-abortion sepsis. Do not insert.
Two — defer and treat when pregnancy cannot be reasonably excluded, with current PID, symptomatic chlamydia, gonorrhoea or Mycoplasma genitalium, or purulent cervicitis — UKMEC 4 — with known asymptomatic infection, UKMEC 3, and between 48 hours and 4 weeks postpartum. Offer bridging contraception.
Three — investigate first: unexplained bleeding suspicious of serious pathology, suspected cavity distortion, or past breast cancer needing specialist advice.
Four — proceed when the method is UKMEC 1 or 2 and pregnancy is reasonably excluded. If the patient is at STI risk, take the screen on the day — do not delay insertion. Vaginitis, including BV, is UKMEC 2 — not every vaginal infection is a contraindication.
Evidence note: UKMEC 2025 grades a distorted cavity as UKMEC 3 and severe liver disease as UKMEC 3, but the Irish SmPC lists them as contraindications for Mirena — the product information governs. Past breast cancer is UKMEC 3: seek specialist advice.
→ Transition: once eligible, run the safety check.
Before insertion: the safety check
HISTORY & CONSENT
Indication confirmed, informed consent
Pregnancy reasonably excludeda negative test may miss a very early pregnancy
STI risk assessed — screen on the day if needed
ELIGIBILITY & EXAMINATION
Medical eligibility: Irish SmPC + UKMEC
Bimanual and speculum examinationno routine ultrasound or cytology needed
READINESS
Trained assistant, resuscitation equipment, device & expiry checked
Postpartum timing
Breastfeeding raises perforation risk
0–48 h
Specialist immediate postpartum insertionUKMEC 1
≥ 4 wk
Interval insertionUKMEC 1
Irish SmPC
Not before 6 weeks; uterus fully involuted
Evidence 2 FSRH IUC 3 UKMEC 2025 1 Irish SmPC §4.2
⏱ 2:10–3:10 (60 s) · KEY: history, examination, readiness.
History and consent: confirm the indication and obtain informed consent. Ask about the last menstrual period, recent unprotected intercourse and current contraception — a negative urine pregnancy test may not exclude a very early pregnancy. Assess STI risk; if screening is needed it can be taken on the day without delaying insertion.
Examination: confirm medical eligibility, then perform a bimanual and speculum examination. Routine ultrasound and routine cytology are not prerequisites; investigate only when findings suggest it.
Readiness: agree a pain plan, and make sure a trained assistant, resuscitation equipment and the correct, in-date device are ready. FSRH expects insertion by a clinician with the Letter of Competence or equivalent.
Postpartum timing: immediate postpartum insertion within 48 hours is a specialist technique; avoid 48 hours to 4 weeks — UKMEC 3 — because of perforation risk, especially with breastfeeding. The Irish SmPC advises waiting at least six weeks, until the uterus is fully involuted.
→ Transition: now, pain.
Make insertion comfortable and safe
OFFER EVERY PATIENT
Explain the procedure; agree a pain plan
Oral analgesia beforehand, for crampingnot reliable for insertion pain itself
Local anaesthetic optionsparacervical or intracervical block · 10% lidocaine spray · lidocaine–prilocaine cream
Gentle, unhurried instrumentation
NOT ROUTINE
Misoprostolconsider only after a failed attempt
The patient can pause or stop at any time
Evidence 2 FSRH IUC (local anaesthetic, Grade C) 4 CDC SPR 2024
⏱ 3:10–4:00 (50 s) · KEY: offer analgesia to everyone; nothing routine that lacks evidence.
Pain varies widely and clinicians tend to underestimate it. FSRH says analgesia options should be discussed and offered to everyone.
Local anaesthetic has the best support: paracervical or intracervical block, 10% lidocaine spray, or lidocaine–prilocaine cream — FSRH grade C; CDC says lidocaine might be useful. Oral analgesia may help cramping afterwards but should not be presented as reliably preventing insertion pain.
Two things are not routine: misoprostol, which CDC reserves for selected cases such as a previous failed placement, and prophylactic antibiotics, which CDC does not recommend for IUD placement.
Above all, the patient can pause or stop at any point.
→ Transition: preparing the cervix and uterus.
Uterine assessment and sounding
1 Bimanual examination
2 Speculum examination
3 Aseptic preparation
4 Tenaculum: stabilise and straighten
5 Gentle uterine sounding
6 Record depth and direction
Typical sounded uterine depth US PRESCRIBING INFORMATION
6–10 cm
Unexpected depth or direction → stop and reassess
Never force through resistance
Evidence 2 FSRH IUC 9 Mirena US PI (6–10 cm) 1 Irish SmPC
⏱ 4:00–4:50 (50 s) · KEY: know the direction and depth before you insert.
Perform a bimanual examination for size, mobility and orientation, then visualise the cervix and prepare it aseptically.
Apply the tenaculum to stabilise the cervix and straighten the canal — FSRH notes this reduces perforation risk and helps fundal placement. In a retroverted uterus, posterior traction may be more appropriate.
Sound gently to establish direction and depth. The US prescribing information expects a sounded depth of six to ten centimetres; the Irish SmPC simply asks you to determine the position and size of the cavity.
If the depth is unexpectedly short, long or inconsistent with your examination — stop and reassess. Never use force.
→ Transition: now the insertion itself.
Insertion 1–4: load and advance
Evidence 1 Irish SmPC §4.2 8 Bayer insertion instructions · images adapted
⏱ 4:50–6:00 (70 s) · KEY: load fully, set the flange, stop 1.5–2 cm short.
Stage 1 — open the sterile package completely, immediately before insertion, using aseptic technique.
Stage 2 — push the slider fully forward to load Mirena into the insertion tube; you can see the arm tips just inside the tube. Keep the slider fully forward — if it slips back, the device can be released early and it cannot be reloaded.
Stage 3 — holding the slider forward, set the upper edge of the flange to the sounded depth.
Stage 4 — introduce the inserter gently through the cervix and stop when the flange is about one and a half to two centimetres from the cervix. Pause there: this space lets the arms open in the cavity. Never advance against resistance.
→ Transition: deploying the arms.
Presenter tip: press D for an automatic demonstration, Z to magnify the highlighted component.
Insertion 5–7: deploy, position, release
Evidence 1 Irish SmPC §4.2 8 Bayer insertion instructions · images adapted
⏱ 6:00–7:10 (70 s) · KEY: wait 5–10 seconds, then fundus, then release.
Stage 5 — holding the inserter steady, pull the slider back to the mark. This opens the horizontal arms. Wait five to ten seconds for them to open fully.
Stage 6 — advance gently towards the fundus until the flange touches the cervix. Mirena should now sit at the fundus. Do not continue if you meet unexpected resistance.
Stage 7 — hold the inserter firmly, pull the slider all the way down to release Mirena, and withdraw the inserter with the slider held down. Cut the threads to leave about two to three centimetres visible.
Fundal placement reduces expulsion. If you are uncertain about position, assess clinically and consider ultrasound. A removed system must never be reinserted.
→ Transition: how do we think during the procedure?
During insertion: green, amber or red?
GREEN Proceed — keep checking
YOU SEE
Expected discomfort only; still consenting Smooth passage Depth and direction fit your examination YOU DO
Continue gently; re-check at every stage
AMBER Pause — fix the cause
YOU SEE
Pain worse than expected, or asks to pause Mild resistance at the cervix Depth or direction that doesn't fit Early vasovagal signs YOU DO
Stop instrumenting; reassure; more local anaesthetic Re-check position; adjust traction; dilate gently — never force
YOU SEE
Any stop trigger — next slide YOU DO
Stop the procedure; assess and escalate
Amber resolves → back to green · does not resolve → red
Evidence Teaching framework · 1 Irish SmPC §4.2 (do not force; dilate if necessary) 2 FSRH IUC
⏱ 7:10–8:00 (50 s) · KEY: amber is where good practice happens.
A simple way to think during the procedure is a traffic light. This is a teaching framework rather than a guideline algorithm, but every action on it comes from the SmPC and FSRH.
Green: everything behaves as expected — the patient has only the discomfort you prepared her for and still consents, instruments pass smoothly with no more than the usual slight resistance at the internal os, and the depth and direction match your bimanual. Continue gently, and re-check at every stage — green can change at any moment.
Amber: warning signs that are not yet stop criteria — pain clearly worse than expected or a request to pause, mild resistance at the cervix or internal os, a depth or direction that doesn't fit your examination, or early vasovagal signs such as pallor, yawning, sweating or nausea. Stop instrumenting and fix the cause: talk to the patient, give more local anaesthetic, re-check the uterine position and adjust tenaculum traction to straighten the canal, dilate gently if needed — the SmPC says never force, dilate if necessary — and let a vasovagal episode settle.
If amber resolves, you are back to green. If it doesn't, or gets worse, it becomes red.
Most complications come from pushing through amber.
→ Transition: so what exactly counts as red?
Red: stop the procedure
Stop the procedure if:
Severe or unexpected pain
Significant vasovagal reaction
RED Any one trigger = stop, then assess and escalate
Vasovagal: stop, check airway, breathing, circulation; monitor; follow local emergency protocol
1–2 / 1,000
perforation · higher 48 h–4 wk postpartum and with breastfeeding
Evidence 2 FSRH IUC 1 Irish SmPC §4.4 (1.4 per 1,000 for Mirena)
⏱ 8:00–8:40 (40 s) · KEY: completing the procedure is never the goal at all costs.
These are the red triggers — any one of them means stop. Stop immediately if the patient asks you to. Severe unexpected pain, marked resistance or excessive bleeding should make you think of a false passage or perforation — do not make repeated forceful attempts.
A vasovagal episode can occur with cervical manipulation: stop, assess airway, breathing and circulation, monitor, and follow local emergency protocols.
The overall perforation risk is about one to two per thousand — the SmPC cohort found 1.4 per thousand for Mirena — and it is higher when inserting between 48 hours and four weeks postpartum, particularly when breastfeeding.
→ Transition: so what do we do if perforation is suspected?
Suspected perforation: a safety pathway
1–2 / 1,000
Most occur at insertion,
1 RECOGNISE
At insertion
Difficult insertion Exceptional pain or bleeding Later
Pelvic pain, threads not visible, change in bleeding
2 STOP & ASSESS
Stop — no further attempts
Check pulse, BP and pain; monitor until stable
Remove the system as soon as possible — never by force
Examine; arrange ultrasound
3 INVESTIGATE · LOCATE
Ultrasound ± abdominal and pelvic X-ray, as soon as possible
Missing threads: exclude pregnancy, consider EC, provide contraception
Device in cavity → reassure, leave in situ
4 ESCALATE
Instability or suspected bowel / vessel injury → emergency
Extrauterine device → gynaecology; laparoscopic removal
Embedded or difficult removal → specialist, not force
Next IUC ≥ 6 weeks, with ultrasound available
Evidence 1 Irish SmPC §4.4 2 FSRH IUC (perforation; non-visible threads)
⏱ 8:40–9:20 (40 s) · KEY: recognise, stop and assess, locate, escalate.
Recognise: at insertion — a difficult insertion, or exceptional pain or bleeding; later — pelvic pain, threads that are no longer visible, or a change in bleeding.
Stop and assess: no further attempts. Check pulse, blood pressure and pain, and monitor until stable. The SmPC says a suspected perforated system should be removed as soon as possible — but never by force; surgery may be required. Then examine and arrange ultrasound.
Investigate and locate: ultrasound, with or without an abdominal and pelvic X-ray, as soon as possible. With missing threads: exclude pregnancy, consider emergency contraception and provide contraception. If the device is correctly sited in the cavity, reassure and leave it.
Escalate: haemodynamic instability or suspected bowel or vessel injury is an emergency. An extrauterine device needs gynaecology referral for laparoscopic removal — usually planned. FSRH suggests waiting at least six weeks before another IUC, ideally where ultrasound is available. Document and report to the HPRA.
→ Transition: aftercare.
After insertion: what the patient needs to know
Thread self-checkwithin 4–6 weeks, then regularly
Threads missing or changeduse condoms until reviewed
≤ 7 days from start of period → immediate protection; otherwise 7 days extra precautions
Review Irish SmPC: 4–12 weeks · FSRH & CDC: no routine visit needed
≈ 1 in 20 expel, mostly in the first year — especially the first 3 months
Evidence 1 Irish SmPC §4.2, §4.4 2 FSRH IUC 4 CDC SPR 2024
⏱ 9:20–10:05 (45 s) · KEY: what is normal, what is not, and who needs to come back.
Expected: mild cramping, and spotting or irregular bleeding over the first three to six months, usually settling. Teach thread checks — within four to six weeks, then regularly.
Prompt review: severe or persistent pelvic pain, fever or abnormal discharge, heavy bleeding, symptoms of pregnancy, or threads that are missing or feel different — use condoms until reviewed.
Protection is immediate if inserted within seven days of the start of the period; otherwise use additional precautions for seven days.
Follow-up: the Irish SmPC recommends re-examination at four to twelve weeks; FSRH and CDC do not require a routine visit after uncomplicated interval insertion. Follow the product information and local policy, and do not book routine ultrasound.
Expulsion is about one in twenty, mostly in the first year. Document the procedure and give the patient a reminder card.
→ Transition: removal and replacement.
Removal and replacement
Any time: on request
5 years
HRT protection: replace
Heavy bleeding: reassess
8 years
Contraception & heavy bleeding:
remove or replace
Inserted ≥ 45: contraception to 55 (FSRH)
Within licensed or guideline-supported duration; effective and well tolerated
Suspected pregnancy, expulsion, malposition or perforation · PID: treat and review at 48–72 h
Duration reached, patient request, new contraindication or unacceptable adverse effects
Evidence 1 Irish SmPC §4.2 2 FSRH IUC 7 FSRH Contraception over 40
⏱ 10:05–10:40 (35 s) · KEY: duration depends on the indication.
Remove or replace according to indication: contraception by eight years; HRT endometrial protection after five years; heavy bleeding — reassess at five years and replace by eight. If inserted at 45 or over, FSRH supports contraception until 55 — but not HRT protection beyond five years.
Remove whenever the patient asks, including when planning pregnancy — and if contraception is still needed, plan the next method first to avoid a gap.
PID with an IUD in place does not automatically mean removal: treat and review at 48 to 72 hours; if not improving, remove — considering emergency contraception if there was recent unprotected sex.
→ Transition: three things to take away.
01 SELECT
02 INSERT
03 RECOGNISE COMPLICATIONS EARLY
Dr Ashraf
Practical Evidence-Based Gynaecology Education
Thank you · Questions welcome
⏱ 10:40–10:50 (10 s) · KEY: the three messages.
Select safely. Insert gently. Recognise complications early. Thank you — I'm happy to take questions.
References
Health Products Regulatory Authority.
Mirena 20 micrograms/24 hours intrauterine delivery system — Summary of Product Characteristics (Ireland), PA1410/008/001. §4.1–4.4, 6.
hpra.ie/find-a-medicine/…/details/27903 College of Sexual & Reproductive Healthcare.
UK Medical Eligibility Criteria for Contraceptive Use (UKMEC 2025). BMJ Sex Reprod Health 2026;52:1–138.
cosrh.org/…/UKMEC_2025.pdf National Institute for Health and Care Excellence.
Heavy menstrual bleeding: assessment and management. NICE guideline NG88.
nice.org.uk/guidance/ng88 Faculty of Sexual & Reproductive Healthcare (now CoSRH). Contraception for Women Aged Over 40 Years.
Bayer. Mirena insertion instructions and HCP instructional video. Procedural images adapted with attribution; teaching overlays are illustrative.
Bayer HealthCare / U.S. FDA.
Mirena (levonorgestrel-releasing intrauterine system) prescribing information (2021): T-body 32 × 32 mm; sounded depth 6–10 cm.
accessdata.fda.gov/…/021225s042lbl.pdf
Evidence-based medical education · October 2026
Reference slide — not spoken. Invite questions.