Cochrane for Clinicians

Putting Evidence into Practice

Levonorgestrel-Releasing Intrauterine System for Reducing Heavy Menstrual Bleeding


Am Fam Physician. 2021 Aug ;104(2):138-140.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is the levonorgestrel-releasing intrauterine system (Mirena) safe and effective for reducing heavy menstrual bleeding?

Evidence-Based Answer

The levonorgestrel-releasing intrauterine system is more effective than other medical therapies at reducing menstrual bleeding volume (mean difference [MD] = 67 mL; 95% CI, 43 to 91 mL), with similar rates of adverse effects. The effectiveness of the levonorgestrel-releasing intrauterine system compared with endometrial ablation and hysterectomy has been inadequately studied.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Heavy menstrual bleeding is defined by the perception of excessive bleeding affecting a patient's quality of life and is common among those of reproductive age. Numerous medical and surgical therapeutic options exist for heavy menstrual bleeding. The authors of this Cochrane review sought to evaluate the effectiveness and safety of the levonorgestrel-releasing intrauterine system compared with other therapeutic options for heavy menstrual bleeding.1

This Cochrane review included 25 randomized controlled trials and 2,511 patients, with studies comparing the levonorgestrel-releasing intrauterine system with no treatment, placebo, medical therapies (including nonsteroidal anti-inflammatory drugs, antifibrinolytic drugs, and hormone-containing medications), endometrial ablation, and hysterectomy.1 Participants were of reproductive age with regular heavy periods. The study locations and durations were heterogeneous, spanning multiple countries and ranging in length from three months to 10 years. The primary outcomes were effectiveness (reduction in blood loss measured objectively, semi-objectively, or subjectively) and patient satisfaction (measured on a five-point Likert scale). Secondary outcomes were quality of life, adverse effects, withdrawal from treatment, treatment failure, need for subsequent surgery, and cost.

The levonorg

Author disclosure: No relevant financial affiliations.


1. Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2020;(6):CD002126.

2. Matteson KA, Rahn DD, Wheeler TL II, et al.; Society of Gynecologic Surgeons Systematic Review Group. Non-surgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013;121(3):632–643.

3. National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management. NICE guideline [NG88]. Updated March 31, 2020. Accessed January 15, 2021.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at



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