Unresolved symptoms after surgery & mirena

2017, Responses from: Dr Charles Koh and Prof Neil Johnson

(Summarised) Miss M (25yrs) Symptom onset in 2011 – 2016 – abnormal discharge, irregular bleeding, pelvic pain worsening symptoms over 5 years. Mirena placed. In Jan 2016 laparoscopy confirmed endo – ‘widespread but superficial’. Mirena left in place. Continues to experience discharge + bleeding. Pelvic pain improved. 10 days a month symptom free. I need some advice! Is there anything that will help my irregularities and should I also have the Mirena removed.

Dr Charles Koh:
Charles asked the question: ‘was all the widespread ‘superficial’ endometriosis removed (excising) in an en bloc (all together) manner?’

It is the Mirena causing her irregular bleeding, unless she has a polyp which can be removed at the same time as removing the Mirena.

I suggest she considers asking her specialist gynaecologist whether a presacral neurectomy should be done if she undergoes further surgery to remove all the endometriosis.

Prof Neil Johnson: This is not at all an uncommon experience that Miss M has had.

The effect of the Mirena typically improves steadily to 6 months, sometimes taking up to 12 months before the full beneficial effect is seen. Improvements from Mirena after 12 months are rarely seen, so if there hasn’t been a satisfactory response (ie if the Mirena “hasn’t helped”) by 12 months, it’s unlikely that it will help. The Mirena works well for around 80% of women; not so well for up to 20% of women.

Of course, it’s possible that the Mirena may have moved or become dislodged, so it would be important to have the position of the Mirena checked- this can be done firstly by checking the length of the Mirena threads, but a transvaginal ultrasound is usually necessary to be confident about the Mirena siting. It would also be important to be confident that there were no organisms detectable that can be associated with pelvic infection – appropriate swabs by the doctor should exclude this.

Persistent irregular bleeding that are posing problems – once abnormal siting of the Mirena and infection have been excluded – would be reasonable justification to have the Mirena removed and for consideration for histology sampling of the endometrium (for example by Pipelle sampling). And sometimes simply removing the Mirena will resolve this problem.

It’s worth mentioning also that, even when the Mirena works well initially for endometriosis pain problems and bleeding problems, it doesn’t always last the typical five years for which the Mirena works effectively as a contraceptive. I commonly have to replace a Mirena after 3-5 years when my patients are using it to control endometriosis symptoms.

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