Dosing & Uses
Dosage Forms & Strengths
levonorgestrel-releasing intrauterine system
- 13.5mg/device (Skyla)
- 19.5mg/device (Kyleena)
- 52mg/device (Liletta, Mirena)
Contraception
Mirena
- Initial levonorgestrel release rate is ~21 mcg/day after 24 days following insertion; rate decreases progressively to ~11 mcg/day after 5 years and 7 mcg/day after 8 years
- Remove by 8 years following insertion and replace if continuing treatment
Skyla
- Levonorgestrel release rate is 14 mcg/day after 24 days and 5 mcg/day after 3 years
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by 3 years following insertion
Liletta
- Initially, levonorgestrel release rate is ~20 mcg/day; rate decreases progressively to ~6.5 mcg/day after 8 yr
- Average in vivo release rate is ~13.5 mcg/day over a period of 8 yr
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by the end of eighth year following insertion
Kyleena
- Release rate is 17.5 mcg/day after 24 days and declines to 7.4 mcg/day after 5 years
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by 5 years following insertion
Heavy Menstrual Bleeding
Indicated for heavy menstrual bleeding for up to 5 years in women who choose to use intrauterine contraception as a method of contraception
Initial levonorgestrel release rate is 20 mcg/day; rate reduced by 50% after 5 years
Replace after the end of fifth year if continued treatment needed
Dosage Modifications
Renal or hepatic impairment: No studies conducted
Dosing Considerations
Starting levonorgestrel intrauterine in women not currently using hormonal or intrauterine contraception
- Insert any time the healthcare professional assesses the woman is not pregnant
- Consider the possibility of ovulation and conception before initiation of this product
- If inserted during the first 7 days of the menstrual cycle or immediately after a first trimester abortion, back up contraception is not needed
- If NOT inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain from vaginal intercourse for 7 days to prevent pregnancy
Switching to intrauterine from an oral, transdermal, or vaginal hormonal contraceptive
- Insert intrauterine device at any time
- May be inserted during the hormone-free interval of the previous method
- If inserted during active use of the previous method, continue that method for 7 days after intrauterine device insertion or until current treatment cycle has ended
- If using continuous hormonal contraception, discontinue that method 7 days after insertion
Switching to levonorgestrel intrauterine from an injectable progestin contraceptive
- May be inserted at any time
- If inserted >3 months (13 weeks) after the last injection, use a barrier method of contraception (eg, condoms, spermicide) for 7 days after insertion
Switching to intrauterine from a contraceptive implant or another IUS
- Insert intrauterine on the same day the implant or IUS is removed; may be insert at any time during the menstrual cycle.
Inserting intrauterine after abortion or miscarriage
- First-trimester: May insert immediately after a first-trimester abortion or miscarriage.
- Second-trimester: Delay inserting intrauterine until a minimum of 4 weeks (Liletta) or 6 weeks (Kyleena, Skyla, Mirena) after second-trimester abortion or miscarriage, or until the uterus is fully involuted
- If involution is delayed, wait until involution is complete before insertion
- If the woman has not yet had a period, consider the possibility of ovulation and conception occurring before insertion
- Insert at any time the healthcare professional assesses woman is not pregnant
- If not inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain the patient from vaginal intercourse for 7 days after insertion to prevent pregnancy
Inserting after childbirth
- Delay insertion until a minimum of 4 weeks (Liletta) or 6 weeks (Kyleena, Skyla, Mirena) after delivery, or until the uterus is fully involuted
- If involution is delayed, wait until involution is complete before insertion
- If woman has not yet had a period, consider the possibility of ovulation and conception occurring before insertion
- May be inserted any time the healthcare professional assesses the woman is not pregnant
- If not inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain from vaginal intercourse for 7 days after insertion to prevent pregnancy
- Increased risk of perforation in lactating women
Dosage Forms & Strengths
levonorgestrel-releasing intrauterine system
- 13.5mg/device (Skyla)
- 19.5mg/device (Kyleena)
- 52mg/device (Liletta, Mirena)
Contraception
Postpubertal females
-
Skyla
- Levonorgestrel release rate is 14 mcg/day after 24 days and 5 mcg/day after 3 years
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by 3 years following insertion
-
Liletta
- Initially, levonorgestrel release rate is ~20 mcg/day; rate decreases progressively to ~6.5 mcg/day after 8 yr
- Average in vivo release rate is ~13.5 mcg/day over a period of 8 yr
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by the end of eighth year following insertion
-
Mirena
- Initial levonorgestrel release rate is ~21 mcg/day after 24 days following insertion; rate decreases progressively to ~11 mcg/day after 5 years and 7 mcg/day after 8 years
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by 8 years following insertion
-
Kyleena
- Release rate is 17.5 mcg/day after 24 days and declines to 7.4 mcg/day after 5 years
- May remove and replace with a new unit anytime during menstrual cycle
- Must be removed or replaced by 5 years following insertion
Dosage Modifications
Renal or hepatic impairment: No studies conducted
Dosing Considerations
Starting levonorgestrel intrauterine in women not currently using hormonal or intrauterine contraception
- Insert any time the healthcare professional assesses the woman is not pregnant
- Consider the possibility of ovulation and conception before initiation of this product
- If inserted during the first 7 days of the menstrual cycle or immediately after a first trimester abortion, back up contraception is not needed
- If NOT inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain from vaginal intercourse for 7 days to prevent pregnancy
Switching to intrauterine from an oral, transdermal, or vaginal hormonal contraceptive
- Insert intrauterine device at any time
- May be inserted during the hormone-free interval of the previous method
- If inserted during active use of the previous method, continue that method for 7 days after intrauterine device insertion or until current treatment cycle has ended
- If using continuous hormonal contraception, discontinue that method 7 days after insertion
Switching to levonorgestrel intrauterine from an injectable progestin contraceptive
- May be inserted at any time
- If inserted >3 months (13 weeks) after the last injection, use a barrier method of contraception (eg, condoms, spermicide) for 7 days after insertion
Switching to intrauterine from a contraceptive implant or another IUS
- Insert intrauterine on the same day the implant or IUS is removed; may be insert at any time during the menstrual cycle.
Inserting intrauterine after abortion or miscarriage
- First-trimester: May insert immediately after a first-trimester abortion or miscarriage.
- Second-trimester: Delay inserting intrauterine until a minimum of 4 weeks (Liletta) or 6 weeks (Kyleena, Skyla, Mirena) after second-trimester abortion or miscarriage, or until the uterus is fully involuted
- If involution is delayed, wait until involution is complete before insertion
- If the woman has not yet had a period, consider the possibility of ovulation and conception occurring before insertion
- Insert at any time the healthcare professional assesses woman is not pregnant
- If not inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain the patient from vaginal intercourse for 7 days after insertion to prevent pregnancy
Inserting after childbirth
- Delay insertion until a minimum of 4 weeks (Liletta) or 6 weeks (Kyleena, Skyla, Mirena) after delivery, or until the uterus is fully involuted
- If involution is delayed, wait until involution is complete before insertion
- If woman has not yet had a period, consider the possibility of ovulation and conception occurring before insertion
- May be inserted any time the healthcare professional assesses the woman is not pregnant
- If not inserted during the first 7 days of the menstrual cycle, use a barrier method of contraception or abstain from vaginal intercourse for 7 days after insertion to prevent pregnancy
- Increased risk of perforation in lactating women
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (0)
Serious - Use Alternative (28)
- abametapir
abametapir will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- antithrombin alfa
levonorgestrel intrauterine, antithrombin alfa. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- antithrombin III
levonorgestrel intrauterine, antithrombin III. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- apalutamide
apalutamide will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- argatroban
levonorgestrel intrauterine, argatroban. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- bemiparin
levonorgestrel intrauterine, bemiparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- bivalirudin
levonorgestrel intrauterine, bivalirudin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- cobicistat
cobicistat will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- dabrafenib
dabrafenib will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- dalteparin
levonorgestrel intrauterine, dalteparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- elagolix
levonorgestrel intrauterine decreases effects of elagolix by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Based on the mechanism of action of elagolix, estrogen-containing contraceptives are expected to reduce elagolix efficacy. Effects of progestin-only contraceptives on the efficacy of elagolix is unknown. Advise women to use nonhormonal contraceptives during treatment with elagolix and for 1 week after discontinuing elagolix.
- encorafenib
encorafenib will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of encorafenib with hormonal contraceptives (CYP3A4 substrates) can result in decreased concentrations and loss of hormonal contraceptive efficacy. Since encorafenib can cause fetal harm, advise women of childbearing potential to use a highly effective nonhormonal contraceptive during treatment and for 2 weeks after final encorafenib dose.
- enoxaparin
levonorgestrel intrauterine, enoxaparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- fondaparinux
levonorgestrel intrauterine, fondaparinux. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- heparin
levonorgestrel intrauterine, heparin. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- ivosidenib
ivosidenib will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- lesinurad
lesinurad decreases effects of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Use additional methods of nonhormonal contraception. Do not rely on hormonal contraception alone when taking lesinurad.
- lorlatinib
lorlatinib will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- lumacaftor/ivacaftor
lumacaftor/ivacaftor will decrease the level or effect of levonorgestrel intrauterine by unspecified interaction mechanism. Avoid or Use Alternate Drug. Avoid coadministration unless benefit outweighs risk. When coadministered, hormonal contraceptives are not a reliable method of effective birth control. Concomitant use may increase incidence of menstruation associated adverse effects (amenorrhea, dysmenorrhea, menorrhagia).
- mavacamten
mavacamten will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Progestin and ethinyl estradiol are CYP3A4 substrates. Mavacamten may decrease systemic exposures of ethinyl estradiol and progestin, which may lead to contraceptive failure or an increase in breakthrough bleeding. Advise patients to use a contraceptive method that is not affected by CYP450 enzyme induction (eg, intrauterine system) or add nonhormonal contraception (eg, condoms) during coadministration and for 4 months after last mavacamten dose.
- mifepristone
mifepristone will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.
- nelfinavir
nelfinavir will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- omaveloxolone
omaveloxolone will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Omaveloxolone may reduce efficacy of hormonal contraceptives (eg, pill, patch, ring), implants, and progestin-only pills owing to weak CYP3A4 induction.
- perampanel
perampanel will decrease the level or effect of levonorgestrel intrauterine by unspecified interaction mechanism. Avoid or Use Alternate Drug. Levonorgestrel levels reduced by 40% when coadministered with high dose perampanel (ie, 12 mg/day); effect on other progestins is unknown, consider back up contraception
- phenindione
levonorgestrel intrauterine, phenindione. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- protamine
levonorgestrel intrauterine, protamine. Either decreases effects of the other by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Risk of thromboembolic disorders.
- ritonavir
ritonavir will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.
- sugammadex sodium
sugammadex sodium decreases effects of levonorgestrel intrauterine by receptor binding competition. Avoid or Use Alternate Drug. In vitro binding studies showed that sugammadex may bind to progestogen, thereby decreasing progestogen exposure. Therefore, a sugammadex bolus dose is considered to be equivalent to missing dose(s) of hormonal contraceptives containing an estrogen or progestogen. If an oral contraceptive is taken on the same day of sugammadex, or the patient has a transdermal or implant hormonal contraceptive, the patient must use an additional, nonhormonal contraceptive method or back-up method of contraception (eg, condoms and spermicides) for the next 7 days.
Monitor Closely (42)
- amobarbital
amobarbital will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- atazanavir
atazanavir, levonorgestrel intrauterine. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Atazanavir may increase or decrease levels of levonorgestrel. Use alternatives if available.
- bosentan
bosentan decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- carbamazepine
carbamazepine decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- cenobamate
cenobamate will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Increase dose of CYP3A4 substrate, as needed, when coadministered with cenobamate.
cenobamate will decrease the level or effect of levonorgestrel intrauterine by unspecified interaction mechanism. Modify Therapy/Monitor Closely. Advise women to use additional or alternative non-hormonal birth control when concomitantly using cenobamate with oral contraceptives. - ceritinib
ceritinib will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- clobazam
clobazam will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Clobazam is a weak CYP3A4 inducer; effectiveness of hormonal contraceptives may be diminished when given concurrently with clobazam. Additional non-hormonal forms of contraception are recommended.
- crofelemer
crofelemer increases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Crofelemer has the potential to inhibit CYP3A4 at concentrations expected in the gut; unlikely to inhibit systemically because minimally absorbed.
- cyclosporine
levonorgestrel intrauterine, cyclosporine. Either increases levels of the other by decreasing metabolism. Use Caution/Monitor. Combined oral contraceptives containing EE may inhibit the metabolism and increase plasma concentrations of cyclosporine.
- dexamethasone
dexamethasone decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- efavirenz
efavirenz decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- enzalutamide
enzalutamide decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- eslicarbazepine acetate
eslicarbazepine acetate will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Use additional or alternative nonhormonal birth control.
- etravirine
etravirine decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- felbamate
felbamate decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- fosphenytoin
fosphenytoin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- griseofulvin
griseofulvin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- insulin degludec
levonorgestrel intrauterine decreases effects of insulin degludec by pharmacodynamic antagonism. Use Caution/Monitor. Progestins may impair glucose tolerance.
- insulin degludec/insulin aspart
levonorgestrel intrauterine decreases effects of insulin degludec/insulin aspart by pharmacodynamic antagonism. Use Caution/Monitor. Progestins may impair glucose tolerance.
- insulin inhaled
levonorgestrel intrauterine decreases effects of insulin inhaled by pharmacodynamic antagonism. Use Caution/Monitor. Progestins may impair glucose tolerance.
- lamotrigine
levonorgestrel intrauterine will decrease the level or effect of lamotrigine by increasing hepatic clearance. Use Caution/Monitor. Combination oral contraceptives have been shown to significantly decrease plasma concentrations of lamotrigine, likely due to induction of lamotrigine glucuronidation.
- lenacapavir
lenacapavir will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Lencapavir may increase CYP3A4 substrates initiated within 9 months after last SC dose of lenacapavir, which may increase potential risk of adverse reactions of CYP3A4 substrates.
- maraviroc
levonorgestrel intrauterine increases levels of maraviroc by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Potential for increased toxicity.
- metformin
levonorgestrel intrauterine decreases effects of metformin by pharmacodynamic antagonism. Use Caution/Monitor.
- mifepristone
mifepristone decreases effects of levonorgestrel intrauterine by pharmacodynamic antagonism. Use Caution/Monitor. Backup contraceptive method recommended.
- mitotane
mitotane will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Monitor; use of nonhormonal contraceptive may be necessary
- nafcillin
nafcillin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- nevirapine
nevirapine decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- oxcarbazepine
oxcarbazepine decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- pentobarbital
pentobarbital decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- phenobarbital
phenobarbital decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- phenytoin
phenytoin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- primidone
primidone decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- ribociclib
ribociclib will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- rifabutin
rifabutin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- rifampin
rifampin decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- rifapentine
rifapentine decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- secobarbital
secobarbital will decrease the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- St John's Wort
St John's Wort decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
- teriflunomide
teriflunomide increases levels of levonorgestrel intrauterine by unknown mechanism. Use Caution/Monitor.
- tesamorelin
tesamorelin will decrease the level or effect of levonorgestrel intrauterine by altering metabolism. Use Caution/Monitor. Use alternative contraception
- topiramate
topiramate decreases levels of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.
Minor (5)
- acetazolamide
acetazolamide will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.
- anastrozole
anastrozole will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.
- cyclophosphamide
cyclophosphamide will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.
- larotrectinib
larotrectinib will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.
- levoketoconazole
levoketoconazole will increase the level or effect of levonorgestrel intrauterine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.
Adverse Effects
>10%
Unscheduled uterine bleeding (31.9%)
Decreased uterine bleeding (23.4%)
Abdominal/pelvic pain (22.6%)
Amenorrhea (18.4%)
Headache/migraine (16.3%)
Genital discharge (14.9%)
Increased scheduled uterine bleeding (11.9%)
Vulvovaginitis (10.5%)
1-10%
Breast pain (8.5%)
Back pain (7.9%)
Benign ovarian cyst and associated complications (7.5%)
Acne (6.8%)
Dysmenorrhea (6.4%)
Depression/depressive mood (6.4%)
Female genital tract bleeding (3.5%)
<1%
Angioedema
Cervical perforation
Failed insertion
Sepsis
Uterine bleeding
Device breakage
Pulmonary emboli
Deep vein thrombosis and stroke
Increased blood pressure
Postmarketing Reports
Arterial thrombotic and venous thromboembolic events, including cases of pulmonary emboli, deep vein thrombosis and stroke
Device breakage
Hypersensitivity (eg, rash, urticaria and angioedema)
Increased blood pressure
Warnings
Contraindications
Pregnancy or suspicion of pregnancy; cannot be used for postcoital contraception (emergency contraception)
Congenital or acquired uterine anomaly including fibroids if they distort the uterine cavity
Acute pelvic inflammatory disease or a history of pelvic inflammatory disease unless there has been a subsequent intrauterine pregnancy
Postpartum endometritis or infected abortion in the past 3 months
Known or suspected uterine or cervical neoplasia
Known or suspected breast cancer or other progestin-sensitive cancer, now or in the past
Uterine bleeding of unknown etiology
Untreated acute cervicitis or vaginitis, including bacterial vaginosis or other lower genital tract infections until infection is controlled
Acute liver disease or liver tumor (benign or malignant)
Conditions associated with increased susceptibility to pelvic infections
Previously inserted intrauterine device (IUD) that has not been removed
Hypersensitivity to any component of this product
Cautions
Evaluate women for ectopic pregnancy; ~50% of pregnancies that occur with IUD are likely to be ectopic; also consider possibility of ectopic pregnancy in case of lower abdominal pain, especially in association with missed menses or if an amenorrheic woman starts bleeding
Severe infection, including group A streptococcal sepsis reported
Bleeding pattern alterations may occur, including amenorrhea, infrequent bleeding, prolonged bleeding, or irregular bleeding
Perforation may occur, most often during insertion; an interim analysis from a large postmarketing safety study shows an increased risk of perforation in lactating women; perforation risk may be increased in women with fixed retroverted uteri, and during the postpartum period; perforation may also occur at any time during IUS use; perforation may reduce contraceptive efficacy and result in pregnancy; this may be associated with severe pain and continued bleeding
Inform women who use product about recognizing signs and symptoms of ectopic pregnancy and promptly reporting them to their healthcare professional, and about the associated risks of ectopic pregnancy (eg, loss of fertility)
Exclude underlying endometrial pathology (eg, polyps or cancer) prior to insertion of device in women with persistent or uncharacteristic bleeding; irregular bleeding/spotting is common during first months of use and may preclude adequate assessment after insertion
If the threads are not visible or are significantly shortened, they may have broken or retracted into cervical canal or uterus; consider possibility that IUS may have been displaced, (for example, expulsed or perforated the uterus); exclude pregnancy and verify location of device by an appropriate diagnostic method
Women who currently have or have had breast cancer, or have a suspicion of breast cancer, should not use hormonal contraception, because some breast cancers are hormone-sensitive
Product not intended for use in menopausal women
Women with symptomatic actinomycosis should have device removed and should receive antibiotics
Pelvic inflammatory disease
- Pregnant women whose device cannot be removed or if patient chooses not to have it removed, increases risk of miscarriage, sepsis, premature labor, and premature delivery; advise patient of isolated reports of virilization of the female fetus following local exposure to drug during pregnancy with an IUS in place
- Prenatal care should include counseling about these risks and instructions to immediately report any flu-like symptoms, fever, chills, cramping, pain, bleeding, vaginal discharge or leakage of fluid, or any other symptom that suggests complications of the pregnancy
- After initiation of antibiotic treatment, the IUS may be removed or kept in place; the patient should continue to receive antibiotic treatment according to current recommendations and should have close clinical follow-up; guidelines for PID or endometritis treatment are available from the Centers for Disease Control (CDC), Atlanta, Georgia
- If patient opts for ongoing IUS contraception, patient may forego immediate removal of the device after initiation of antibiotic treatment; however, the patient should have close clinical follow-up
- If no clinical improvement occurs within 48–72 hours of initiating treatment, IUS removal is appropriate with continued antibiotic therapy, as indicated
- PID may be asymptomatic but still result in tubal damage and its sequelae
- Promptly examine users with complaints of lower abdominal or pelvic pain, odorous discharge, unexplained bleeding, fever, genital lesions or sores; remove device in cases of recurrent endometritis or PID, or if an acute pelvic infection is severe or does not respond to treatment
- IUDs have been associated with an increased risk of PID, most likely due to organisms being introduced into the uterus during insertion
- PID is often associated with a sexually transmitted infection (STI), and this therapy does not protect against STI; risk of PID is greater for women who have multiple sexual partners, and also for women whose sexual partner(s) have multiple sexual partners; other risk factors for these infections include unprotected sex and acquired immune deficiency syndrome (AIDS)
- Women who have had PID are at increased risk for a recurrence or re-infection; in particular, ascertain whether woman is at increased risk of infection (for example, leukemia, acquired immune deficiency syndrome [AIDS], intravenous drug abuse)
- Following a diagnosis of PID, or suspected PID, obtain bacteriologic specimens and initiate antibiotic therapy promptly; removal of device after initiation of antibiotic therapy is usually appropriate
Perforation
- Perforation may occur, most often during insertion; an interim analysis from a large postmarketing safety study shows an increased risk of perforation in lactating women
- Risk of uterine perforation is increased in women who have recently given birth, and in women who are breastfeeding at time of insertion and during postpartum period; risk of perforation may be increased if device is inserted when the uterus is fixed, retroverted or not completely involuted
- Perforation may also occur at any time during IUS use and may reduce contraceptive efficacy and result in pregnancy; this may be associated with severe pain and continued bleeding
- If perforation occurs, locate, and remove device; surgery may be required; delayed detection or removal of device in case of perforation may result in migration outside uterine cavity, adhesions, peritonitis, intestinal perforations, intestinal obstruction, abscesses and erosion of adjacent viscera
Bleeding pattern alterations
- Device can alter the bleeding pattern and result in spotting, irregular bleeding, heavy bleeding, oligomenorrhea and amenorrhea; during first 3–6 months of use, number of bleeding and spotting days may be higher and bleeding patterns may be irregular
- Thereafter number of bleeding and spotting days usually decreases but bleeding may remain irregular; if bleeding irregularities develop during prolonged treatment, take appropriate diagnostic measures to rule out endometrial pathology
- Amenorrhea develops in approximately 20% of device users by one year
- Consider possibility of pregnancy if menstruation does not occur within six weeks of onset of previous menstruation; once pregnancy has been excluded, repeated pregnancy tests are generally not necessary in amenorrheic women unless indicated, for example, by other signs of pregnancy or by pelvic pain
- In most women with heavy menstrual bleeding, the number of bleeding and spotting days may also increase during initial months of therapy but usually decrease with continued use; the volume of blood loss per cycle progressively becomes reduced
Expulsion
- Partial or complete expulsion of intrauterine device may occur resulting in loss of contraceptive protection; expulsion may be associated with symptoms of bleeding or pain, or it may be asymptomatic and go unnoticed
- Drug typically decreases menstrual bleeding over time; an increase of menstrual bleeding may be indicative of an expulsion
- Consider further diagnostic imaging, such as x-ray, if expulsion is suspected based on ultrasound
- Risk of expulsion is increased with insertions immediately after delivery and appears to be increased with insertion after second-trimester abortion based on limited data; in a large postmarketing safety study conducted in US, risk of expulsion was lower with breastfeeding status
- Remove a partially expelled device; if expulsion has occurred, a new device can be inserted any time the provider can be reasonably certain the woman is not pregnant
- A 5-year expulsion rate of 3.5% (59 out of 1,690 subjects) reported in clinical trials; delay insertion a minimum of 4 weeks or until uterine involution complete following a delivery or a second-trimester abortion
Septic abortion
- If a patient becomes pregnant with an IUS in place, septic abortion—potentially including septicemia, septic shock, and death—may occur; septic abortion typically requires hospitalization and treatment with intravenous antibiotics
- Septic abortion may result in spontaneous abortion or a medical indication for pregnancy termination. Should severe infection of the uterus occur, hysterectomy may be required, which will result in permanent infertility. This device is contraindicated in patients who have had an infected abortion in the prior 3 months
Ovarian cysts:
- The contraceptive effect of this therapy is mainly due to its local effects within the uterus; therefore, ovulatory cycles with follicular rupture usually occur in patients of fertile age using this therapy
- Most ovarian cysts that occur during use of LNG-releasing IUSs are asymptomatic and disappear spontaneously during two to three months of observation
- Cysts that cause clinical symptoms can result in pelvic or abdominal pain or dyspareunia
- Evaluate persistent ovarian cysts; surgical intervention is not usually required, but may be necessary in some cases, and occurred in 1 (0.06%) of participants in the trial; discuss this risk with patients, as indicated
MRI
- Safe scanning with MRI may occur under specific conditions
- static magnetic field ≤3 Tesla
- spatial gradient field ≤36,000 Gauss/cm (T/m)
- maximum SAR (whole body) of 4W/kg in first level controlled mode for 15 min
Clinical Considerations for Use and Removal
- Coagulopathy or use of anticoagulants
- Migraine, focal migraine with asymmetrical visual loss or other symptoms indicating transient cerebral ischemia
- Exceptionally severe headache
- Marked increase of blood pressure
- Severe arterial disease such as stroke or myocardial infarction
- Consider removing device if jaundice or uterine or cervical malignancy occur during use
- Clinical considerations for use and removal
- Obtain a complete medical and social history, including partner status, to determine conditions that might influence the selection of an IUS for contraception
- Exclude underlying endometrial pathology (eg, polyps or cancer) prior to insertion of the device in patients with persistent or uncharacteristic bleeding because irregular bleeding/spotting is common during first months of use and may preclude adequate assessment after insertion.
- Exclude underlying congenital or acquired uterine anomalies, including fibroids, that distort uterine cavity and would be incompatible with correct IUS placement
- Ensure a previously inserted IUS has been removed prior to insertion of the device
- Assess whether the patient is at increased risk of pelvic infection (eg, unprotected sex, history of PID, or acquired immune deficiency syndrome [AIDS]); this therapy does not protect against HIV/STI transmission
Drug interaction overview
- Drug interactions not studied; drugs or herbal products that induce or inhibit drug metabolizing enzymes, including CYP3A4, may decrease or increase, respectively, the serum concentrations of drug during use; however, contraceptive effect of drug is mediated via direct release of drug into uterine cavity and is unlikely to be affected by drug interactions via enzyme induction or inhibition
Pregnancy & Lactation
Pregnancy
Contraindicated in pregnancy or suspected pregnancy
If a females becomes pregnant with IUD in place, risk of ectopic pregnancy is increased as well as miscarriage, sepsis, premature labor, and premature delivery
Isolated cases of virilization of external genitalia of female fetus following exposure to levonorgestrel during pregnancy with a levonorgestrel intrauterine device in place
Remove IUD, if possible, if pregnancy occurs in a woman using IUD
If a woman becomes pregnant with levonorgestrel intrauterine device in place and the woman chooses not to have it removed or can’t be removed, advise her of reports of virilization of the female fetus following local exposure to levonorgestrel during pregnancy; closely follow pregnancy
Female and male reproductive potential
- Probability to conceive within 12 months after removal of intrauterine system reported to be approximately 77%
Lactation
Published studies report presence of LNG in human milk
Small amounts of progestins (~0.1% of the total maternal doses) were detected in the breast milk of nursing mothers who used other LNG-releasing IUSs, resulting in exposure of LNG to the breastfed infants
There are no reports of adverse effects in breastfed infants with maternal use of progestin-only contraceptives
Isolated cases of decreased milk production have been reported with a LNG-releasing IUS
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Local mechanism by which continuously released LNG enhances contraceptive effectiveness has not been demonstrated
Suggested mechanisms of preventing pregnancy are thickening of cervical mucus preventing passage of sperm into the uterus, inhibition of sperm capacitation or survival, and alteration of the endometrium
Absorption
LNG concentrations
-
Kyleena
- 12 months: 199 pg/mL
- 24 months: 120 pg/mL
- 36 months: 122 pg/mL
- 48 months: 79 pg/mL
- 60 months: 65 pg/mL
-
Liletta
- 6 months: 195 pg/mL
- 12 months: 168 pg/mL
- 24 months: 150 pg/mL
- 36 months: 132 pg/mL
- 48 months: 114 pg/mL
- 60 months: 101 pg/mL
- 72 months: 93 pg/mL
-
Mirena
- 12 months: 150 pg/mL
- 24 months: 192 pg/mL
- 60 months: 159 pg/mL
- 72 months: 121 pg/mL
-
Skyla
- 12 months: 7 pg/mL
- 24 months: 62 pg/mL
- 36 months: 72 pg/mL
Distribution
Vd: ~1.8 L//kg
Protein-bound
- Mirena: ~97.5-99%
- Liletta: ~98.9%
Metabolism
LNG conjugates to form sulfate conjugates and, to a lesser extent, glucuronide conjugates in serum
Also, studies demonstrated oxidative metabolism of LNG catalyzed by CYP enzymes, especially CYP3A4
Elimination
Clearance
- Skyla and Kyleena: 1 mL/min/kg
Half-life
- Mirena: ~17 hr
- Skyla: ~ 20 hr
- Liletta: ~13.9 hr
- Kyleena: ~20 hr
Excretion
- All formulations: ~45% (urine); ~32% (feces)
Administration
Intrauterine Administration
See prescribing information for full instructions
Ensure use of aseptic technique throughout the entire procedure
Open package; do NOT move the slider downward at this time as this may prematurely release the threads of the device
Once the slider is moved below the mark, device cannot be reloaded
Set the flange
Device is ready to be inserted ~1.5–2 cm from the cervix
Do not force inserter; if necessary, dilate cervical canal
Advance to fundal position; release insertion
Storage
All formulations
- Protect from light
- Store at 25ºC (77ºF); excursions permitted to 15–30ºC (59–86ºF)
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| Aftera oral - | 1.5 mg tablet |  | |
| Aftera oral - | 1.5 mg tablet |  | |
| Econtra One-Step oral - | 1.5 mg tablet |  | |
| Econtra One-Step oral - | 1.5 mg tablet |  | |
| levonorgestrel oral - | 1.5 mg tablet |  | |
| Opcicon One-Step oral - | 1.5 mg tablet |  | |
| My Choice oral - | 1.5 mg tablet | | |
| Plan B One-Step oral - | 1.5 mg tablet | | |
| Plan B One-Step oral - | 1.5 mg tablet |  | |
| After Pill oral - | 1.5 mg tablet |  | |
| Take Action oral - | 1.5 mg tablet | | |
| My Way oral - | 1.5 mg tablet | |
Copyright © 2010 First DataBank, Inc.
Patient Handout
levonorgestrel intrauterine
LEVONORGESTREL-RELEASING 8 YEAR SYSTEM - INTRAUTERINE
(LEE-voe-nor-JES-trel)
COMMON BRAND NAME(S): Liletta
USES: This product is a small, flexible device that is placed in the womb (uterus) to prevent pregnancy. It is used by women who want to use a reversible birth control method that works for a long time (up to 8 years). The device slowly releases a hormone (levonorgestrel) that is similar to a hormone that women normally make. This device and hormone helps prevent pregnancy.Using this product does not protect you or your partner against sexually transmitted diseases (such as HIV, gonorrhea, chlamydia).
HOW TO USE: Read the Patient Information Leaflet provided by your pharmacist before you start using this product. The leaflet contains very important information about this device. If you have any questions, ask your doctor or pharmacist.This device is placed in your uterus by a health care provider during an in-office visit. It is left in place for up to 8 years. Schedule a follow-up visit 4 to 6 weeks after the device is placed to make sure it is still in the proper position.Ask your doctor if you need to use a backup form of birth control for the first 7 days after this device is placed, to prevent pregnancy until the device has enough time to work.This device may sometimes move out of place or come out by itself. After each menstrual period, check to make sure it is in the proper position. Learn how to carefully check the position of this device from the Patient Information Leaflet and/or your health care provider. If it comes out or if you cannot feel the threads, contact your doctor promptly and use a backup form of non-hormonal birth control (such as condoms, spermicide) to prevent pregnancy until otherwise directed by your doctor.If you wish to continue this method of birth control after 8 years, the used device may be removed and replaced with a new one. Either way, the used device should be removed after 8 years. Your health care provider can remove this device whenever you want to stop using this method of birth control.
SIDE EFFECTS: Pain, bleeding, or dizziness during and after placement of the device may occur. Cramps, irregular menstrual periods, and vaginal bleeding between periods (spotting) may occur, especially during the first few weeks of use. Headache, nausea, breast tenderness, or weight gain may also occur. If any of these effects last or get worse, tell your doctor promptly.After your body adjusts to this product, it is normal to have fewer bleeding days during your menstrual periods, and some women stop having periods altogether. This will not affect your ability to become pregnant after stopping use of this product.Remember that this medication device has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this device do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: stomach/abdominal pain, vomiting, lumps in the breast, mental/mood changes (such as new/worsening depression), unusual changes in vaginal bleeding (such as continuous spotting, sudden heavy bleeding, missed periods), dark urine, yellowing eyes/skin, unusual headaches (including headaches with vision changes/lack of coordination, worsening of migraines, sudden/very severe headaches).Using an intrauterine device (IUD) may increase your risk for a rare but serious pelvic infection (pelvic inflammatory disease-PID), which can cause permanent damage to sex organs and infertility. The risk is greater in women who have multiple sexual partners, or who are infected with a sexually transmitted disease (STD), or who have had PID in the past (see also Precautions section). Tell your doctor right away if you experience symptoms of PID, including: unexplained fever/chills, lower abdominal/pelvic pain, pain during sexual intercourse, genital sores, unusual vaginal discharge.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before using this medication device, tell your doctor or pharmacist if you are allergic to levonorgestrel, or to any other progestins (such as norethindrone, desogestrel); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this product, tell your doctor or pharmacist your medical history, especially of: recent pregnancy, current breastfeeding, bleeding/blood disorders, high blood pressure, abnormal breast exam, cancer (especially endometrial or breast cancer), depression, diabetes, severe headaches/migraines, heart problems (such as heart valve disease, irregular heartbeat, previous heart attack), liver disease (including tumors), previous pregnancy outside the uterus (ectopic pregnancy), stroke, unexplained vaginal bleeding, uterus problems (such as fibroids, pelvic inflammatory disease-PID), conditions that weaken the immune system/increase the risk of infection (such as HIV, leukemia, IV drug abuse).If you or partner have other sexual partners, this device may not be the best birth control method for you. If you or your partner get a sexually transmitted disease (including HIV, gonorrhea, chlamydia), contact your doctor right away. Ask your doctor if you should continue to use this device for birth control.Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products). Also, if you are going to have an MRI test, tell testing personnel that you are using this device. They may need to adjust your MRI test.This device should not be used during pregnancy. If you become pregnant or think you may be pregnant, tell your doctor right away.Levonorgestrel passes into breast milk. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.
OVERDOSE: This medication device may be harmful if swallowed. If someone has swallowed it and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.
NOTES: Keep all regular medical and lab appointments. You should have regular complete physical exams including blood pressure, breast exam, pelvic exam, and screening for cervical cancer (Pap smear). Follow your doctor's instructions for examining your breasts, and report any lumps right away. Consult your doctor for more details.
MISSED DOSE: Not applicable.
STORAGE: Before use, store at room temperature. Keep all medications and medical devices away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
Information last revised November 2022. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
Adding plans allows you to compare formulary status to other drugs in the same class.
To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.
Adding plans allows you to:
- View the formulary and any restrictions for each plan.
- Manage and view all your plans together – even plans in different states.
- Compare formulary status to other drugs in the same class.
- Access your plan list on any device – mobile or desktop.
