Dear Alice,

I have recently been advised that my on-going migraines might be caused and/or increased by the use of contraceptives containing estrogen. To that end, I have been recommended to switch to a progesterone-only form of birth control. Which, in turn, basically means I get to choose between Implanon and Mirena (I really can't stand needles, so Depo is out for me!). I am only 23 years old, and have not yet started a family. I do want to have children someday, and am very enticed by the idea of Mirena lasting to the point when I might want to begin trying to get pregnant. However, all of the advertisements for Mirena state that ideal candidates have already had children.

Is Mirena still safe for use in women who have not yet given birth? If so are there any additional side effects to consider in this instance?

Dear Reader,

It sounds like figuring out what birth control is right for you has been a literal headache — but rest assured it doesn’t have to be. Regarding your migraines, research has established a link between estrogen and migraine headaches. Since you’ve been advised to look into progesterone-only types of birth control, it’s great that you’re seeking out more information on these methods while also planning for your reproductive future. There are several options available on the market that will fit the bill, including ones you’ve mentioned: Implanon (the contraceptive implant — of which there is a newer version called Nexplanon) and Mirena (a hormonal intrauterine device or IUD). And, according to the American College of Obstetricians and Gynecologists (ACOG), the World Health Organization (WHO), and Centers for Disease Control and Prevention (CDC), IUDs and contraceptive implants are highly effective since they don't depend on regular user compliance. To answer your question about IUDs like Mirena in particular, health care providers once advised against IUD use for women who had not previously given birth, but recent research shows this is no longer cause for such a restriction. With that in mind, learning more about Mirena and other birth control methods sans estrogen may help you decide which option is best for you.

First, a little history on IUD use: The use of IUDs in women who had not yet given birth was previously not advised, because the initial clinical trials were only conducted with women who had at least one previous birth had informed this recommendation. It’s now recognized that even women in their teens who have not previously given birth can use Mirena and other IUDs safely.  It was also thought that the insertion of the device in women who had not given birth before would result in higher risk for complications, including increased difficulty with insertion, discomfort for patient during insertion procedure, and potential expulsion of the device (when the body rejects the device and it comes out of the uterus). Studies have shown, however, that rates of insertion difficulty and pain associated with it isn’t much different between younger (having never given birth) and older patients. Moreover, the risk of the device being expelled from the body may be slightly increased for those who have not yet given birth. With that said though, if the device is expelled, it’s good to know that it doesn’t exclude a person from being eligible from receiving it again.

Additionally, it was also thought that IUD use in younger women without children was linked to complications like pelvic inflammatory disease (PID) in the past. While the risk of PID can increase within the first 20 days following IUD insertion, the higher rates of sexually transmitted infections (STIs) or bacteria that enters during insertion is typically to blame, not IUD use itself,. What’s more, Mirena and other hormonal contraceptives may actually protect against PID by thickening the cervical mucus and decreasing menstrual flow. While Mirena does help to protect against PID, it doesn't protect against STIs, so the use of condoms in conjunction with an IUD are still recommended.

Like most contraceptives, Mirena has some side effects, both as a result of the hormones it contains and the device itself. To learn more about the specifics with this birth control method, take a look at Mirena: The hormonal IUD in the Go Ask Alice! archives. One other specific concern to point out with the use of Mirena: A common belief has been that any IUD can increase the risk of having an ectopic pregnancy (a pregnancy where the fertilized egg implants in the fallopian tube, which can be dangerous for the woman). Although IUDs do not increase the risk of ectopic pregnancy, women who get pregnant while using an IUD are at higher risk of ectopic pregnancy (risk of pregnancy while using an IUD is less than one percent).

The questions you’ve posed about this method are a great start. Before you make your final decision on a progesterone-only birth control method, you might also want to explore the other IUD options (both hormonal and non-hormonal), and progesterone-only birth control pill options, in addition to the contraceptive implant. Take a look through the Contraception category in the Go Ask Alice! Sexual & Reproductive Health archives for more information. Doing a little birth control homework and speaking with your health care provider can help you find your best contraceptive match!

Alice!

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