THE MIRENA CRASH
By Craig Turczynski, Ph.D.
Their blog says “the Mirena crash is real and affecting countless women.” They even quote a woman saying she felt “smothered with severe despair.” The website for Dolman Law Group in Clearwater, FL, may have mastered the SEO for the term “Mirena Crash,” but what does the term mean and is it real? Unfortunately, when I reached out to this law group (and holder of the first position on Google search) for additional information, their response was “we are unable to assist with the matter.” So then I went to the scientific literature, thinking surely there must be some published evidence for this condition. But that failed to produce any definitive results specifically related to the Mirena device. Finally, I thought that with the existence of so many blogs containing comments from women, clearly articulating similar symptoms and side effects after IUD removal, it must be a well-described side effect listed on the product insert. Once again, nothing about side effects after removal and not even a mention of depressive symptoms. So what can I tell you about this mysterious, apparently well-known but curiously undocumented side effect to removal of the Mirena IUD? Let me try to piece together the evidence and use a little scientific deductive reasoning.
What Is Mirena?
Mirena is a progestin-releasing intrauterine device (IUD). It releases a progestin called levonorgestrel and is indicated for contraception lasting for up to 5 years or for treatment of heavy menstrual bleeding. After 5 years, the implant can be removed and a new device reinserted, providing another 5 years of “no compliance required” contraception. It is considered a long acting, reversible contraception (LARC) and is a progestin-only form of contraception. There are several published studies indicating that Mirena is safe and effective, but they do not address symptoms after removal. The device is supported by the published literature and the American College of Obstetricians and Gynecologists (ACOG). Stoddard et al. (2011) concluded that LARC, including the Mirena implant, “should be offered as the first-line contraception for most women.” An ACOG committee opinion states that complications of IUDs are rare and LARC is safe for adult and adolescent women. It goes on to say that offering it is essential to reproductive justice and equitable health care (ACOG 2018). The mechanism of action is stated to be multifactorial but mostly prevention of fertilization by thickening the cervical mucus and inhibiting sperm motility and capacitation (Stoddard et al., 2011). Those of us who have studied reproduction know that the term “multifactorial” means that it can also work by inhibiting implantation or disrupting development of an embryo (aka abortion). The implant contains 52 mg of levonorgestrel, which is released at a rate of 20 mcg/day. At this dose, some women will have ovarian activity with cyclic menstrual bleeding, some will have variable ovarian activity and irregular bleeding, and some will have complete suppression of ovarian activity (ESHRE Capri Workshop Group, 2001). The only data I could find about removal was a pilot study examining fertility after removal of IUDs. The study reported that pregnancy rates for former IUD and non-IUD users were no different, except for African American women, who experienced reduced fertility after removal (Stoddard et al., 2015).
Hormonal Effects on the Brain
It is unfortunate that I could not find any scientific or medical documentation of mood or emotional symptoms after removal of the Mirena implant, while reporting of it is so prevalent on the internet. Nevertheless, there is evidence that hormonal contraception is associated with depression, and a recent review by Del Rio, et al. (2018) discusses how the lack of hormonal balance can affect a women’s brain. In a study of over 1 million women followed for 6.4 years in Denmark, all forms of contraception were associated with a higher incidence of first-time diagnosis of depression. Regarding Mirena users specifically, women actively using the implant had a 40% increased risk of being diagnosed with depression (Skovlund et al., 2016). The same authors published additional work in 2018 reporting on a half million women followed for over 8 years (Scovlund et al., 2018). The authors found that women who used hormonal contraception had a relative risk of 1.97 for suicide attempt and 3.08 for committing suicide compared to women who never used hormonal contraception. That’s a 97% greater risk of attempting suicide and 208% greater risk of committing suicide! Clearly something is going on here. Another study published in 2018 indicates that users of progestin-only contraception may have a greater risk of depression than estrogen-progestin combined contraception. Using reduced levels of the protein marker Beta-Arrestin 1 as a diagnostic indicator of depression, progestin-only contraception led to more mood disorder pathophysiology than either combined hormonal contraception or no contraception (Smith et al., 2018).
The paper published by Del Rio et al. (2018) was previously summarized on our [HT1] blog by Santiago Molina, but it is particularly pertinent for understanding how both the administration and withdrawal of hormonal contraception can result in mood disorders. Steroid hormones organize and activate different actions on the central nervous system. They can modulate the activity of neurotransmitters, regulate neuron survival and proliferation, alter cell metabolism, or influence nerve impulse transmission. Collectively these actions determine how the brain functions. Furthermore, normal cyclic fluctuations in estrogen and progesterone cooperate to produce the physiological response appropriate for the proper stage of the women’s ovarian continuum. The Mirena implant would alter this physiology in the following ways:
Oral contraception is known to depress levels of B vitamins (B6, B12, and folate), vitamin C, and zinc and to elevate levels of vitamin K, copper, and iron (Webb, 1980). While nutritional studies may not have been conducted specifically on women using the Mirena implant, it is likely that a similar alteration in nutritional status would occur. The B vitamin pyridoxine (B6) is responsible for converting the essential amino acid tryptophan into serotonin and is involved in the formation of GABA. Both serotonin and GABA are vital for normal functioning of the central nervous system. Furthermore, vitamin B6 deficiency is known to cause central nervous system abnormalities. Therefore, in addition to the effects listed above, if the woman has not been taking adequate B-vitamin supplementation while on hormonal contraception, a deficiency in vitamin B6 would exacerbate her symptoms because she would already have a shortage of neurotransmitters, resulting in anxiety and a loss of well-being.
Taken together, the anecdotal and published evidence support the existence of a neurological condition called the “Mirena Crash.” It can severely reduce a women’s quality of life at best, and it can be life threatening at worst. It is hard to imagine why any women would want to take this risk, given the existence of an alternative method that is both effective and totally free of any side effects. The Billings Ovulation Method® does take some effort to learn and practice compared to the Mirena, but the effort is rewarded with a lifetime of body literacy that leads to a cleaner, healthier, and happier life.
ACOG (2018) Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. ACOG Committee Opinion. Number 735, May.
Del Rio et al., (2018) Steroid Hormones and Their Action in Women’s Brains: The Importance of Hormonal Balance. Frontiers in Public Health. Vol 6, 141.
ESHRE Capri Workshop Group, (2001) Ovarian and Endometrial Function during Hormonal Contraception. Human Reprod. Vol 16, 7.
Scovlund et al., (2018) Association of Hormonal Contraception with Suicide Attempts and Suicides. Am J Psychiatry. Vol 175, 4.
Skovlund et al., (2016) Association of Hormonal Contraception with Depression. JAMA Psychiatry. Vol 73, 11.
Smith et al., (2018) Do Progestin-Only Contraceptives Contribute to the Risk of Developing Depression as Implied by Beta-Arrestin 1 Levels in Leukocytes? A Pilot Study. Int J. Environ. Res Public Health. Vol 15, 1966.
Stoddard et al., (2015) Fertility after Intrauterine Device Removal: A Pilot Study. Eur J. Contracept Reprod Health Care. Vol 20, 3.
Stoddard et al., (2011) Efficacy and Safety of Long Acting Reversable Contraception. Drugs. Vol 78, 8.
Webb (1980) Nutritional Effects of Oral Contraceptive Use: A Review. J. Reprod Med. Vol 25, 4.
BOMA-USA provides education and training for The Billings Ovulation Method® which is a natural method of fertility management that teaches you to recognize the body's natural signs of fertility.