Adenomyosis and Mirena: How to Handle Persistent Menstrual Pain

For patients with adenomyosis, doctors often recommend using the Mirena intrauterine device (IUD). This device slowly releases levonorgestrel inside the uterus, using local hormones to suppress endometrial overgrowth, helping most women relieve severe menstrual pain and heavy bleeding. 

However, some women may still experience dysmenorrhea after insertion. This does not mean Mirena is completely ineffective; there are various reasons behind it, and clear solutions are available. The following will discuss specific management strategies.

Reasons Why Adenomyosis Patients May Still Experience Menstrual Pain After Using Mirena

The effectiveness of Mirena depends on certain conditions. If pain persists, the cause may be complex and should be identified before further management.

The IUD is misplaced, reducing effectiveness:

Mirena must be properly positioned within the uterine cavity to release hormones evenly and cover the affected areas. If the device shifts, falls out, or embeds into the uterine muscle, hormone release will be disrupted, and menstrual pain may persist. Intense physical activity or heavy menstrual flow can cause position changes, which some women may not notice. Therefore, checking the IUD's position is important if pain continues.

Uterus is enlarged or lesions are extensive:

Mirena has a limited coverage area. If adenomyosis causes the uterus to enlarge to the size of an 8-week pregnancy, or if there are large adenomyomas, the device may not cover all lesions. Uncovered areas can still cause pain, so treatment plans may need to be adjusted accordingly.

Individual differences or insufficient hormone response:

Some women may be less sensitive or have low tolerance to levonorgestrel. Even if the IUD is correctly positioned and the uterus size is appropriate, pain may persist. Additionally, the slight pressure of the device on the uterine muscle can cause lower abdominal heaviness or pain during intercourse, which is considered an individual adaptation issue.

Identifying Cases Where Adenomyosis Patients Still Experience Menstrual Pain After Using Mirena

If menstrual pain persists, it is recommended to visit a hospital for professional evaluation to determine the cause.

Gynecological Ultrasound: Confirm IUD Position:

Ultrasound is a fundamental and important step. Doctors can clearly see the position of the Mirena within the uterus and determine whether it has shifted, embedded, or fallen out. If the IUD is misplaced, it usually needs to be repositioned or removed and reinserted. Most women experience significant pain relief after adjustment.

Gynecological Examination: Rule Out Other Issues:

During a pelvic exam, doctors assess the uterus for size, texture, and tenderness. Combined with ultrasound results, they can evaluate the progression of adenomyosis and rule out other potential causes of pain, such as pelvic inflammatory disease or endometriosis. Only through a thorough evaluation can an accurate and effective treatment plan be developed.

Symptom-Based Management: Methods to Relieve Pain in Different Situations

After identifying the cause, doctors will develop a personalized plan. The following are common approaches, all of which should be carried out under medical guidance.

Situation 1: Correct IUD Position, Mild Pain—Short-Term Painkillers or Enhanced Hormone Therapy

If the IUD is properly positioned, adenomyosis has not progressed significantly, and pain is mild but persistent, doctors often recommend short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen sustained-release capsules or celecoxib capsules. 

These medications reduce pain at its source by inhibiting prostaglandin synthesis and are suitable for mild to moderate dysmenorrhea and for preventing menstrual pain.

If pain relief from NSAIDs is insufficient, doctors may add medications such as dienogest tablets to enhance the effect of hormone therapy. All these drugs are prescription medications and must be used strictly according to the doctor's instructions regarding dosage and duration; self-adjustment is not recommended.

Situation 2: Enlarged Uterus or Extensive Lesions—Adjusting the Treatment Plan

If examinations reveal an enlarged uterus or large adenomyomas, Mirena may not adequately control the condition, and a different treatment approach may be needed. Medications such as leuprolide acetate microspheres can temporarily suppress ovarian function, reducing uterine size and lesion volume to relieve pain. Once the uterus has shrunk, doctors can reassess whether reinsertion of Mirena is appropriate. If drug therapy is ineffective, surgical intervention may be considered.

Situation 3: Hormone Intolerance—Herbal or Physical Therapies

Some women are sensitive to hormone side effects, experiencing symptoms such as nausea or dizziness, and may choose herbal therapies. Traditional Chinese medicine attributes adenomyosis-related pain to blood stasis and damp-heat obstruction, requiring individualized treatment. 

Commonly used remedies include Guizhi Fuling capsules and Fuyan Pill. Fuyan Pill from Dr.Lee's clinic has heat-clearing, detoxifying, and blood-activating properties to improve the pelvic environment, reduce inflammation, and alleviate lower abdominal heaviness and pain. Physical therapies such as nerve blocks can also relieve pain, suitable for those intolerant to medications.

Alternative Treatment Options

If Mirena and conventional medications are ineffective, doctors may recommend the following alternatives for patient consideration.

Laparoscopic Endometrial Resection:

This minimally invasive surgery removes part of the endometrium to reduce menstrual bleeding and relieve pain. It is suitable for women with adenomyosis who have abnormal or heavy menstrual bleeding and do not respond to medication. The procedure is usually performed under local anesthesia, causing minimal trauma and allowing quick recovery. Suitability must be assessed by a doctor.

Other Hormone Therapies:

Oral contraceptives, progesterone, and other hormone treatments are also commonly used to regulate estrogen and progesterone levels and alleviate symptoms. Women planning pregnancy must use these under medical supervision to avoid affecting fertility.

Painkillers for Emergency Use:

For acute episodes of severe menstrual pain, short-term use of painkillers such as enteric-coated aspirin or sustained-release diclofenac can provide rapid relief. However, painkillers are intended only for temporary use and should not be relied upon long-term to avoid side effects.

Daily Care

In addition to medication, daily care is important for effectively reducing pain and improving quality of life.

Avoid Intense Exercise to Reduce Pelvic Pressure:

During IUD use or menstruation, avoid running, jumping, lifting heavy objects, or other intense activities to prevent IUD displacement and pelvic congestion. Gentle exercises such as walking or yoga are recommended.

Heat Therapy and Regular Routine During Menstruation:

Applying a warm water bag or heat pack to the lower abdomen can promote blood circulation and relieve uterine cramps. Maintaining a regular routine, avoiding late nights, and getting sufficient sleep help the body recover and reduce discomfort.

Balanced Diet to Support Anti-Inflammation:

Reduce intake of red meat and high-fat foods, as they may worsen inflammation. Increase consumption of anti-inflammatory foods rich in Omega-3 fatty acids, such as deep-sea fish and flaxseed. Avoid spicy or irritating foods to prevent aggravating uterine pain.

Pelvic Floor Muscle Training to Improve Circulation:

Moderate pelvic floor exercises, such as Kegel exercises, can strengthen pelvic muscles and improve blood circulation in the pelvic region, helping to relieve menstrual pain.

Conclusion

Adenomyosis requires long-term management. After inserting Mirena, it is recommended to have an ultrasound check every 3–6 months to monitor the IUD position and disease progression. If pain worsens or abnormal bleeding or fever occurs, prompt medical consultation is necessary.

All adjustments to treatment—including changing medication doses, replacing the IUD, or considering surgery—should be done under the guidance of a gynecologist to avoid delaying care.

In short, persistent menstrual pain after using Mirena is not a cause for alarm; the key is to identify the underlying cause and manage it appropriately.