Short- and long-term influence of the levonorgestrel-releasing intrauterine system (Mirena®) on vaginal microbiota and Candida

Background. Recurrent vulvovaginal infections are a frequent complaint in young women in need of contraception. However, the influence of the contraceptive method on the course of the disease is not well known. Aim. To investigate the influence of the levonorgestrel-releasing intrauterine-system (LNG-IUS) on the vaginal microflora. Methods. Short-term (3 months) and long-term (1 to 5 years) changes of vaginal microbiota were compared with preinsertion values in 252 women presenting for LNG-IUS insertion. Detailed microscopy on vaginal fluid was used to define lactobacillary grades (LBGs), bacterial vaginosis (BV), aerobic vaginitis (AV) and the presence of Candida. Cultures for enteric aerobic bacteria and Candida were used to back up the microscopy findings. Fisher's test was used to compare vaginal microbiome changes pre- and post-insertion. Results. Compared to the pre- insertion period, we found a temporary worsening in LBGs and increased rates of BV and AV after 3 months of LNG-IUS. After 1 and 5 years, however, these changes were reversed, with a complete restoration to preinsertion levels. Candida increased significantly after long-term carriage of LNG-IUS compared to the period before insertion [OR 2.0 (CL(95)1.1-3.5), P=0.017]. Conclusions. Short-term use of LNG-IUS temporarily decreases lactobacillary dominance, and increases LBG, AV and BV, but after 1 to 5 years these characteristics return to pre- insertion levels, reducing the risk of complications to baseline levels. Candida colonization, on the other hand, is twice as high after 1 to 5 years of LNG-IUS use, making it less indicated for long-term use in patients with or at risk for recurrent vulvovaginal candidosis.