If you have been trying to conceive without success, your weight may be playing a larger role than you realize. The connection between body weight and fertility is well established in medical research, and it affects women on both ends of the spectrum. Whether you are carrying excess weight or are significantly underweight, hormonal balance and reproductive function can both be impacted in ways that make conception more difficult.

How Weight Affects Hormones and Ovulation

The relationship between weight and fertility comes down largely to hormones. Fat tissue, also known as adipose tissue, is not just passive storage. It is metabolically active and produces estrogen. When there is too much fat tissue in the body, estrogen levels rise beyond what is healthy, disrupting the hormonal signals that regulate ovulation. When body fat is too low, estrogen production drops and the body essentially shuts down reproductive function as a protective response.

A study published in Human Reproduction found that women with a BMI above 30 had a significantly lower probability of conceiving within 12 months compared to women with a healthy BMI, even after accounting for other factors like age and lifestyle.

The Role of Insulin Resistance

Excess weight, particularly abdominal fat, is closely linked to insulin resistance, a condition in which cells do not respond normally to insulin. Insulin resistance raises insulin levels in the blood, which in turn stimulates the ovaries to produce excess androgens like testosterone. This disrupts ovulation and is one of the primary mechanisms behind PCOS-related infertility. Research published in the Journal of Clinical Endocrinology and Metabolism found that insulin resistance is present in the majority of overweight women with ovulatory infertility, making it one of the most treatable underlying causes of fertility struggles.

Being Underweight and Fertility

Fertility challenges are not exclusive to women who are overweight. Women with a BMI below 18.5 are also at significant risk of reproductive dysfunction. Very low body fat disrupts the production of gonadotropin-releasing hormone, which is essential for triggering ovulation. This can lead to a condition called hypothalamic amenorrhea, where periods stop entirely because the brain signals the body that there are insufficient energy reserves to support a pregnancy.

Research from the American Journal of Clinical Nutrition found that women who were underweight took significantly longer to conceive than women in a healthy weight range, and their risk of preterm birth and low birth weight babies was also considerably higher.

How Much Does Weight Loss Help?

The encouraging news is that even modest changes in weight can have a meaningful impact on fertility. A landmark study published in Fertility and Sterility found that a weight loss of just 5 to 10 percent of body weight in overweight women with ovulatory dysfunction was enough to restore regular ovulation and significantly improve pregnancy rates without any fertility medication. This highlights how powerful lifestyle intervention can be as a first step before pursuing assisted reproductive technologies.

Weight and IVF Success Rates

For women undergoing assisted reproduction, weight also matters. A large meta-analysis published in Reproductive Biomedicine Online found that overweight and obese women undergoing IVF had significantly lower clinical pregnancy rates and live birth rates compared to women with a healthy BMI. The research suggests that optimizing weight before beginning fertility treatment improves outcomes and reduces the number of cycles needed.

Practical Steps to Support Fertility Through Weight Management

• Focus on a balanced diet rich in whole foods, healthy fats, lean proteins, and complex carbohydrates that support hormonal balance
• Incorporate regular moderate exercise, which improves insulin sensitivity and supports a healthy weight without over-stressing the body
• Avoid extreme calorie restriction, which can worsen hormonal disruption even if it leads to weight loss
• Work with a healthcare provider to rule out underlying conditions like PCOS or thyroid disorders that may be driving weight and fertility issues simultaneously
• Consider working with a registered dietitian who specializes in reproductive health

When to See a Doctor

If you have been trying to conceive for 12 months without success, or six months if you are over 35, it is time to speak with a women’s health specialist. A thorough evaluation including hormonal panels, ovulation tracking, and metabolic screening can identify whether weight-related hormonal disruption is a contributing factor and what the most effective treatment path looks like for you.

Weight is one piece of the fertility puzzle, and it is one of the most modifiable. Small, consistent changes can make a profound difference.

Schedule your women’s health appointment with IVANA MD in Missouri City, TX. 

346-585-4077. 

4220 Cartwright Road, Suite 201, Missouri City, Texas 77459.

References

Bellver, J., Busso, C., Pellicer, A., et al. (2006). Obesity and assisted reproductive technology outcomes. Reproductive BioMedicine Online, 12(5), 562–568. https://www.sciencedirect.com/science/article/pii/S1472648310611819 

Crosignani, P. G., Colombo, M., Vegetti, W., et al. (2003). Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet. Human Reproduction, 18(9), 1928–1932. https://academic.oup.com/humrep/article/18/9/1928/708215 

Gesink Law, D. C., Maclehose, R. F., & Longnecker, M. P. (2007). Obesity and time to pregnancy. Human Reproduction, 22(2), 414–420. https://academic.oup.com/humrep/article/22/2/414/2939454 

Rich-Edwards, J. W., Goldman, M. B., Willett, W. C., et al. (1994). Adolescent body mass index and infertility caused by ovulatory disorder. American Journal of Obstetrics and Gynecology, 171(1), 171–177. https://www.sciencedirect.com/science/article/pii/0002937894904650 

Talmor, A., & Dunphy, B. (2015). Female obesity and infertility. Best Practice & Research Clinical Obstetrics & Gynaecology, 29(4), 498–506. https://www.sciencedirect.com/science/article/abs/pii/S1521693414002417

The post Does Weight Affect Fertility? appeared first on IvanaMd.

Bringing a child into the world is one of the most powerful experiences a woman can have. But the conversation about what happens to your body afterward, specifically your pelvic health, is one that does not happen nearly enough. Many women silently struggle with pelvic floor issues for years after childbirth simply because they did not know what to expect or that effective treatment exists.

What Is the Pelvic Floor?

The pelvic floor is a group of muscles, ligaments, and connective tissues that form a hammock-like structure at the base of the pelvis. These muscles support the bladder, uterus, rectum, and bowel. They play a critical role in bladder and bowel control, sexual function, core stability, and supporting the weight of pregnancy. During childbirth, this entire system undergoes significant stress and stretching, and the effects can last long after delivery.

How Childbirth Affects the Pelvic Floor

Both vaginal delivery and cesarean section can impact pelvic health, though in different ways.

During vaginal delivery the pelvic floor muscles stretch to many times their normal length to allow the baby to pass through the birth canal. Research published in the American Journal of Obstetrics and Gynecology found that vaginal delivery, especially when involving prolonged pushing, large babies, or the use of forceps or vacuum assistance, significantly increases the risk of pelvic floor muscle injury and nerve damage.

Cesarean delivery reduces some risks but does not fully protect pelvic health. The weight of pregnancy alone places months of pressure on the pelvic floor, and the surgical incision can affect core muscle function and healing in ways that influence pelvic stability long term.

Long-Term Pelvic Health Conditions Linked to Childbirth

Pelvic Organ Prolapse

Pelvic organ prolapse occurs when one or more pelvic organs, including the bladder, uterus, or rectum, drop from their normal position and press against the vaginal wall. A large study published in Obstetrics and Gynecology found that vaginal childbirth is the single strongest risk factor for pelvic organ prolapse, with risk increasing with each vaginal delivery. Symptoms include:

• A feeling of pressure or heaviness in the pelvis
• A bulge or protrusion at the vaginal opening
• Difficulty with bowel movements
• A feeling that something is falling out of the vagina
• Lower back pain

Urinary Incontinence

Leaking urine when you sneeze, laugh, cough, or exercise is known as stress urinary incontinence, and it is extremely common after childbirth. Research from the International Urogynecology Journal found that women who had vaginal deliveries were significantly more likely to experience urinary incontinence compared to those who had cesarean deliveries or no children. While many women assume this is just a normal part of motherhood, it is a treatable medical condition.

Pelvic Pain and Dyspareunia

Chronic pelvic pain and pain during sex, medically known as dyspareunia, are reported by a significant number of women in the months and years following childbirth. Causes include perineal tearing, episiotomy scarring, hormonal changes during breastfeeding, and pelvic floor muscle tension or dysfunction. A study in the British Journal of Obstetrics and Gynecology found that up to 41 percent of women reported painful intercourse at three months postpartum, and for many the pain persisted well beyond that.

Bowel Dysfunction

Damage to the anal sphincter or pelvic nerves during delivery can lead to fecal urgency, difficulty controlling bowel movements, or constipation. This is more common than most women realize and is rarely discussed openly despite significantly impacting quality of life.

What Does the Research Show?

A landmark study published in the New England Journal of Medicine followed women for up to 20 years after childbirth and found that the effects of vaginal delivery on pelvic floor function were measurable and persistent decades later. The study highlighted that pelvic floor disorders including prolapse, urinary incontinence, and bowel dysfunction were significantly more prevalent in women who had vaginal deliveries compared to those who had not given birth. This research underscores the importance of long-term pelvic health monitoring and proactive care after childbirth.

How to Support Pelvic Health After Childbirth

The encouraging news is that pelvic health conditions are highly treatable and in many cases preventable with the right care. Strategies include:

• Pelvic floor physical therapy, which is one of the most evidence-based and effective treatments for postpartum pelvic floor dysfunction and is recommended by the American College of Obstetricians and Gynecologists
• Kegel exercises performed consistently to strengthen pelvic floor muscles, though these should be guided by a pelvic floor therapist to ensure proper technique
• Avoiding heavy lifting and high-impact exercise too soon after delivery
• Managing constipation through diet and hydration to reduce strain on the pelvic floor
• Vaginal estrogen therapy for women experiencing postpartum hormonal changes that affect pelvic tissue health
• Pessary devices for prolapse management as a non-surgical option
• Surgical repair for severe prolapse or incontinence that does not respond to conservative treatment

When to Seek Help

You should speak with a women’s health provider if you are experiencing any leakage of urine or stool, pelvic pressure or a sensation of bulging, pain during sex that has persisted beyond a few months postpartum, chronic pelvic pain, or difficulty with bowel or bladder function. These symptoms are common but they are not something you simply have to accept. Early intervention leads to significantly better outcomes.

Your body did something extraordinary. It deserves extraordinary care in return.

Schedule your women’s health appointment with IVANA MD in Missouri City, TX. 

346-585-4077. 

4220 Cartwright Road, Suite 201, Missouri City, Texas 77459.

References

Dietz, H. P., & Lanzarone, V. (2005). Levator trauma after vaginal delivery. Obstetrics & Gynecology, 106(4), 707–712. https://pubmed.ncbi.nlm.nih.gov/16199625/ 

Handa, V. L., Blomquist, J. L., McDermott, K. C., et al. (2012). Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstetrics & Gynecology, 119(2 Pt 1), 233–239. https://pubmed.ncbi.nlm.nih.gov/22227639/ 

MacArthur, C., Bick, D. E., Keighley, M. R., et al. (1997). Faecal incontinence after childbirth. British Journal of Obstetrics and Gynaecology, 104(1), 46–50. https://pubmed.ncbi.nlm.nih.gov/8988696/ 

Nygaard, I., Barber, M. D., Burgio, K. L., et al. (2008). Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), 1311–1316. https://pubmed.ncbi.nlm.nih.gov/18799443/ 

Rortveit, G., Daltveit, A. K., Hannestad, Y. S., et al. (2003). Urinary incontinence after vaginal delivery or cesarean section. New England Journal of Medicine, 348(10), 900–907. https://www.nejm.org/doi/full/10.1056/NEJMoa021788

The post How Childbirth Affects Pelvic Health Long-Term appeared first on IvanaMd.

If you dread the week before your period because of mood swings, bloating, fatigue, or emotional overwhelm, you are not alone and you are not overreacting. Premenstrual syndrome and premenstrual dysphoric disorder are real, recognized medical conditions that affect millions of women every month, and both are manageable with the right support.

What Is PMS?

Premenstrual syndrome, commonly known as PMS, refers to a collection of physical and emotional symptoms that appear in the one to two weeks before menstruation and typically resolve once your period begins. Symptoms can range from mild to disruptive and affect up to 75 percent of menstruating women according to the American College of Obstetricians and Gynecologists.

Common PMS symptoms include:

• Bloating and water retention
• Breast tenderness
• Headaches
• Fatigue and low energy
• Irritability and mood swings
• Food cravings
• Difficulty concentrating
• Sleep disturbances

What Is PMDD?

Premenstrual dysphoric disorder, or PMDD, is a severe form of PMS that goes beyond typical discomfort. PMDD is a clinically recognized condition listed in the Diagnostic and Statistical Manual of Mental Disorders and is characterized by intense emotional and psychological symptoms that significantly interfere with daily life, relationships, and work. It affects approximately 3 to 8 percent of menstruating women according to research published in the American Journal of Psychiatry.

Symptoms of PMDD include:

• Severe depression or feelings of hopelessness
• Intense anxiety or panic attacks
• Extreme mood swings or anger
• Feeling out of control
• Severe fatigue
• Difficulty functioning at work or in relationships
• Physical symptoms similar to PMS but more intense

What Causes PMS and PMDD?

Both conditions are linked to hormonal fluctuations during the luteal phase of the menstrual cycle, specifically the drop in estrogen and progesterone that occurs before menstruation. Research suggests that women with PMDD may have an abnormal sensitivity to these hormonal changes rather than abnormal hormone levels themselves. A landmark study published in the Proceedings of the National Academy of Sciences found that women with PMDD have an altered expression of a gene complex called ESPR1 that makes their cells more sensitive to estrogen and progesterone, essentially creating a biological vulnerability to hormonal shifts.

How to Manage PMS and PMDD Naturally

Diet and Nutrition

What you eat has a measurable impact on hormonal symptoms. Research published in the American Journal of Clinical Nutrition found that women with higher intakes of calcium and vitamin D had significantly lower rates of PMS. Focus on:

• Increasing calcium-rich foods like dairy, leafy greens, and fortified foods
• Eating complex carbohydrates to stabilize blood sugar and mood
• Reducing salt, caffeine, sugar, and alcohol in the week before your period
• Adding magnesium-rich foods like nuts, seeds, and dark chocolate to reduce bloating and mood symptoms

Exercise

Regular aerobic exercise is one of the most well-supported natural interventions for PMS and PMDD. A study in the Journal of Psychosomatic Obstetrics and Gynecology found that women who exercised regularly reported significantly fewer and less severe premenstrual symptoms. Aim for at least 30 minutes of moderate activity most days of the week.

Stress Management

Chronic stress worsens hormonal imbalances and amplifies PMS and PMDD symptoms. Practices that have shown benefit include:

• Yoga and mindfulness meditation
• Deep breathing exercises
• Journaling
• Consistent sleep schedules of seven to nine hours per night

Supplements with Scientific Support

Several supplements have clinical evidence supporting their use for PMS and PMDD, including:

• Calcium 1200mg daily, shown in multiple studies to reduce mood and physical symptoms
• Magnesium glycinate, which helps reduce bloating, anxiety, and headaches
• Vitamin B6, which supports serotonin production and has been shown to improve mood-related symptoms
• Chasteberry, also known as Vitex agnus-castus, which a review in the Journal of Women’s Health found to significantly reduce both PMS and PMDD symptoms

Medical Treatment Options

For women whose symptoms are severe or do not respond to lifestyle changes, medical treatments are available and effective. These include:

• Antidepressants called SSRIs, which are considered the first-line medical treatment for PMDD and have been shown in multiple clinical trials to significantly reduce emotional symptoms even when taken only during the luteal phase
• Hormonal contraceptives, particularly the pill containing drospirenone and ethinyl estradiol, which is FDA-approved specifically for PMDD
• GnRH agonists for severe cases that do not respond to other treatments
• Cognitive behavioral therapy, which research has shown to be as effective as medication for managing PMDD symptoms long term

When to See a Doctor

You should speak with a women’s health provider if your premenstrual symptoms are severe enough to affect your relationships, work, or daily functioning, if you feel depressed or anxious in the weeks before your period, if natural remedies have not provided enough relief, or if you are unsure whether what you are experiencing is PMS or PMDD. A proper diagnosis makes all the difference in getting the right treatment.

You do not have to white-knuckle your way through every cycle. Effective help is available.

Schedule your women’s health appointment with IVANA MD in Missouri City, TX. 

346-585-4077.

4220 Cartwright Road, Suite 201, Missouri City, Texas 77459.

References

American College of Obstetricians and Gynecologists. (2021). Premenstrual Syndrome (PMS). ACOG Patient Education FAQs. https://www.acog.org/womens-health/faqs/premenstrual-syndrome 

Epperson, C. N., Steiner, M., Hartlage, S. A., et al. (2012). Premenstrual dysphoric disorder: evidence for a new category for DSM-5. American Journal of Psychiatry, 169(5), 465–475. https://pubmed.ncbi.nlm.nih.gov/22764360/

Loch, E. G., Selle, H., & Boblitz, N. (2000). Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. Journal of Women’s Health & Gender-Based Medicine, 9(4), 355-361. https://journals.sagepub.com/doi/abs/10.1089/152460900318515 

Nevatte, T., O’Brien, P. M. S., Bäckström, T., et al. (2013). ISPMD consensus on the management of premenstrual disorders with PMDD as a distinct entity. Archives of Women’s Mental Health, 16(4), 279–291. https://pubmed.ncbi.nlm.nih.gov/23624686/ 

Thys-Jacobs, S., Starkey, P., Bernstein, D., et al. (1998). Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. American Journal of Obstetrics and Gynecology, 179(2), 444–452. https://pubmed.ncbi.nlm.nih.gov/9731851/

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If you have been struggling to lose weight despite eating well and exercising, and you also deal with irregular periods, acne, or excess hair growth, polycystic ovary syndrome may be the missing piece of the puzzle. PCOS and weight gain are deeply connected, and understanding why makes all the difference in how you approach treatment.

What Is PCOS?

Polycystic ovary syndrome, commonly known as PCOS, is one of the most common hormonal disorders affecting women of reproductive age, impacting an estimated 8 to 13 percent of women worldwide according to the World Health Organization. It is characterized by hormonal imbalances, irregular menstrual cycles, elevated androgen levels, and in many cases the development of small cysts on the ovaries.

Why Does PCOS Cause Weight Gain?

The relationship between PCOS and weight gain is not simply about lifestyle. It is rooted in biology. The primary driver is insulin resistance, a condition in which the body’s cells do not respond properly to insulin, causing the pancreas to produce more of it. Excess insulin promotes fat storage, particularly around the abdomen, and makes losing weight significantly harder regardless of diet or exercise habits.

A study published in the Journal of Clinical Endocrinology and Metabolism found that up to 70 percent of women with PCOS have some degree of insulin resistance, even those who are not overweight. This means the weight struggle is not a matter of willpower. It is a metabolic issue that requires targeted medical support.

The Hormonal Cycle Making It Worse

PCOS creates a frustrating cycle. Excess weight worsens insulin resistance, which raises insulin levels further, which in turn drives up androgen production, which disrupts ovulation and worsens PCOS symptoms. Research published in Human Reproduction confirms that even a modest weight gain can significantly worsen hormonal imbalances in women with PCOS, while even a 5 to 10 percent reduction in body weight can restore ovulation, improve insulin sensitivity, and reduce androgen levels.

Other Reasons Weight Management Is Harder with PCOS

Beyond insulin resistance, several other factors make weight management more challenging for women with PCOS, including:

• Elevated cortisol levels, which promote abdominal fat storage
• Low-grade chronic inflammation, which interferes with metabolism
• Disrupted hunger hormones, with research showing women with PCOS have altered levels of ghrelin and leptin, the hormones that regulate appetite and fullness
• Sleep disturbances and fatigue, which are common in PCOS and directly affect metabolism and food choices

What the Science Says About Treatment

Managing weight with PCOS requires a strategy that addresses the hormonal root cause, not just calories. Evidence-based approaches include:

• A low glycemic index diet, which reduces insulin spikes and has been shown in multiple studies to improve both weight and hormonal markers in women with PCOS
• Regular resistance training combined with cardio, which improves insulin sensitivity and supports healthy body composition
• Metformin, a medication that improves insulin sensitivity and is commonly prescribed for PCOS-related weight and metabolic issues
• Inositol supplements, particularly myo-inositol, which a review in the International Journal of Endocrinology found to significantly improve insulin resistance, hormone levels, and menstrual regularity in women with PCOS
• GLP-1 receptor agonists, which are emerging as an effective option for women with PCOS and significant insulin resistance or obesity

When to See a Doctor

If you suspect PCOS is behind your weight struggles, a diagnosis is the critical first step. A women’s health provider can run hormonal panels, check insulin and glucose levels, perform an ultrasound, and create a personalized treatment plan that addresses both your metabolic health and your reproductive health together.

You are not failing at weight loss. Your hormones may simply be working against you, and that is something a doctor can help you fix.

Schedule your women’s health appointment with IVANA MD in Missouri City, TX. 

346-585-4077. 4220 Cartwright Road, Suite 201, Missouri City, Texas 77459.

References

Azziz, R., Carmina, E., Dewailly, D., et al. (2016). Polycystic ovary syndrome. Nature Reviews Disease Primers, 2(1), 16057.https://www.nature.com/articles/nrdp201657

Dunaif, A. (1997). Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocrine Reviews, 18(6), 774–800. https://academic.oup.com/edrv/article/18/6/774/2530788

Kiddy, D. S., Hamilton-Fairley, D., Bush, A., et al. (1992). Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clinical Endocrinology, 36(1), 105–111. https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.1992.tb02909.x 

Unfer, V., Carlomagno, G., Dante, G., & Facchinetti, F. (2012). Effects of myo-inositol in women with PCOS: a systematic review of randomized controlled trials. Gynecological Endocrinology, 28(7), 509–515. https://www.tandfonline.com/doi/abs/10.3109/09513590.2011.650660 

World Health Organization. (2026). Polycystic ovary syndrome. WHO Fact Sheets. https://www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome

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If you have just had an IUD inserted or are considering one, knowing what to expect afterward can make the experience much less stressful. IUDs are one of the most effective forms of long-acting reversible contraception available, but the days and weeks following insertion come with an adjustment period every woman should be prepared for.

What Is an IUD?

An intrauterine device is a small T-shaped device inserted into the uterus to prevent pregnancy. There are two main types: hormonal IUDs, which release a small amount of progestin, and copper IUDs, which are completely hormone-free. Both are over 99 percent effective according to the Centers for Disease Control and Prevention.

Immediately After Insertion

In the first few hours it is completely normal to experience:

• Moderate to severe cramping
• Dizziness or lightheadedness
• Light spotting or bleeding
• Nausea or pelvic heaviness

These symptoms typically ease within a few hours. Take ibuprofen before and after the procedure and plan to rest for the remainder of the day.

The First One to Three Months

With a hormonal IUD expect irregular spotting for the first three to six months, with periods gradually becoming lighter over time. With a copper IUD expect heavier periods and stronger cramping, particularly in the first few months. Research published in Contraception journal confirms that most bleeding irregularities resolve on their own with time.

Signs of Complications to Watch For

While serious complications are rare, contact your provider immediately if you experience:

• Severe pelvic pain that worsens after the first few days
• Heavy bleeding soaking through more than one pad per hour
• Fever, chills, or unusual discharge
• Pain during sex
• You can feel the hard plastic of the IUD

When Does It Become Effective?

Hormonal IUDs are effective immediately if inserted within the first seven days of your cycle. Otherwise use a backup method for seven days. Copper IUDs are effective immediately and can even be used as emergency contraception within five days of unprotected sex.

An IUD is a highly effective long-term option, but it should always feel like the right fit for your body and your life.

Schedule your women’s health appointment with IVANA MD in Missouri City, TX. 

346-585-4077

4220 Cartwright Road, Suite 201, Missouri City, Texas 77459.

References

Centers for Disease Control and Prevention. (2024). Intrauterine contraception. U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). https://www.cdc.gov/contraception/hcp/usspr/intrauterine-contraception.html 

ESHRE Capri Workshop Group. (2008). Intrauterine devices and intrauterine systems. Human Reproduction Update, 14(3), 197–208. https://academic.oup.com/humupd/article/14/3/197/683294

Heinemann, K., Reed, S., Moehner, S., & Minh, T. D. (2015). Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: The European Active Surveillance Study for Intrauterine Devices. Contraception, 91(4), 280–283.https://pubmed.ncbi.nlm.nih.gov/25601350/ 

Hidalgo, M., Bahamondes, L., Perrotti, M., et al. (2002). Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception, 65(2), 129–132. https://pubmed.ncbi.nlm.nih.gov/11927115/ 

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