Long-Acting Reversible Contraception (LARC)

Adapted from NEJM 2/2/2017 review article, “Long-Acting Reversible Contraception”:

THE PROBLEM:

  • Unintended pregnancies are common in the US, though decreasing from 2008 to 2011:  45% of US pregnancies are unintended (compared to 35% in W Europe).  54/1000 in 2008 down to 45/1000 in 2011.
  • From 2011-13, only 62% of women 15-44 yo were using contraception; IUDs were 10%, implants 1% – these highly effective methods are underutilized.

AVAILABLE METHODS:

  1. IUDs:  Cu-containing (Paraguard); and levonorgestrel (LNG)-containing (Mirena, Liletta, Kyleena and Skyla).
    1. Paraguard = 10 years
    2. 52mg LNG: Mirena 5 years; Liletta 3 years (5 y approval pending).
    3. 19.5mg LNG:  Kyleena 5 years
    4. 13.5mg LNG: Skyla 3 years
  2. Subdermal hormonal implant:  Nexplanon

EFFICACY:

  • 20x as effective as OCPs, patch or ring!
  • Young women (<21yo) -> 2x failure rate with OCP, patch, ring; but no increased failure with LARC.

IUDs

MECHANISM OF IUDs:

  • LARCs do NOT abort a fertilized, implanted embryo.
  • Cu – toxic to sperm
  • LNG – suppresses ovulation and thickens cervical mucus

EFFICACY OF IUDs:

  • < 1% pregnancy in the first year of use
  • LNG – 0.1-0.2%
  • Cu -0.5-0.8%

CONTINUATION RATES OF IUDs:

  • 85-88% at 1 year; 80% at 2 years; 52-56% at 5 years.

CONTRAINDICATIONS TO IUD USE:

  • Current pelvic infection or STD (if IUD already in, leave it in and treat the STD)
  • Current gyn cancer
  • Current or recent breast CA (avoidance recommended though evidence unclear)
  • If pt screened according to CDC guidelines (e.g., yearly GC/chlam for pts <25yo), no extra screening needed prior to insertion.

CAUTIONS AND EDUCATION RE IUD USE:

  • Cu IUD likely to increase menstrual bleeding
  • LNG IUD likely to decrease menstrual bleeding
  • All IUDs likely to cause some irregular, spotty bleeding
  • Cu IUD can be used as emergency contraception placed after intercourse

HORMONAL IMPLANT (Nexplanon in US)

MECHANISM OF NEXPLANON:

  • Etonorgestrol secretion
  • Decreases ovulation
  • Thickens cervical mucus

EFFICACY:

  • 0.1% pregnancy at 1 year (independent of BMI)
  • 82% continuation at one year

CONTRAINDICATION:

  • Current or recent breast cancer (recommendation, but evidence unclear)

CAUTIONS:

  • Irregular bleeding, spotting common
  • Amenorrhea achieved in about 20%

LARC USE IN SPECIFIC POPULATIONS:

  • PID:  low risk, <1% even without STD screening prior to insertion
    • LNG may protect against pelvic infection
  • Post-partum and post-abortion:  safe to insert immediately, less expulsion if inserted immediately after placental delivery.
  • Breast-feeding:  may increase risk of perf, but unclear (5.6/1000)
  • No clear effect on breastfeeding success or the breastfed infant

AREAS OF UNCERTAINTY:

Barriers to use:

  • Low awareness
  • Lack of trained clinicians
  • Low reimbursement for procedure
  • Extra steps, extra visits (unnecessary)
  • Catholic healthcare systems

If STD acquired with IUD in place, leave it in and treat the STD per usual.

HIV and LNG-IUDs:  Some HIV drugs (ritonavir and efavirenz) may reduce LNG levels, increasing pregnancy risk.   Counsel pts accordingly.

 

 

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