ACOG updates guidelines on long-acting, reversible contraceptives

The American College of Obstetricians and Gynecologists has issued new clinical management guidelines for long-acting reversible contraceptives (LARCs): intrauterine devices (IUDs) and contraceptive implants. Practice Bulletin 121, published in Obstetrics and Gynecology (2011;118[1]:184-196), updates guidelines published in January 2005.

The guidelines note that LARCs are the most effective reversible contraceptives, with the advantages of not requiring ongoing effort by the user and rapid return of fertility after removal. A copper IUD is the most effective method of postcoital contraception when inserted up to 5 days before unprotected intercourse. Patients should receive anticipatory guidance about the effect of LARCs on menstrual bleeding.

LARCs have few contraindications, and “almost all women are eligible for implants and IUDs,” according to the guidelines. Nulliparous and adolescent women can use both implants and IUDs. Although the levonorgestrel intrauterine system isn’t specifically approved for nulliparous women, the US Medical Eligibility Criteria for Contraceptive Use classify both copper and levonorgestrel IUDs as Category 2 for nulliparous and adolescent women, noting that the advantages generally outweigh the risks. The contraceptive implant is rated Category 1 (ie, no restriction) for both groups. Women with a history of ectopic pregnancy can use IUDs.

An IUD or implant may be inserted at any time during the menstrual cycle “as long as pregnancy may be reasonably excluded,” the guidelines state. Inserting an IUD or implant immediately after an abortion or miscarriage is safe and effective as is immediate postpartum IUD insertion (within 10 minutes of placental separation). An implant may be inserted safely at any time after childbirth in women who aren’t breastfeeding and more than 4 weeks postpartum in women who are breastfeeding. The US Medical Eligibility Criteria for Contraceptive Use classify placing an implant in breastfeeding women less than 4 weeks after childbirth as Category 2 because of theoretical concerns about milk production and infant growth and development.

The guidelines don’t recommend routine antibiotic prophylaxis to prevent pelvic infection before IUD insertion. They do suggest screening for sexually transmitted infections in women at high risk (ie, 25 years of age or younger or those with multiple sex partners), while placing the IUD on the same day and treating infection if test results are positive, or when results become available.

The United States Food and Drug Administration and the World Health Organization recommend that IUDs be removed from pregnant women without resorting to an invasive procedure when possible. The devices can be left in place for endometrial biopsy, cervical colposcopy, and cervical ablation or excision.