Leveraging long-acting reversible contraceptives (LARCs)

Dr. Singh is an assistant professor in the Department of Obstetrics and Gynecology at the University of New Mexico, Albuquerque, and Dr. Espey is a professor in the Department of Obstetrics and Gynecology at the University of New Mexico, Albuquerque.

Neither author has a conflict of interest to disclose with respect to the contents of this article.

Intrauterine devices (IUDs) and the subdermal implant-together called long-acting reversible contraceptives (LARCs)-are the most effective contraceptive methods available in the United States. LARC methods are user independent, forgettable, and have high continuation and satisfaction rates. In this article, we review the basics of IUDs and implants and present case scenarios to help providers expand the use of LARC in their patients.

Unintended pregnancy rates have increased slightly over the last decade in the United States. Of the 6.7 million pregnancies in 2006, approximately 3.2 million were unintended, and 1.4 million ended in abortion.¹ About 95% of unintended pregnancies occur in women who are incorrectly, inconsistently, or not using contraception.² The use of modern contraceptives has been hailed as 1 of the 10 great public health successes of the 20th century.³ Birth control pills are the most popular form of contraception among US women with typical failure rates of 9% and continuation rates of 67% at 1 year.⁴ LARC methods, which include intrauterine devices (IUDs) and the subdermal implant, are highly effective with failure rates of less than 1% and high continuation and satisfaction rates. Despite the few contraindications to the use of LARC methods and their proven safety and efficacy, only about 8.5% of women in the United States use LARCs.⁵

With stubbornly high unplanned pregnancy rates and despite an increase in the uptake of LARC methods from 2.4% in 2002 to 8.5% in 2009,⁵ there is room for improvement. Rates of uptake and use of LARC methods are affected by provider practices, access, cost, and women’s attitudes and knowledge of methods.⁶ Yet when women seeking birth control understand the benefits of LARC methods and see providers who are willing to initiate these methods, they tend to choose them preferentially.

The Contraceptive CHOICE project is a prospective cohort of more than 9,000 women aged 14 to 45 years who were given the freedom to choose a contraceptive method from IUDs, implant, depot medroxyprogesterone acetate (DMPA) injection, pills, patch, or ring without the limitation of financial, provider, or logistical barriers.⁷ An initial analysis of 7,486 women showed more than 75% chose an IUD or implant as their contraceptive method. This study also confirmed significantly higher contraceptive failure rates for pills, patch, and ring users compared with DMPA, IUD, and implant users. Additionally, the study demonstrated higher failure rates of pills, patch, and ring in adolescents than in older women using the same methods. A subsequent analysis of all 9,256 women enrolled in the CHOICE study confirmed a 75% uptake of a LARC method and a significant reduction in this population of abortion rates, repeat abortions, and teenaged birth rates; data points that all serve as a proxy for unintended pregnancies.⁸

^{NEXT: LARC OPTIONS >>}

LARC Options

There are 2 IUDs available in the United States: the copper T 380A IUD (ParaGard) and the levonorgestrel intrauterine contraception system (LNG-IUS). The only subdermal implant available in the United States is an etonogestrel implant called Nexplanon, which is bioequivalent to the previously marketed Implanon.

Copper IUD

The nonhormonal copper T 380A IUD is T-shaped, with copper wire wrapped around the stem and arms. It primarily prevents pregnancy by inhibiting fertilization. The hypothesized mechanisms of action include inhibition of sperm migration and survival, alteration in transport of the ovum, and damage to or destruction of the ovum.^9,10 The copper IUD is FDA approved for up to 10 years of use, and data suggest effectiveness up to 12 years.¹¹ The reported failure rate is 0.8 per 100 women at 1 year.⁴ The most common adverse effects reported with the use of the copper IUD include abnormal bleeding and pain.^9,10

LNG-IUS

The LNG-IUS is T- shaped with a sleeve containing 52 mg of LNG in the stem.^9,10 Its mechanism of action is similar to the copper IUD, and primarily prevents fertilization. The LNG-IUS also suppresses the endometrial lining and changes the amount and viscosity of cervical mucus, which inhibits sperm motility and capacitation. The LNG-IUS is FDA approved for up to 5 years but may be effective for up to 7 years.^10,12,13 The failure rate at 1 year is 0.2 per 100 women.⁴ The LNG-IUS releases 20 mcg of LNG daily. This small amount of progesterone has minimal systemic adverse effects and several noncontraceptive benefits.^9,10 The LNG-IUS may decrease average monthly blood loss by up to 90% and up to 20% to 40% of users may become amenorrheic by 1 year of use. In addition, the LNG-IUS reduces heavy menstrual bleeding, dysmenorrhea, and pelvic pain, and can be used to treat endometrial hyperplasia with and without atypia.¹⁴

Contraceptive implant

The subdermal implant is a single 4-cm rod that contains 68 mg of the third-generation progestin etonogestrel.^10,15 It is FDA approved for up to 3 years of use and has an approximate failure rate of 0.5 to 1 per 1,000 insertions. The implant suppresses ovulation almost completely during the 3 years of its use.^15-17 Other contraceptive mechanisms include inhibition of sperm motility by thickening the cervical mucus and thinning the endometrial lining.¹⁷ Few contraindications exist to the placement of the subdermal implant.^15,18,19 The main adverse effect is irregular bleeding, and complications related to insertion and removals are rare. Clinicians are required to complete formal company-sponsored training for insertion and removal of the implant.

NEXT: CASE SCENARIOS >>

LARC case scenarios

Case 1: IUD in a 16-year-old

Ariel is a 16-year-old nulliparous female who has been sexually active with her 16-year-old boyfriend for the last 6 months. They have been using condoms for contraception. Ariel presents to you for contraceptive counseling and is interested in not getting pregnant until she has completed college. Her pregnancy test is negative and she has not had unprotected intercourse in the last 2 weeks.

Q: Is an IUD an appropriate choice for Ariel?

A: IUDs are safe and effective options for adolescents both as contraceptives and for noncontraceptive benefits such as treating menorrhagia. Seven in 10 young women have had sexual intercourse by the time they reach age 19.²⁰ Every year, almost 750,000 US women aged 15 to 19 years become pregnant. Condoms and oral contraceptive pills are the most common contraceptive methods used by teenagers in the United States and the failure rates in this population are high.⁷ IUD uptake in adolescents is only about 3.6% for women aged 15 to 19 years.²¹ Among adolescents attending a family planning clinic, 55% were not aware of the IUD as a contraceptive option.²² Those who had heard of IUDs from healthcare providers were almost 3 times as likely to be interested in using them.

In 2005, the FDA approved use of the copper T 380A in nulliparous women and the data submitted for this indication can, and should, be applied to the LNG-IUS as well.²³ Professional organizations including the American College of Obstetricians and Gynecologists (ACOG) endorse the use of IUDs in nulliparous and multiparous teenagers.²⁴ The US Medical Eligibility Criteria (USMEC; Table 1) created by the Centers for Disease Control and Prevention (CDC) provide evidence-based guidance to providers for the prescription and use of contraceptives. The USMEC give the use of IUDs in nulliparous and adolescent women a category 2 rating, meaning the advantages of using a method outweigh the theoretical or proven risks.²⁵

There are no apparent increased risks associated with IUD placement and use in adolescents versus adult women. Risk of developing pelvic inflammatory disease (PID) in the first 20 days after insertion of an IUD is less than 1% and drops to about 1 in 1,000 thereafter.⁹ In the absence of a cervical infection, risk of PID with IUD placement is 0% to 2% compared with approximately 0% to 5% in the setting of a documented infection.²⁶ Asymptomatic women diagnosed with chlamydia on tests obtained at the time of IUD insertion can be treated with antibiotics and the IUD retained in situ; they are unlikely to develop PID. The LNG-IUS may actually lower the risk of PID by thickening cervical mucus.²⁷

IUDs do not affect fertility and are safe for nulliparous women.²⁸ Fertility is affected by a history of chlamydia infection and not by prior use of an IUD.²⁹ Prophylactic antibiotics are not indicated for IUD insertion.²⁷ Adolescents should be screened for sexually transmitted infections (STIs) based on CDC criteria for STIs.

Risk of uterine perforation at the time of IUD insertion is 1 per 1,000 placements. Risk of expulsion varies from 2% to 10% within the first year of use and may be slightly higher in nulliparous women, those aged younger than 20 years, and women with severe dysmenorrhea or menorrhagia.⁹

Q: Are special measures required for IUD insertion in an adolescent?

Scant data exist to show that IUD insertion is more difficult in adolescents. Most adolescents report mild to moderate pain with insertion and about 21% report severe pain.²² Good quality data on options for pain relief are limited. Misoprostol does not appear to increase ease of insertion but increases pain prior to insertion.^30,31 Nonsteroidal anti-inflammatory drugs for treatment of pain with IUD insertion are ineffective but do help with pain and bleeding associated with continuing IUD use.^31,32

Q: Can Ariel get her IUD at this visit?

Same-day insertion is ideal in reducing barriers such as transportation problems or waning motivation. An IUD can be placed at any time during the menstrual cycle as long as a pregnancy can be reliably ruled out and if there is no evidence of an active pelvic infection such as mucopurulent cervicitis. All teenagers should undergo STI screening and treatment according to CDC recommendations. Screening for STIs can take place at the same clinic visit for IUD insertion. Ariel is a good candidate for IUD use and for same-day insertion.

Case 2: Implant in a breastfeeding patient

Beyoncé G. is a 23-year-old gravida 2 para 2 patient who is day-2 postpartum and breastfeeding. She is interested in using a contraceptive implant and having it placed before she leaves the hospital.

Q: Is the implant an appropriate choice for a breastfeeding woman?

A. The USMEC consider implant insertion in a breastfeeding woman safe.²⁵ Limited studies show that this progestin-only contraceptive does not adversely affect initiation or continuation of breastfeeding or growth and development of the infant.^33-35

Q: When is the appropriate time to insert an implant in a postpartum breastfeeding woman?

A. Limited evidence supports the safety of the implant at any time postpartum in women who are not breastfeeding (category 1) or in those who are breastfeeding (category 2; Table 2).²⁵ Implant placement before 4 weeks is a category 2 recommendation because of theoretical concerns about the transfer of low concentrations of etonogestrel in breast milk to the neonate. However, the theoretical risks are often outweighed by the benefits of implant placement prior to discharge, given the potential for early ovulation after delivery, likelihood that a woman may not return for the postpartum visit, or possibility that her insurance coverage may expire. Beyoncé is a good candidate for implant placement prior to hospital discharge.

Case 3: Postabortal IUD

Sarah L., a 35-year-old gravida 4 para 3, was diagnosed with a 10-week early pregnancy failure. She is interested in surgical management and also wants an IUD.

Q: Can you place the IUD immediately after her dilation and curettage (D&C)?

A: Insertion of an IUD or an implant immediately after an uncomplicated D&C is safe, effective, and convenient for the patient.³⁶ It avoids an additional procedure and confers immediate contraceptive protection. The USMEC classify placement of an IUD or implant immediately after a first-trimester uterine aspiration as category 1.²⁵ The rating is category 2 for placement immediately after a second-trimester dilatation and evacuation. The risks of complications of immediate postprocedure IUD insertion are very low and are similar to those for interval insertion.^10,36 A large randomized controlled trial demonstrated no increased risk of expulsion with immediate post-first-trimester abortion IUD placement compared with delayed IUD placement.³⁷ IUD use is higher at 6 months with immediate postprocedure insertion compared with use in those where insertion was delayed until 2 to 4 weeks later. Sarah L. should be offered an immediate postprocedure IUD insertion.

Summary

LARC methods have the potential to reduce the high rate of unintended pregnancy in the United States. Ob/gyns should consider an expanded spectrum of women as appropriate candidates for LARC use.

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