Long-acting reversible contraception: Who, what, when, and how

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Applied Evidence

Long-acting reversible contraception: Who, what, when, and how

J Fam Pract. 2015 August;64(8):479-484

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References

1. Daniels K, Daugherty J, Jones J. Current contraceptive status among women aged 15-44: United States 2011-2013. NCHS data brief, no. 173. Hyattsville, MD: National Center for Health Statistics, 2014.

2. Branum AM, Jones J. Trends in long-acting reversible contraception use among US women aged 15-44. NCHS data brief, no. 188. Hyattsville, MD: National Center for Health Statistics, 2015.

3. Centers for Disease Control and Prevention (CDC). US medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep. 2010;59:1-86.

4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011;118:184-196.

5. Pickle S, Wu J, Burbank-Schmitt E. Prevention of unintended pregnancy: a focus on long-acting reversible contraception. Prim Care. 2014;41:239-260.

6. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366:1998-2007.

7. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117:1105-1113.

8. O’Neil-Callahan M, Peipert JF, Zhao Q, et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol. 2013;122:1083-1091.

9. Grunloh DS, Casner T, Secura GM, et al. Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use. Obstet Gynecol. 2011;117:705-719.

10. Birgisson NE, Zhao Q, Secura GM, et al. Preventing unintended pregnancy: the contraceptive CHOICE project in review. J Womens Health (Larchmt). 2015;24:349-353.

11. ParaGard T 380A. (intrauterine copper contraceptive) [package insert]. Sellersville, PA : Teva Pharmaceuticals USA, Inc., 2013.

12. Skyla (levonorgestrel-releasing intrauterine system) [package insert]. Wayne, NJ : Bayer HealthCare Pharmaceuticals, Inc., 2013.

13. Liletta (levonorgestrel-releasing intrauterine system) [package insert]. Parsippany, NJ : Actavis Pharma, Inc., 2015.

14. Mirena (levonorgestrel-releasing intrauterine system) [package insert]. Whippany, NJ : Bayer HealthCare Pharmaceuticals, Inc., 2014.

15. Nexplanon (etongestrel implant) [package insert]. Whitehouse Station, NJ: Merck & Co Inc.; 2014.

16. Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception. 2014;89:495-503.

17. Stoddard A, McNicholas C, Peipert JF. Efficacy and safety of long-acting reversible contraception. Drugs. 2011;71:969-980.

18. Xu H, Wade JA, Peipert JF, et al. Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women. Obstet Gynecol. 2012;120:21-26.

19. Centers for Disease Control and Prevention (CDC). US selected practice recommendations for contraceptive use. MMWR Recomm Rep. 2013;62:1-60.

20. Centers for Disease Control and Prevention (CDC). Sexually transmitted disease treatment guidelines. MMWR Recomm Rep. 2010;59:1-110.

21. Gurtcheff SE, Turok DK, Stoddard G, et al. Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial. Obstet Gynecol. 2011;117:1114-1121.

22. Chen BA, Reeves MF, Creinin MD, et al. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration. Contraception. 2011;84:499-504.

23. Heinemann K, Reed S, Moehner S, et al. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception. 2015;91:274-279.

24. Tocce K, Sheeder J, Python J, et al. Long acting reversible contraception in postpartum adolescents: early initiation of etonogestrel implant is superior to IUDs in the outpatient setting. J Pediatr Adolesc Gynecol. 2012;25:59-63.

25. Mwalwanda CS, Black KI. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust N Z J Obstet Gynaecol. 2013;53:331-337.

26. Sober, S, Schreiber CA. Postpartum contraception. Clin Obstet Gynecol. 2014;57:763-776.

27. Dickerson LM, Diaz VA, Jordon J, et al. Satisfaction, early removal, and side effects associated with long-acting reversible contraception. Fam Med. 2013;45:701-707.

28. Berenson AB, Tan A, Hirth JM. Complications and continuation rates associated with 2 types of long-acting contraception. Am J Obstet Gynecol. 2015;212:e1-e8.

29. Kavanaugh ML, Frowirth L, Jerman J, et al. Long-acting reversible contraception for adolescents and young adults: patient and provider perspectives. J Pediatr Adolesc Gynecol. 2013;86:86-95.

30. Espey E, Ogburn T. Long-acting reversible contraceptives: intrauterine devices and the contraceptive implant. Obstet Gynecol. 2011;117:705-719.

31. Madden T, McNicholas C, Zhao Q, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol. 2014;124:718-726.

Common adverse effects

The most common adverse effect seen with all LARC devices is an alteration in menstrual bleeding, and a frequent adverse effect with IUDs is pain. Vaginitis is less common and can be seen with any of the devices. The progestin-containing LARC devices are associated with hormonal effects: vaginitis, headache, weight gain, acne, breast pain, hair loss, and emotional lability.^12-15

Copper IUD. Many women using the copper IUD experience either a transient increase in menstrual bleeding lasting for a few months or inter-menstrual bleeding that tends to continue for the duration of use.^4,17 However, according to data from the Contraceptive CHOICE Project, the most common reason cited for early discontinuation of the copper IUD is pain and cramping.⁹

LNG-IUDs. Like the copper IUD, many users of LNG-IUDs experience an initial increase in menstrual bleeding. However, unlike the other LARC devices, 20% to 33% of Mirena users are likely to experience amenorrhea after one year of use and 70% at 2 years.^4,14 According to package inserts, amenorrhea after 3 years is less common with both Skyla (12%) and Liletta (38%).^12,13 As with the copper IUD, based on data from the Contraceptive CHOICE Project, the most common reason cited for early discontinuation of LNG-IUDs is pain and cramping.⁹

Subdermal implant. Changes in menses in women using the subdermal implant range from amenorrhea (22%) to prolonged bleeding (18%).^15,17 Although it is difficult to predict which pattern a particular woman will experience, heavier women are more likely to have heavier bleeding patterns, and initial bleeding patterns are predictive of future ones.⁴ The most common reason women choose to discontinue use of the implant is abnormal bleeding.^4,9,27,28

Newer IUDs do not increase risk of STIs

Many patients and clinicians erroneously believe that IUDs increase the risk of STIs and therefore assume that patients with a history of STI are not appropriate candidates for an IUD.²⁹ There is a slightly increased risk of pelvic inflammatory disease (PID) in the first 21 days after insertion of an IUD. However, in contrast to older IUDs, currently available IUDs do not increase the general risk for STIs.^17,30

Risk of infertility is nil

There is no risk of infertility from use of currently available LARCs. For those who want to become pregnant, fertility typically returns immediately after removal of the device, regardless of which method of LARC is used.^11-15,30

Complications of IUD insertion

Uterine perforation. Uterine perforation occurs in 0.8 to 2.1 per 1000 women, usually at the time of IUD placement. If IUD strings are not visible during a speculum examination, locate the IUD with ultrasound.^4,17,30 If the IUD is in the abdomen, refer to a gynecologist for laparoscopic removal and select another form of contraception for use in the interim.³⁰

Expulsion. Rates of expulsion are low, occurring in less than 10% of women^4,17 and are not affected by parity or BMI.³¹ Expulsion rates are higher when the IUD is inserted immediately postpartum.^4,25,26 Adolescents also have a 2-fold higher risk of uterine expulsion than older women.³¹

Ectopic pregnancy. Although a woman’s overall risk of ectopic pregnancy is not increased by using an IUD,⁴ it is true that if a woman becomes pregnant with an IUD in place, the pregnancy is more likely to be ectopic. Thus, if pregnancy is confirmed in a woman with an IUD in place, rule out ectopic pregnancy.

The most common reason for early discontinuation of IUDs is pain and cramping.

The FDA and the World Health Organization recommend that if an intrauterine pregnancy is confirmed with an IUD in place and the strings are visible, the IUD should be removed.⁴ Although removing the IUD increases the risk of spontaneous abortion (SAB) as compared with pregnancies without an IUD in place, the risk of SAB is still lower than if the IUD is left in place.⁴ Additional risks of continuing a pregnancy with an IUD in place include increased risks of preterm labor, chorioamnionitis, and septic abortion.^4,30

Complications of subdermal implant insertion

After insertion of the implant, women usually experience temporary bruising and soreness at the insertion site. Less than 1% of women develop an infection or hematoma.¹⁷ There is a low risk of nerve damage if the implant is inserted too deeply.¹⁵ Removal of the subdermal implant is recommended if pregnancy occurs.¹⁵

For those who want to become pregnant, fertility typically returns immediately after removal of the device, regardless of which form of long-acting reversible contraception is used.

CASE DECISIONS › Jenny has been using oral contraceptive pills, but not regularly. You suggest that LARC may be a better option and counsel her that if she does choose an IUD or the implant, it is likely that her menses will change. You provide information and reassurance that LARC is safe to use in adolescents. Jenny says she would like to try an implant. Six months later, Jenny returns and says the implant is working well. She has some irregular bleeding, but it is not bothersome.