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

By

Karyn B. Kolman, MD

Susan K. Hadley, MD

Melody A. Jordahl-Iafrato, MD

This review provides practical tips—and dispels some common misconceptions—about these devices, which have higher rates of patient satisfaction and lower rates of failure than any other reversible contraceptives.

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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.

PRACTICE RECOMMENDATIONS

› Suggest long-acting reversible contraception (LARC), including intrauterine devices (IUDs), as a first-line method of contraception to most women, including adolescents and nulliparous women. A
› Offer immediate post-placental insertion of LARC when counseling women who have barriers to seeking contraception at a postpartum visit or are unlikely to return for a postpartum visit. B
› Treat sexually transmitted infections in most cases without removing an IUD that is already in place. Consider removing the IUD, however, if there is no clinical improvement after 2 to 3 days of antibiotics. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

The number of women using long-acting reversible contraception (LARC) in the United States has been increasing, with current use accounting for approximately 18% of reversible contraception, according to the National Survey of Family Growth.^1,2 LARC includes any method of contraception that lasts ≥3 years, is easily reversed, and does not rely on the user to maintain efficacy. Five LARC devices are available in the United States: 4 intrauterine devices (IUDs) and one subdermal implant.

The number of women using LARC is surprisingly low, given that it is considered a first-line contraceptive method for most women and adolescents,³ and when compared with other forms of reversible contraception, is more efficacious,^4-6 has higher satisfaction rates,^7-9 and higher rates of continuation.⁹ In fact, the Contraceptive CHOICE Project—a St. Louis community-based research program promoting and enabling access to reversible contraceptive methods—has shown that when appropriate counseling is provided and cost barriers are removed, up to 79% of women choose LARC as their preferred method of contraception.¹⁰

CASES › Jenny, who is 16 years old, comes to your office with her mother to discuss contraceptive options. She is nulliparous, has regular menses, and, aside from a body mass index (BMI) of 28, has no medical problems. Her mother is concerned about Jenny becoming pregnant while she is still in high school.

Maria D, a 32-year-old G2P1, comes in for a prenatal visit with her husband. She tells you that after delivery she is interested in a long-acting contraceptive, but is planning on breastfeeding and does not want anything to interfere with that.

What LARC options do these and other patients have?

The 4 IUDs and one implant approved for use are all viable options depending on a patient’s preference and comorbidities (TABLE 1).^3-9,11-15 The copper IUD is the oldest method of LARC available and the only one that is nonhormonal. It is approved by the Food and Drug Administration (FDA) for use up to 10 years,¹¹ but studies support its effectiveness for up to 12 years.¹⁶

Overweight and obese women enrolled in the Contraceptive CHOICE Project did not experience reduced contraceptive efficacy when using the implant when compared with normal-weight women.

The remaining IUDs (Skyla, Liletta, Mirena) contain varying amounts of the progestin levonorgestrel (LNG), released by each device at a slightly different rate that declines over time. Skyla releases a significantly lower dose of hormone than Liletta or Mirena.^12-14 Skyla and Liletta are FDA-approved for up to 3 years of use,^12,13 and Liletta is currently undergoing trials to gain approval for use up to 5 years. Mirena is FDA-approved for use up to 5 years,¹⁴ but studies have shown that it can be effective for 7 years.^4,16

The only implant available in the US is Nexplanon, a plastic rod containing 68 mg of etonorgestrel. It is inserted subdermally and is FDA-approved for use up to 3 years.¹⁵

Through systemic hormonal effects, the primary mechanism of action of the implant is prevention of ovulation. Additionally, the implant has been shown to inhibit endometrial proliferation and cervical mucus thickening, both of which may contribute to the implant’s overall effectiveness.¹⁷ In contrast, both the copper IUD and the LNG-IUDs work primarily by preventing fertilization. The LNG-IUDs also exhibit local hormonal effects (endometrial atrophy and thickened cervical mucus) that contribute to their effectiveness.¹⁷

Who is eligible for LARC?

LARC is suitable for the vast majority of women of reproductive age. For most multiparous women ≥20 years, all LARC devices are classified as category 1 (use without restriction) in the Centers for Disease Control and Prevention’s (CDC) US Medical Eligibility Criteria (US MEC).³ For women <20 years, the implant is also considered category 1, but IUDs in this age group are classified as category 2 (recommended with the caution that advantages usually outweigh risks) because of concerns about an increased risk of IUD expulsion and the increased prevalence of sexually transmitted infections (STIs) in adolescents.³ Contraindications to use of LARC vary depending on the method chosen (TABLE 1).³