Practical and straightforward information on LARC

Committee on Practice Bulletins-GYNECOLOGY Practice Bulletin #186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e251–69. Full text of Practice Bulletin #186 is available to ACOG members at https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Long-Acting-Reversible-Contraception-Implants-and-Intrauterine-Devices

LONG-ACTING REVERSIBLE CONTRACEPTION: IMPLANTS AND INTRAUTERINE DEVICES
Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).

Commentary: Practical and straightforward information on LARC

Much has been written about long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and contraceptive implants.  As top tier contraception, they are THE most effective means of reversible contraception available. I used to describe IUDs as the “Cadillac” model of birth control, although I’ve now updated my phrase, and talk about the “Lexus” model. In addition to being as effective as sterilization, their ease of use is making them increasingly popular among women of all age groups. The American College of Obstetricians and Gynecologists (ACOG) issued Practice Bulletin #186 Long-Acting Reversible Contraception: Implants and Intrauterine Devices” in November 2017.¹ In addition, ACOG has a number of other clinical resources on LARC options including: Committee Opinion #672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods, Committee Opinion #760: Immediate Postpartum Long-Acting Reversible Contraception, Committee Opinion #670: Increasing Access to Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy, and Committee Opinion #735: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices (available to ACOG members at https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/LARC-Clinical-Resources)

Practice Bulletin #186 highlights the increasing use of LARCs by US women-13.8% in 2013-2014, the most recent year for which US national data are available.^1,2 In the United States, rates of unintended pregnancy in general, and unintended pregnancies among adolescents in particular, have significantly declined, attributable in part to increased use of LARC.³

The Bulletin provides a summary of the evidence for the efficacy and safety of LARC, which have few medical contraindications and can be used by most women.⁴

The Bulletin answers the question of appropriateness for nulliparous women and adolescents with a straightforward response, declaring, “Intrauterine devices and the contraceptive implant should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents.”⁵ The document highlights insertion of LARC immediately after an induced or spontaneous abortion, while noting a somewhat higher risk of IUD expulsion after a second-trimester procedure. In addition, ACOG supports immediate postpartum LARC insertion (before hospital discharge) as a best practice that is convenient for women and clinicians, and that addresses women’s high motivation to prevent a rapid repeat pregnancy during this time period. For IUDs, immediate postpartum insertion is defined as insertion within 10 minutes after delivery of the placenta, obviating the need for insertion at a postpartum visit, as many women do not follow up at that time and, thus, miss the opportunity for effective contraception. There is a trade-off for the convenience of early postpartum IUD insertion, with a somewhat increased risk of IUD expulsion.  

LARC methods clearly impact menstrual bleeding, but the effects on bleeding differ by method. Preventive guidance and counselling about expected bleeding changes with LARC can allow women to make an informed choice and can improve satisfaction and continuation. The IUD that releases 20-µg  levonorgestrel/day is approved by the US Food and Drug Administration for treatment of heavy bleeding in women who use the method for contraception, resulting in a marked reduction in menstrual blood loss of 79% to 97%.⁶  One important use of the copper IUD is that it is the most effective option for emergency contraception when inserted within 5 days of unprotected intercourse; the Practice Bulletin notes that it should be routinely offered to women who request emergency contraception and are eligible for IUD use. 

 The ACOG Practice Bulletin answers a variety of practical questions about LARC methods including effects on breastfeeding, timing of insertion, and options for managing menstrual changes associated with LARC methods by summarizing the evidence and recommendations, sorted by their level of evidence ranging from good and consistent (Level A) to consensus and expert opinion (Level C). It’s a worthwhile reference for clinicians.

Disclosures:

The author reports no potential conflicts of interest with regard to this article

References:

ACOG ABSTRACT REFERENCES

• Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subsequent fertility-follow-up after participation in a randomized clinical trial. Contraception 2007;75:88–92.

• Andersson K, Batar I, Rybo G. Return to fertility after removal of a levonorgestrel-releasing intrauterine device and Nova-T. Contraception 1992;46:575–84.

• Clinical challenges of long-acting reversible contraceptive methods. Committee Opinion No. 672. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e69–77.

COMMENTARY REFERENCES

• Kavanaugh ML, Jerman J, Finer LB. Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012. Obstet Gynecol. 2015;126(5):917-927.

• Heisel E, Kolenci GE, Moniz M, Kobernick, EK, Minadeo L, Kamdar NS, et al. Intrauterine Device Insertion Before and After Mandated Health Care Coverage: The Importance of Baseline Costs. Obstet Gynecol 2018; 131(5):843-849.

• Harper CC, Rocca CH, Thompson KM, Morfesis J, Goodman S, Darney PD, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015;386:562–8.

• Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016;65(3):1-103.

• Long-acting reversible contraception: implants and intrauterine devices. Practice Bulletin No. 186. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e251–69

• Varma R, Sinha D, Gupta JK. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)--a systematic enquiry and overview. European journal of obstetrics, gynecology, and reproductive biology. 2006;125(1):9-28.