Long Acting Reversible Contraceptives (LARCs)
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1)
Background
a.
Roughly half of US pregnancies are unplanned
b.
Typical use pregnancy rates are lowest for LARCs
c.
Increased use over last decade, from 1.3% in
2002 to 5.5% in 2006-2008.
d.
Increasing access possibly will continue this
trend: A study that showed that in the absence of barriers (financial,
knowledge, health care, logistical) LARCs were most popular form of
contraception
2)
Types
a.
Copper IUD (Paragard)
i. Design
1.
Copper T380A; polyethylene wrapped with copper
wire around stem/arms
ii. MOA
1.
Prefertilization
a.
Inhibition of sperm migration/viability
b.
Change in transport speed of ovum
c.
Damage/destruction of ovum
2.
Postfertilization – Occur pre-implantation
a.
Damage/destruction to fertilized ovum
iii. Use
1.
Up to 10 years
2.
Failure rate
a.
1yr 0.8/100 women
b.
10yr 1.9/100 women
iv. Complications
1.
Insertion difficulties
a.
Vasovagal, cervical dilation, pain, inability to
insert IUD, perforation
i. Perforation
<1:1000, less in practitioners with more experience
1.
Confirm location w/ XR
2.
Perforation into peritoneum requires removal by
laparoscopy or laparotomy
ii. Improved
with pretreatment NSAIDs, paracervial block, mechanical dilation, concomitant
U/S
2.
Expulsion 2-10%
a.
R/o if
i. Strings
are longer than expected
ii. Partner
reports penile discomfort
1.
May trim strings to cervical os or into
endocervical canal
v. Side
Effects & Non-contraceptive Considerations
1.
Heavier, longer menses, worsening menorrhagia
2.
Dysmenorrhea, cramping
3.
No change in cyclicity of menses, avoidance of
hormone exposure
vi. Contraindications
1.
Distortion of the uterine cavity
a.
More difficult to place, greater risk of
perforation/expulsion
2.
Acute pelvic infection
3.
Known or suspected pregnancy
4.
Unexplained abnormal uterine bleeding
a.
Perform EMB first to assess if hyperplasia or
malignancy are present
5.
Wilson’s Disease
b.
Levonorgestrel IUD
i. Design
1.
Polydimethylsiloxane sleeve containing levonorgestrel
in the stem
2.
Releases hormone daily
ii. MOA
1.
Prefertilization
a.
Increased amount/viscosity of cervical mucus
b.
To a lesser degree:
i. Inhibition
of sperm migration/viability
ii. Change
in transport speed of ovum
iii. Damage/destruction
of ovum
iii. Use
– Listed in decreasing amount of levonorgestrol released
1.
Mirena
a.
52mg Levonorgestrol
b.
FDA approved for 5yrs; may be effective to 7yrs
c.
Failure rate
i. 1yr
0.2/100 women
2.
Liletta
a.
52mg Levonorgestrol
b.
FDA approved for 3yrs, trials ongoing to see if
it can be used longer
3.
Kyleena
a.
19.5mg Levonorgestrol
b.
FDA approved for 5yrs
c.
Smaller in size and diameter
i. Easier
insertion
1.
Nulliparous
2.
Cervical Stenosis
4.
Skyla
a.
13.5mg Levonorgestrol
b.
FDA approved for 3yrs
c.
Smaller in size and diameter
i. Easier
insertion
1.
Nulliparous
2.
Cervical Stenosis
iv. Complications
1.
Same insertion difficulties
2.
Insertion difficulties
a.
Vasovagal, cervical dilation, pain, inability to
insert IUD, perforation
i. Perforation
<1:1000, less in practitioners with more experience
1.
Confirm location w/ XR
2.
Perf into peritoneum requires removal by
laparoscopy or laparotomy
ii. Improved
with pretreatment NSAIDs, paracervial block, mechanical dilation, concomitant
U/S
3.
Expulsion 2-10%
a.
R/o if
i. Strings
are longer than expected
ii. Partner
reports penile discomfort
1.
May trim strings to cervical os or into
endocervical canal
b.
Risk is higher in smaller sized IUDs
v. Side
Effects and Non-contraception Considerations
1.
Change in bleeding pattern
a.
Irregular menses, spotting (worst in first 6
months), amenorrhea, lighter menses
b.
This is seen less in lower dose IUDs (Skyla)
c.
Often administered to decrease menorrhagia,
reduce blood loss or anemia
2.
Improvement in endometrial hyperplasia
3.
Reduction in endometriosis-related pain and
dysmenorrhea
vi. Contraindications
1.
Distortion of the uterine cavity
a.
More difficult to place, greater risk of
perforation/expulsion
2.
Acute pelvic infection
3.
Known or suspected pregnancy
4.
Unexplained abnormal uterine bleeding
a.
Perform EMB first to assess if hyperplasia or
malignancy are present
5.
Active breast cancer
a.
Can be used in women with a history of breast
cancer if they are counseled regarding possible increased risk of breast cancer
recurrence
c.
Implants (Nexplanon)
i. Design
1.
Subdermal implant of ethylene vinyl acetate
copolymer core; contains 68mg etonogestrel surrounded by ethylene vinyl acetate
copolymer skin
a.
4cm in length by 2mm in diameter
b.
Radio-opaque
ii. MOA
1.
Progesterone suppresses ovulation via HPO axis
2.
Thickens cervical mucus
3.
Endometrial suppression
iii. Use
1.
Up to 3 years
2.
Failure rate
a.
1yr 0.05/100 women
iv. Complications,
Side Effects
1.
Insertion/removal: pain, bleeding, hematoma,
difficult insertion, unrecognized non-insertion
2.
Mild insulin resistance, but does not appear to
change glucose levels
3.
Weight gain of unclear amount
4.
Acne – most women have improvement, but ~10%
have worsening
v. Contraindications
1.
Known or suspected pregnancy
2.
Unexplained abnormal uterine bleeding
a.
Perform EMB first to assess if hyperplasia or
malignancy are present
3.
Active breast cancer
a.
Can be used in women with a history of breast
cancer if they are counseled regarding possible increased risk of breast cancer
recurrence
3)
Pertinent Issues
a.
Eligibility Categorization
i. 1:
No restriction for use (C1)
ii. 2:
Advantages generally outweigh risks (C2)
iii. 3:
Risks generally outweigh advantages (C3)
iv. 4:
Unacceptable health risk (C4)
v. There
may be different categories based upon initiation or continuation of a
contraception method
b.
Nulliparous/Adolescent women
i. Can
receive all LARCs, including IUDs (C2) and implant (C1)
ii. More
effective and higher satisfaction; high continuation rates
iii. IUDs
Similar expulsion in nulliparous vs multiparous
iv. No
e/o increased PID or infertility
c.
Timing of Insertion
i. Not
pregnant: can be inserted anytime during the cycle
ii. Immediately
postpartum
1.
High motivation, convenience, known to not be
pregnant, still at risk of unintended pregnancy
a.
Studies find high rates of unprotected
intercourse at 6w PP visit, and high rates of no shows for delayed LARC
insertion
2.
IUD
a.
Placental separation-4wks PP
i. Copper
IUD (C1); Levenorgestrel (C2)
b.
>4wks PP
i. Copper
and Levonorgestrel (C1)
c.
Patient should be seen 1wk after placement to
verify location and cut strings
d.
Breastfeeding: No difference in levels of
breastfeeding duration or infant growth
e.
Contraindications
i. Chorio/Endometritis,
Puerperal sepsis
1.
Insert 3 months PP
f.
Expulsion rate may be as high as 24%
i. Vaginal>Cesarean
ii. Benefits
of expulsion outweigh risks as some may not attend or not obtain IUD at PP
visit
3.
Implant
a.
Non-breastfeeding (C1)
b.
Breastfeeding <4w PP (C2), >4w (C1)
i. No
effect on lactogenesis or lactation failure, breaskmilk composition, neonatal
body length/weight, or head circumference
iii. Post-abortion
1.
Same benefits as PP insertion
2.
IUD” First-trimester (C1); Second-trimester (C2)
a.
Contraindicated <3mon after septic abortion
3.
Implant (C1)
iv. Emergency
Contraception
1.
Copper IUD effective <5d – pregnancy rate
<1%
d.
Effects on Menstruation
i. Should
be discussed with all patients prior to giving LARC
ii. Copper
IUD
1.
HMB and Dysmenorrhea
a.
Rates of discontinuation 2/2: 9.7/100 vs 1.3/100
for Levonorgestrel
b.
May treat w/ NSAIDs
c.
Often decreases over time
iii. Levonorgestrel
1.
Amenorrhea and spotting
a.
Rates of discontinuation 2/2: 4.3/100 vs 0/100
for Copper
b.
Pathophysiology: Levonorgestrel accumulates in
the endometrium, causes thinning of lining
i. Although
ovulation continues it cannot respond to systemic estrogen (which would cause
proliferation)
c.
33% have oligomenorrhea immediately, 70% have
oligo/amenorrhea by 2yrs
i. Supports
use of IUD for treatment of HMB
2.
Decreased dysmenorrhea
iv. Implant
1.
Bleeding is unpredictable
a.
Rates of discontinuation 2/2: 11.3/100
i. Low
body weight had less bleeding
ii. Women
w/ acceptable bleeding at 90d were likely to have acceptable bleeding at 2y
iii. Women
w/ unacceptable bleeding at 90d had 50% chance of improvement at 2y
2.
Decreases dysmenorrhea
e.
Backup contraception method
i. None
required if:
1.
Immediately postpartum/postabortion
2.
<5d of initiating menses
a.
Anyways consider pregnancy test if patient has
irregular menstruation or abnormal bleeding
3.
Immediately upon switching from OCPs
ii. Copper
IUD: None
iii. Levonorgestrel
IUD: 7d
iv. Implant:
7d
f.
Pregnancy with LARC in place
i. Risks
1.
Miscarriage: SAB and septic
2.
Placental: abruption, previa
3.
Fetus: LBW, preterm delivery
4.
Maternal: Cesarean delivery, chorioamnionitis
5.
Ectopic: Higher proportion of pregnancies are
ectopic, but lower overall risk 2/2 to their high effectiveness at preventing
pregnancy
a.
IUD may be given if h/o ectopic (C1)
ii. Management
1.
Remove w/out invasive procedure
a.
Risks are decreased after removal, but still
higher than a baseline pregnancy
g.
Removal in Postmenopausal Women
i. No
risks to leaving in place
1.
Levonorgestrel has endometrial benefits in women
using tamoxifen for BCa
ii. Menopause:
1yr since last period
iii. Levonorgestrel
may cause amenorrhea, so should measure FSH
h.
Cervical Procedures with IUD
i. Endometrial
biopsy
1.
Use small endometrial suction curettage
ii. Colposcopy,
ablation/excision
1.
Tuck IUD strings into cervix, or cut them
iii. LEEP
1.
Use a hollow tube (ex: hollow handle from
sterile applicators) to protect strings during procedure
i.
Actinomyces with IUD
i. Colonization
occurs and may be noted on cervical cytology
ii. Recs
in pt w/out sxs are to leave IUD in place; no Abx tx.
iii. Actinomycosis
1.
Granulomatous pelvic abscesses
a.
Rate: <0.001%
2.
Treatment
a.
Remove IUD
b.
Abx: PCN or doxycycline
i. Response
is slow and may take months
j.
STI Screening Prior to Insertion of IUD
i. Data
does not support routine screening
1.
STI at time of IUD placement does have increased
risk of PID
a.
Risk appears low
b.
Prevalence of STI in population is an important
predictor of PID
i. Risk
in most US populations is low, so screening based on history will identify most
as low-risk
ii. For
high-risk women (<25yo, multiple partners) reasonable to
1.
Screen prior to insertion
2.
Screen at time of insertion and treat later if
(+)
3.
Consider non-IUD option
a.
Very high-risk (eg sex workers) (C3)
iii. Infection
at time of insertion
1.
Asymptomatic women who happen to test positive
a.
Treat and leave IUD in place
2.
Mucopurulent cervicitis
a.
Treat before insertion
b.
TOC at 3-6m and if negative may place IUD
Image from the National Campaign to Prevent Teen and Unplanned Pregnancies
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