LARC methods: 7 things you need to know

EXECUTIVE SUMMARY

More women are now choosing long-acting reversible contraception (LARC) methods, such as intrauterine devices (IUDs) and the subdermal contraceptive implant. The number of women using LARC methods rose from 2.4% in 2002 to 8.5% in 2009.¹ What do you need to know about LARC methods to inform counseling and provide such methods in your practice?

Incorporate the following points in your clinical database, suggests Anne Burke, MD, MPH, associate professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University of School of Medicine in Baltimore. Burke spoke on the importance of LARC methods at the recent Contraceptive Technology Quest for Excellence conference in Atlanta.²

First, clinicians who are committed to driving down rates of unintended pregnancy need to know that LARC methods work, and they work very well. Burke points to results from the Contraceptive CHOICE project in St. Louis, which was designed to evaluate reversible birth control methods. Its research indicates dramatic differences in method effectiveness. Women who used birth control pills, the patch, or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device or implant.³ (To read more about the research, see the Contraceptive Technology Update articles, "Research proves LARC methods are best — What happens now in practice?" August 2012, p. 85, and "New data: Long-acting reversible methods superior in effectiveness," July 2012, p. 73.)

Secondly, further research from the CHOICE project shows that women like LARC methods, notes Burke. In looking at CHOICE data, IUDs and the subdermal implant have the highest rates of satisfaction and 12-month continuation over the Pill, patch, vaginal ring, and contraceptive injection.⁴ After 24 months, continuation rates for long-acting reversible contraception and non-LARC methods were 77% and 41%, respectively. Continuation rates for the levonorgestrel and the copper IUDs were similar (79% compared with 77%), whereas the implant continuation rate was lower (69%, P<.001) compared with IUDs at 24 months.⁵

Barriers left to remove

Many clinicians might cling to two-visit protocols for IUD insertion to prescreen for sexually transmitted infections (STIs) to reduce the probability of pelvic inflammatory disease (PID). In making her third point, Burke notes 2012 data that show the risk of developing PID following insertion of an intrauterine device is very low, whether or not women have been screened beforehand for gonorrhea and chlamydia.⁶

How about IUD insertions for young women who will not, with certainty, be in a relationship with only one man?

IUDs do not cause infections, says Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. Indeed, it would appear that the levonorgestrel IUD (Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ) actually prevent infections because of the thick cervical mucus it causes and perhaps because of the decrease in menstrual blood loss experienced with its use. Hatcher presented this information, along with other contraceptive topics, at the Atlanta conference.⁷

"Sexual intercourse with a man who has an infection is the culprit, and this strongly suggests that women using any contraceptive use a condom consistently if at any risk for acquiring an infection," says Hatcher.

Teens can use LARC

Adolescents make good candidates for LARC methods, notes Burke in her fourth point. Such use is supported by the American College of Obstetricians and Gynecologists, which issued a 2012 committee opinion stating that LARC methods are safe, effective, and appropriate options for adolescents.⁸

LARC methods also are appropriate methods for women who have never been pregnant, Burke notes in her fifth point. The U.S. Medical Eligibility Guidelines for Contraceptive Use (US MEC) ranks use of the Copper T-380A and the levonorgestrel IUDs as a "2" (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks) for nulliparous women; the contraceptive implant is rated as a "1" (no restrictions on use).⁹

When it comes to postpartum contraception, LARC methods represent safe, effective choices for such women, says Burke in her sixth point. For the contraceptive implant (Nexplanon, Merck, Whitehouse Station, NJ), immediate postpartum use is safe and effective with no adverse effects on breastfeeding.¹⁰

Use for EC lags

Despite top-shelf effectiveness, IUD insertion for emergency contraception (EC) continues to lag, Burke notes in her final point. According to a secondary analysis of data obtained from a prospective cohort study of women who received EC insertions of the Copper T380A IUD (ParaGard, Teva North America, North Wales, PA), if the urine pregnancy test is negative prior to IUD placement, the copper IUD is highly effective for EC at any point in the menstrual cycle.¹¹

Think of IUD insertion as "something for women who want a little more Plan A than Plan B," which is the EC pill, says Burke.

REFERENCES

1. Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007-2009. Fertil Steril 2012; 98(4):893-897.
2. Burke A. The importance of long-acting reversible methods: What have we learned? Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013.
3. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366(21):1,998-2,007.
4. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117(5):1,105-1,113.
5. O’Neil-Callahan M, Peipert JF, Zhao Q, et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol 2013; 122(5):1,083-1,091.
6. Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012; 120(6):1,314-1,321.
7. Hatcher RA. The top 10 questions from ManagingContraception.com. Presented at the 2013 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2013.
8. American College of Obstetricians and Gynecologists. Committee Opinion #539. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012; 120(4):983-988.
9. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
10. 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(5):1,114-1,121.
11. Turok DK, Godfrey EM, Wojdyla D, et al. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Hum Reprod 2013; 28(10):2,672-2,676. n