Long-Acting Reversible Contraceptives (LARC) -- - PowerPoint Presentation

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Long-Acting Reversible Contraceptives (LARC) -- Beyond the Myth, More Than Just Uterus

Shanda R. Dorff, MD, FAAFP

MN AAP Hot Topics Conference, Friday, May 12, 2017Slide2

DisclosureI have zero actual or potential conflicts of interest with anything related to this topic and/or presentation.Slide3

Contraception

Why?

“The US

teen birth rate

remains the highest of industrialized nations. Therefore, sexual safety, including provision of

contraception and prevention of sexually transmitted infections

(STIs), should be a component of adolescent skill development. Adolescents need comprehensive

sex education and access to reproductive health services

, including contraception. The consistent use of both condoms and hormonal contraception are recommended for STI and pregnancy prevention. A range of hormonal contraception is available, varying in drug, dose, and delivery mechanisms. Long-acting reversible contraception use is encouraged to decrease the teen pregnancy rate.”

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Options

PRN (barrier, spermicide, morning after pill)

Daily (pill)

Weekly (patch)

Monthly (ring or injection if outside USA)

Every 3 months (injection)

Every 3 years (implant or IUD)

Every 5 years (IUD)

Every 10 years (IUD)

Permanent (surgical)Slide4

LARC DEFINITION

Patients’ definition (per internet searches and word of mouth)

Injection (q3months medroxyprogesterone acetate or monthly estradiol cypionate/medroxyprogesterone acetate outside USA)

IUD (levonorgestrel [progestin] or copper)

Implant (

etonogestrel

[progestin] now vs levonorgestrel [progestin] no longer available)

Medical Definition

: Per American College of Obstetrics and Gynecology,

intrauterine device or implant

Does NOT include injection because unable to remove it at anytime and have to wait for it wear offSlide5

Myths

Weight gain

Will make unable to ever get pregnant / make infertile

Must start having pap smears

Takes away virginity or purity

Will make sexually active

Parents have to approve

Will protect against sexually transmitted infections and cause

actinomyces

infections

Only able to get an IUD after having delivered a baby

IUD will fall out and make unable to use tampons

IUD will be painful for partner

Implant will cause problem with arm or not work because farther away from ovaries

Too expensiveSlide6

truths

2012 -- the largest cohort study of IUD and implant found that the risk of

contraceptive failure

for those using oral contraceptive pills, the birth control patch, or the vaginal ring was

17 to 20 times higher than the risk for those using long-acting reversible contraception

. For

those under 21, who typically have lower adherence to drug regimens, the risk is twice as high

as the risk among older participants.

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A statistically significant association has been observed in England between a decrease in teenage conception and increased LARC usage.

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Note the record high increases in STDs / STIs both nationally as well as statewide (per CDC and MN

Dept

of Health) would not be prevented by LARC and recommend barrierSlide7

truths

The discrepancy between LARC methods and other forms of birth control lies in the difference between "perfect use" and "typical use".

LARC methods require little to no user action after insertion; therefore, LARC perfect use failure rates are the same as their typical use failure rates.

LARC failure rates rival that of sterilization, but unlike sterilization LARC methods are reversible.

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Other reversible methods, such as oral contraceptive pills, the birth control patch, or the vaginal ring require daily, weekly, or monthly action by the user. While the perfect use failure rates of those methods may equal LARC methods, the typical use failure rates are significantly higher.

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In both effectiveness and continuation, LARC methods are considered the first-line option for contraception.Slide8
Slide9

truthsIf unable to tolerate a tampon, likely would be unable to tolerate having IUD placed at the time but could train the vagina to relax to allow for IUD if desired by patient.

Those with severe developmental delay likely would be unable to understand why or how to have a pelvic exam or place an IUD, making them feel abused / violated.Slide10

IUDs

Paragard (10 Year, no hormone)

Mirena (5 Year)

Kyleena

(5 Year, smaller than Mirena)

Skyla (3 Year, smaller than Mirena)

Liletta

(3 Year though looking for longer approval, smaller than Mirena)Slide11

levonorgestrel

5 year options

Mirena (20 mcg/day)

Kyleena

Same size as Skyla

17.5 mcg/day

3 year option

Skyla (14 mcg/day)

Liletta

(being reviewed for 5 year currently and being studied for 7 year effectiveness, 18.6 mcg/day, same size as Mirena)Slide12
Slide13

copper10 year

Prevents implantation

Does not have hormone so does not make cervical mucus thicker or work to minimize menses

Have found is better option for ones with hypercoagulability since no hormone or for ones who have hormone sensitive conditions / treatments vs peri-menopausal (out of scope of discussion today given

Peds

talk)Slide14

Contraindications6Pregnant

Allergy to ingredients

Active PID or high risk for PID

Uterine anomaly that prevents insertion (

bicornate

uterus, extensive scar tissue, obstructing fibroids,

etc

)

Unexplained uterine bleeding

Concurrent known or suspected progestin sensitive cancer (such as breast cancer, uterine cancer, cervical cancer)

Acute liver diseaseSlide15

cautions6Coagulopathy

Unable to tolerate a tampon or pelvic exam

Migraine, focal migraine with asymmetrical visual loss

Other symptoms indicating transient cerebral ischemia

Exceptionally severe headache

Severe increase of blood pressure

Severe arterial disease

MI

CVASlide16

risks6Rare to have complications though greatest risk timeframe is with insertion or removal.

5% chance will come out in the 1

st

year

1/1,000 will perforate the wall of uterus during insertion

PID (risk slightly increased in 1

st

20 days following insertion, overall risk <1%), which may cause scarring of uterus

Rare risk for pregnancy (same as risk after BTL or

Essure

though naturally lower than TAH BSO) though if get pregnant then more likely ectopic

Hormone risks in general – headaches, nausea, depression, and breast tendernessSlide17

Expectations6Requires a pelvic exam

Cramping and takes longer to put in than to remove

Spotting, irregular, or heavy bleeding

upto

3-6 months after insertion.

Periods may become shorter and/or lighter thereafter.

Cycles may remain irregular, become infrequent, or even cease.

Consider pregnancy if menstruation does not occur within 6 weeks of the onset of previous menstruation.

If a significant change in bleeding develops during prolonged use, take appropriate diagnostic measures to rule out endometrial pathology.Slide18

How do you put it in?

I usually recommend NSAID prior to reduce cramping

Able to be placed when on menses or between menses (though flow works as a lubricant for insertion too)

Bimanual Pelvic Exam

Place speculum to ensure able to visualize full surface of cervix

Apply betadine to clean surface of cervix

Apply tenaculum (expect cramping)

Insert sound or dilator then remove with betadine marking length of uterine cavity.

Adjust stopper on IUD applicator to prevent going too deep and insert through cervix until stopper contacts cervix surface then slide the release and remove applicator.

Cut strings to approximately 1-2”.

Remove tenaculum and speculum.Slide19

How do you take it out?Place speculum to ensure able to see the cervix and able to see the IUD strings.

Grasp the strings with sterile ringed forceps and remove IUD

If unable to visualize strings but able to see full cervix, may need to use a pap brush to turn at cervical

os

to grasp strings to bring out to then remove as above.

If remain unable to see it, recommend ultrasound to ensure IUD is still present. If remains present, will need internal removal. Slide20

implantsNorplant – no longer available

Implanon

(no longer in USA) &

Nexplanon

(available)Slide21

Contraindications6Pregnant

Allergy to ingredients

Active infection at insertion site

Bilateral upper extremity amputee due to lack of approved insertion site

Concurrent known or suspected progestin sensitive cancer (such as breast cancer, uterine cancer, cervical cancer)Slide22

cautions6Coagulopathy

Migraine, focal migraine with asymmetrical visual loss

Other symptoms indicating transient cerebral ischemia

Exceptionally severe headache

Severe increase of blood pressure

Severe arterial disease

MI

CVASlide23

risks6Rare to have complications though greatest risk timeframe is with insertion or removal.

<2% risk of bleeding, infection, abnormal scarring

Rare risk for pregnancy (same as risk after BTL or

Essure

though naturally lower than TAH BSO) though if get pregnant then more likely ectopic

Hormone risks in general – headaches, nausea, depression, and breast tendernessSlide24

Expectations6Does require a needle

Spotting, irregular, or heavy bleeding

upto

3-6 months after insertion.

Periods may become shorter and/or lighter thereafter.

Cycles may remain irregular, become infrequent, or even cease.

Consider pregnancy if menstruation does not occur within 6 weeks of the onset of previous menstruation.

If a significant change in bleeding develops during prolonged use, take appropriate diagnostic measures to rule out endometrial pathology.Slide25

How do you put it in?Requires formal training by the manufacturer for certification

Basics:

Determine which arm and have patient lay where able to have easy access to site

Clean site then inject anesthetic

Once numb, place applicator at less than 30 degree angle to puncture skin then once beyond bevel of applicator tip, slide parallel to skin surface (remaining superficial).

When applicator needle fully in skin, slide the purple handle to release the implant / rod (which also makes the needle retract into the insertion device so no sharp edges) and remove applicator.

Apply bacitracin and pressure dressing that is left in place for 24 hours.

Able to change to Band-aid afterward if neededSlide26

How do you take it out?Requires formal training by the manufacturer for certification

Basics:

Ensure able to palpate the implant then clean distal site (usually around scar from initial insertion that is 3-4 mm in length)

Apply pressure to proximal tip to then lift the distal tip and inject anesthetic under distal tip.

Make incision at distal implant tip (usually prior scar site) and apply pressure to proximal tip to slide it to the incision.

Once able to visualize it, use sterile forceps to grasp the visible rod and remove in its entirety.

Apply

steri

-strips & bacitracin to site then pressure dressing that is left in place for 24 hours followed by a Band-aidSlide27

Compare and contrast

Product

Hormone

Duration (Years)

Location

Amount of hormone

Paragard

No

10

IUD

Zero

Mirena

Yes

5

IUD

52 mg

Kyleena

Yes

5

IUD

19.5 mg

Skyla

Yes

3

IUD

13.5 mg

Liletta

Yes

3

IUD

52 mg

Implanon

Yes

3

Arm

68 mg

Nexplanon

Yes

3

Arm

68 mgSlide28

References

Rowan, S. P.;

Someshwar

, J.; Murray, P. (2012). "Contraception for primary care providers". Adolescent medicine: state of the art reviews.

23

(1): 95–110, x–xi.

PMID

22764557

.

Winner, B;

Peipert

, JF; Zhao, Q;

Buckel

, C; Madden, T;

Allsworth

, JE;

Secura

, GM. (2012),

"Effectiveness of Long-Acting Reversible Contraception"

, New England Journal of Medicine,

366 (21): 1998–2007, doi:10.1056/NEJMoa1110855, PMID

22621627

.

Connolly A,

Pietri

G, Yu J, Humphreys S (2014).

"Association between long-acting reversible contraceptive use, teenage pregnancy, and abortion rates in England."

.

Int

J

Womens

Health.

6

: 961–74.

Trussel

, J (2007), ""Effectiveness of Long-Acting Reversible Contraception"

In:Hatcher

, RA; Nelson, TJ; Guest, F;

Kowal

, D.", Contraceptive Technology 19th ed., New York: Ardent Media.

Kost

, K; Singh, S; Vaughan, B;

Trussel

, J;

Bankole

, A (2008), "Estimates of Contraceptive Failure from the 2002 National Survey of Family Growth", Contraception,

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: 10–21.

Curtis, K;

Peipert

, J (2017), “Long-Acting Reversible Contraception”, New England Journal of Medicine, 376:461-468: Feb 2, 2017, DOI: 10.1056/NEJMcp1608736.Slide29

Questions?