Up to 45% of pregnancies in the United States are unintended.1 Long-acting reversible contraception (LARC), which includes intrauterine devices (IUDs) and drug- or hormone-eluting subdermal implants, are an effective and convenient option for many women, including those who have contraindications to estrogen-containing contraceptives. LARCs also offer a rapid return to fertility.2-5 Four times as many patients in the United States use short-acting contraceptives as use LARCs.6 LARCs may not always be presented by clinicians as first-line contraceptive options, depending on clinician training.7-9 They also have higher upfront costs; however, their safety and long-term efficacy make them some of the most affordable and effective forms of birth control on the market.10,11
Six LARCs are available in the United States, with three options approved in the past 5 years (Table 1). Determining which device is best for each patient may be challenging. Before prescribing, perform pregnancy testing on the patient. Also recommend barrier methods because the options presented in this article do not protect against sexually transmitted infections (STIs).
INTRAUTERINE DEVICES (IUDS)
Five IUDs are available in the United States: one nonhormonal and four hormonal (Table 1). All are highly effective options for contraception, with each being more than 99% effective.5,12-15 The initial cost of an IUD includes a one-time fee for the device plus the cost of the procedure for placement. These initial expenses may be high; however, because patients using these devices avoid monthly prescription costs, their overall cost drops with each year of use, making them some of the most cost-effective options available.
Another barrier to access is that clinicians may believe that women who have not had a vaginal delivery, including adolescents, are not good candidates for IUD placement, when in fact, these women are candidates.16,17 Adolescents in particular are ideal candidates; the American Academy of Pediatrics and the Society of Adolescent Health and Medicine recommend LARCs as first-line contraceptives in adolescents and young adults.18-20
Many contraceptive options are contraindicated in women who have previously experienced a thrombotic event, but IUDs remain a viable option for these women.21 IUD contraindications in all women include congenital or acquired anatomical distortions of the uterine cavity such as bicornuate uterus, septate uterus, uterine fibroids, and cervical stenosis.
Current abnormal uterine bleeding of unknown cause also is a contraindication because of the risk of missing gynecologic cancer. Other contraindications include active pelvic infection and pregnancy.5,12-15
Risks associated with IUDs include pelvic inflammatory disease (PID), which occurs at a rate of 1.4 per 1,000 women years, similar to the rate in the general population of sexually active women. However, the rate was much higher within the first 20 days after placement of the IUD (9.7 per 1,000 women years). This suggests that PID is strongly related to the insertion process.22-24 Spontaneous expulsion occurs in about 1 out of 20 placements, and perforation of the uterus in 1 to 2.6 of 1,000 placements.25,26 IUDs also may become implanted in the uterine wall in 10% to 16% of patients, making removal difficult.27,28 Removal of embedded IUDs often can be achieved with increased traction in the office; however, some may require hysteroscopic removal.
Of the pregnancies that do occur in women with an IUD, a higher proportion are ectopic; however, because women with IUDs are less likely to become pregnant, the actual occurrence of ectopic pregnancy is low when compared with women who do not have IUDs.29 Therefore, the absolute of ectopic pregnancy is lower for women using IUDs than for women not using contraception or using other forms of reversible contraception.29 Of women with IUDs who conceive, risk of ectopic pregnancy can range from 11% to 53%.30-33
The four hormonal IUDs all release levonorgestrel, which thickens the cervical mucus, inhibiting sperm from reaching the egg.12 Hormonal IUDs should be placed within the first 7 days of the patient's last menstrual period (LMP); if this cannot be done, the patient should use a backup contraceptive method for 7 days after placement.12 IUDs also may be placed during menses, which can exclude current pregnancy and may help facilitate insertion as the cervix may slightly dilate during menses.34,35
Because these IUDs use the same hormone, they have similar adverse reactions and risks. They are known to reduce menstrual blood flow, which may result in amenorrhea. Patients also may have irregular bleeding or spotting, which tends to decrease over time.12,36 Devices with higher doses of levonorgestrel cause higher rates of amenorrhea; for example, Mirena has a 20% amenorrhea rate at 12 months compared with 6% for Skyla.12,13 Hormonal IUDs also are associated with an increased risk of ovarian cysts (occurring in 12 of 100 women), and higher rates of perforation (about 1.4 per 1,000 insertions), with lactating women having a 6 to 10 times higher risk of perforation, although these methods are still considered safe to use in lactating women.37,38 Patients tend to have a lower risk of PID compared with patients using the copper IUD (gross rate of 2 vs. 0.5 with levonorgestrel IUDs at 36 months).5,12-15,24,39
This IUD is effective for up to 5 years and is the only IUD with FDA approval to treat heavy menstrual bleeding.12 The IUD can improve dysmenorrhea associated with endometriosis. One study found that pain during a 28-day period fell from 15 days to 6 by 12 months after insertion.40 Although the hormonal IUDs all contain the same hormone, levonorgestrel, this IUD and the subdermal implant have been shown to be effective in treatment of endometriosis-related dysmenorrhea.41 Although nonsteroidal anti-inflammatory drugs remain first-line treatment for dysmenorrhea, this IUD is an additional therapy that clinicians may consider.42,43
Suitable for: Women with heavy menstrual bleeding, women who would like to reduce or stop menstrual bleeding, and women with dysmenorrhea related to endometriosis
Pros: Effective treatment for menorrhagia, reduces dysmenorrhea
Cons: May cause irregular bleeding and spotting
Effective for 3 years, Skyla is the smallest of the hormonal IUDs, along with Kyleena. The smaller size includes a smaller diameter inserter (3.8 mm vs. 4.4 mm).13 The smaller diameter of the device and insertion tube may assist with ease of insertion. One study found that pain was decreased with insertion of smaller IUDs (Skyla and Kyleena) than that of the larger Mirena IUD.44-47 Because Skyla delivers a lower dose of levonorgestrel than other hormonal IUDs, women are more likely to retain their menstrual cycle.48
Suitable for: Women specifically concerned about pain associated with IUD placement, women who wish to maintain their menstrual cycle
Pros: May decrease pain on insertion, maintains menses48
Cons: Approved for 3 years of use compared with 5 for Mirena
The device, which is effective for 4 years, features a single-handed insertion device for ease of insertion.14 Through the 340B drug pricing program, eligible clinics and providers may obtain the device for $50, which may make this the most affordable LARC option for some patients.49
Suitable for: Women without insurance or who have poor insurance coverage
Pros: Improved insertion device, affordable
Cons: Approved for 4 years of use compared with 5 for Mirena
The newest progesterone IUD on the market, Kyleena is effective for 5 years and features a small 3.8 mm diameter insertion tube, which is the same size as Skyla.5 This IUD has a midrange dose of levonorgestrel. In clinical trials, 12% of women stopped menstruating in the first year of use and 20% reported amenorrhea after 3 years.5
Suitable for: Women desiring light menstruation or absence of menstruation with minimal hormones, women specifically concerned about pain associated with IUD placement
Pros: Approved for up to 5 years, smaller size
Cons: Lower amenorrhea rate than IUDs with higher levonorgestrel doses
This copper IUD is the only nonhormonal IUD on the US market. It interferes with sperm motility and egg fertilization and may inhibit implantation.15 The IUD also creates a cytotoxic inflammatory response in the endometrium.50 It is approved for pregnancy prevention for up to 10 years; however, some studies suggest it may be effective for up to 12 years.51,52 Women retain their menstrual cycle while using this IUD, and in contrast to those using hormonal IUDs, may have heavier and longer menses, which may return to normal over time. When inserted within the first 120 hours of unprotected intercourse, the copper IUD can be used for emergency contraception.53 This IUD should be avoided in women with copper allergy.
Suitable for: Women seeking very long-term contraception, women needing emergency contraception, women who wish to avoid hormones or in whom hormones are contraindicated, women desiring to maintain their menstrual cycle
Pros: Can be used for emergency contraception, longest-acting IUD, nonhormonal
Cons: Patients exposed to STIs are at higher risk of PID than patients using hormonal IUDs, as discussed under hormonal IUDs; menses may be heavier and/or longer, largest IUD on the market
For women who do not prefer an IUD or are not able to use one, a contraceptive implant can be a good option and should still be considered first-line contraception. The only subdermal contraceptive implant available in the United States, etonogestrel subdermal, is approved for up to 3 years of use.4 This device also has been shown to be effective in treating dysmenorrhea from endometriosis.41 The 4 cm x 2 mm radiopaque rod containing 68 mg of etonogestrel is inserted in the inner side of the upper arm. Etonogestrel thickens the cervical mucus and inhibits sperm migration.4 The implant is 99% effective and comes with a one-handed insertion device designed to prevent noninsertion, a complication typically seen in preloaded applicators when the device is not inserted into the arm during the procedure. The device may remain in the insertion tube or fall out of the inserter before placement.54,55 Clinicians must be specifically trained in placement and removal of the implant; the manufacturer offers a 2-hour hands-on workshop. The implant may be placed in the first 5 days after the start of the patient's LMP due to low risk of pregnancy during this time.54 If the implant is placed more than 5 days after the start of the LMP, patients should use a backup method for 7 days.
Common adverse reactions to the implant include frequent and/or prolonged bleeding (20%), amenorrhea (20%), weight gain (13.7%), pain (5.2%), scarring at the insertion site (no rate available), ovarian cysts (26.7%), and ectopic pregnancy (0-2.9 per 1,000 woman years).4,56,57 Women with hormone-responsive conditions, such as breast cancer or other progestin-sensitive cancer, should avoid etonogestrel subdermal.
Suitable for: Women who desire long-term contraception but do not wish to undergo the discomfort of an IUD placement, women who want to check placement without the invasiveness of a vaginal examination, women who cannot use an IUD, women with endometriosis-related dysmenorrhea
Pros: Less-invasive placement checks and insertion, less discomfort with placement, lasts up to 3 years, no risk of PID, alleviates endometriosis-related dysmenorrhea
Cons: May cause irregular menstruation that is less predictable than that of patients using IUDs, more difficult to remove than IUDs
Women receiving an IUD should have a 4-week follow-up to check for placement and should perform monthly self-string checks. Routine follow-up is not required after placement of the subdermal implant.
When counseling women about contraception, consider each woman's preferences, including pregnancy time frame, maintenance, cost, efficacy, and safety.
Given the long-term efficacy of LARCs, they are among the most affordable forms of contraception available and should be presented as first-line options for teens and adolescents.19,58 They offer a rapid return to fertility and are a cost-effective method of contraception. The 2012 contraceptive CHOICE study demonstrated that when women were educated on all forms of contraception and received full contraceptive coverage, 75% of women selected a LARC.59 In addition, clinicians should continue to recommend barrier methods for protection against STIs.
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