Put support behind contraception that is long-acting and reversible

ACOG guidance addresses selecting appropriate candidates

Long-acting reversible contraceptive (LARC) methods — the Copper T 380A intrauterine device (IUD), the levonorgestrel intrauterine system, and the contraceptive implant — are the best tools clinicians have to fight against unintended pregnancies, which account for about half of U.S. pregnancies each year.1 The American College of Obstetricians and Gynecologists has just issued new guidance to help clinicians identify appropriate candidates for these highly effective methods.2

In addition to their high efficacy, LARC methods don't require ongoing effort on the part of the user for long-term, effective use, and they ensure rapid return of fertility after discontinuation. Women who are suitable LARC candidates can avoid the gaps in use and discontinuation of shorter-acting methods that are associated with unintended pregnancy rates in high-risk women.2

"The major advantage is that after insertion, LARC methods work without having to do anything else," says guidance co-developer Eve Espey, MD, MPH, professor of obstetrics and gynecology in the University of New Mexico School of Medicine, Albuquerque. "There's no maintenance required."

The T380A IUD copper IUD, marketed as ParaGard by Teva Women's Health, North Wales, PA, is approved by the Food and Drug Administration (FDA) for up to 10 continuous years, during which it remains highly effective. It has a reported failure rate at one year of 0.8 per 100 women, and it has a 10-year failure rate comparable with that of female sterilization: 1.9 per 100 women over 10 years.3 Its most common adverse effects are abnormal bleeding and pain.4

The levonorgestrel intrauterine system, marketed as the Mirena IUS by Bayer HealthCare Pharmaceuticals, Wayne, NJ, is FDA-approved for up to five years of use, but it may be effective for up to seven years.5 The one-year failure rate is 0.2 per 100 women.3

Complications with IUDs are uncommon and mainly include expulsion, method failure, and perforation. The expulsion rate is between 2% and 10% during the first year.3 Perforation occurs in one per 1,000 insertions or fewer.6

The contraceptive implant, marketed in the United States as Implanon by Merck & Co., Kenilworth, NJ, is the most effective method of reversible contraception, with a typical-use pregnancy rate of 0.05%.3 It is FDA-approved for three years of continuous use. Changes in menstrual bleeding patterns are common after implant insertion. They include amenorrhea or infrequent, frequent, or prolonged bleeding.2

Who can use LARCs?

Nulliparous women and adolescents can be offered LARC methods, including IUDs, notes the new guidance. In fact, the FDA in 2005 approved a change in the labeling for the Copper T380A: It removed a section titled "recommended patient profile" and deleted language that stated, "T380A is recommended for women who have had at least one child...".7

The U.S. "Medical Eligibility Criteria for Contraceptive Use" (US MEC) assigns a Category 1 (no restrictions) rating to the use of the contraceptive implant by nulliparous women and adolescents.8 While evidence is limited on the use of the implant in adolescents, data indicates that implants are well-accepted in this population. In a study of 137 postpartum adolescents, at 24 months, continuation rates were higher in contraceptive implant users compared with contraceptive injection and combined contraceptive pill users.9

When to use?

When is it an appropriate time to insert an IUD or implant? According to the new guidance, insertion may occur at any time during the menstrual cycle, as long as pregnancy may be reasonably excluded. No backup contraception method is needed after inserting the copper IUD, regardless of when in the menstrual cycle it is inserted; however, backup method, such as condoms, should be used for seven days after insertion of the levonorgestrel intrauterine system or contraceptive implant. The only time backup methods do not need to be used for these methods is when either is inserted within five days of initiating menses, immediately after childbirth or after abortion, or immediately upon switching from another hormonal contraceptive.10

IUDs and the contraceptive implant can be used safely by postpartum women; the US MEC rates immediate postpartum copper IUD insertion as Category 1 and immediate postpartum levonorgestrel intrauterine system insertion in nonbreastfeeding and breastfeeding women as Category 2 (advantages generally outweigh risks). For the implant, the US MEC classifies insertion of the implant as safe at any time in nonbreastfeeding women after childbirth Placement of an implant in breastfeeding women less than four weeks after childbirth is rated as Category 2 due to theoretic concerns regarding milk production and infant growth and development. However, use of the implant is rated as Category 1 for women who are breastfeeding and more than four weeks after childbirth.8

Eye other opportunities

Insertion of an IUD or implant immediately after an abortion or miscarriage is safe and effective and has many of the same advantages as immediate postpartum insertion, according to the new guidance.

According to a new study, women who receive a IUD immediately following a first trimester abortion experience few complications and were less likely to have an unintended pregnancy than those who delayed getting an IUD by several weeks.11

Don't forget use of the Copper T380A for use as an emergency contraceptive. Insertion of a copper IUD is the most effective method of postcoital contraception when inserted up to five days after unprotected intercourse.12 The levonorgestrel intrauterine system has not been studied for emergency contraception.

Both forms of intrauterine contraception and the implant should be offered as first-line contraceptive methods and encouraged as options for most women, says Espey.

"The benefits of IUDs and the contraceptive implant in preventing unplanned pregnancy could be profound with widespread adoption of these methods," and women's health providers are in a great position to effect change, she notes.

The success of the Contraceptive Choice Project in St. Louis, headed by Jeffrey Peipert, MD, MPH, MHA, should be out there in front of all clinicians, inspiring all to figure out ways to increase use of LARC methods, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta.

"From what I can tell, the single most important factor in St. Louis has not been the free availability of these contraceptives, but rather stressing the high effectiveness rates of these methods," observes Hatcher. "This is what is presented to the patients when they call to ask about the project, when the decision is made as to whether a person can join the project, and in the visit at which the contraceptive chosen by the woman is made."

References

  1. Finer LB, Henshaw SK., Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90-96.
  2. Practice bulletin no. 121: long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2011; 118:184-196.
  3. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. 19th rev. ed. New York, NY: Ardent Media; 2007.
  4. Brockmeyer A, Kishen M, Webb A. Experience of IUD/ IUS insertions and clinical performance in nulliparous women — a pilot study. Eur J Contracept Reprod Health Care 2008; 13:248-254.
  5. Sivin I, Stern J, Coutinho E, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception 1991; 44:473-480.
  6. World Health Organization (WHO). Mechanism of action, safety and efficacy of intrauterine devices: report of a WHO scientific group. World Health Organization Technical Report Series 753. Geneva: WHO; 1987.
  7. Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011; 83:291-294.
  8. Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep 2010; 59(RR-4):1-86.
  9. Lewis LN, Doherty DA, Hickey M, et al. Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 81:421-426.
  10. Makarainen L, van Beek A, Tuomivaara L, et al. Ovarian function during the use of a single contraceptive implant: Implanon compared with Norplant. Fertil Steril 1998; 69:714-721.
  11. Bednarek PH, Creinin MD, Reeves MF, et al; Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. NEJM 2011; 364:2,208-2,217.
  12. Cheng L, Gulmezoglu AM, Piaggio GG, et al. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2008. Doi: 10.1002/14651858.