Contraceptive implant makes inroads as birth control option
Use of long-acting reversible methods continues, clinicians say
Whether it's the intrauterine device (IUD) or the contraceptive implant, women are choosing long-acting reversible contraceptive (LARC) methods, say respondents to the 2013 Contraceptive Technology Update Contraception Survey. About 60% of survey respondents said they placed more than 10 intrauterine devices last year, while 73% said their facility is offering/plans to offer the contraceptive implant, a 10% jump from 2012.
Southern Nevada Health District Family Planning Clinic - East Las Vegas and Henderson has IUDs and implants readily available, says clinician Susan Kilburn, RN, APRN-BC. The clinic operates on a sliding pay scale basis, and most patients are donation-only status, she explains. Clinicians favor the LARC methods for women who are appropriate candidates, Kilburn notes.
Karen Albright, WHNP-BC, lead clinician at Planned Parenthood Southeastern Virginia in Virginia Beach, says, "We are using more and more LARCs because we have a grant for long-term contraception; without the grant, our self-pay clients would never be able to afford it. We are also putting IUDs in at the in-clinic abortion visit."
When Caroline Strzesynski, WHNP-BC, a clinician at Wood County Community Health & Wellness Center in Bowling Green, OH, came to her facility, LARC was not available, and few patients were following up when referred for LARC elsewhere. Since mid-2013, LARC is offered and, as a result, women are requesting that option, she reports.
Family Planning Association of Northeast Ohio in Painesville is better supplied with LARC methods due to an increase in Medicaid patients, says Dianne Rafferty, CNP, director of nursing. Since Ohio has expanded Medicaid, the extra Medicaid reimbursement has allowed the organization to offer LARCs to more clients who don't have insurance.
How about the implant?
The contraceptive implant (Nexplanon, Merck & Co., Whitehouse Station, NJ) is highly effective, not motivation dependent, and can be used during lactation. It is discreet. virtually invisible, and is rapidly reversible. As a subdermal implant, its features include:
- a long duration of action (labeled for up to three years);
- not subject to patient error or imperfect use;
- continuous steady state steroid levels;
- avoidance of 'first-pass' peak effect via the hepatic portal system, which is associated with oral contraceptives; and
- higher bioavailability, which yields lower doses with parallel decreases in adverse effects.1
One of the downsides of implant use is irregular bleeding. According to a fact sheet issued by the Association of Reproductive Health Professionals, some women might have heavy and/or longer periods, while other women have periods that are lighter and occur less often. Some women stop getting their period completely. (Download a free patient sheet on the implant, available in English and Spanish, at http://bit.ly/1eSUbxO.)
Donna Gray, CNM, WHNP, a clinician at the Wyoming County Health Department's Men's and Women's Reproductive Health Services in Silver Springs, NY, has performed more Nexplanon insertions in the last six months than the first year the device was on the market.
"Some do complain of the increased bleeding episodes, but we usually work with them trying [a nonsteroidal anti-inflammatory drug], estrogen, or oral contraceptives to cut back on episodes of bleeding, instead of removing it," says Gray.
With a LARC grant, clinicians at Planned Parenthood Southeastern Virginia are putting in more implants, but unfortunately they also are seeing a lot of removals for bleeding, says Albright. Even with increased counseling and offering medication to help with bleeding, the client tends to opt for removal, she notes.
Handle call backs
With contraceptive use comes patient call backs. At the LARC First web site, www.larcfirst.com, developed by the St. Louis-based Washington University School of Medicine's Contraceptive CHOICE project, answers can be found for commonly asked questions about the implant and IUD.
The project has developed a clinician callback system to provide an efficient way to manage patient concerns, which might lead to higher continuation and satisfaction rates for contraceptive methods. Staff members, from receptionists to clinicians, participate in training in appropriate responses. Questions marked in green represent those that can be answered by receptionists, with yellow indicating questions for counselors and staff nurses, and red denoting attention from advanced practitioners.
If a patient calls to ask "Why I am having all this irregular bleeding with the implant?" the suggested CHOICE Project response for a receptionist would be: "It can be normal to experience irregular bleeding with the implant. This method releases a small amount of the hormone progesterone that keeps the lining of the uterus thin. Although it may be somewhat annoying, it is not harmful. If the bleeding persists for a long time and is bothersome, discuss this with your clinician. There are some medications that may help."
If a patient with an IUD calls in asking about irregular bleeding, the CHOICE Project suggests the following response for a receptionist: "It can be normal to experience irregular bleeding with the IUDs, especially for the first few months. This usually subsides with the copper IUD. The hormonal IUD is releasing a small amount of the hormone progesterone that is thinning out the lining of your uterus. This is why it is perfectly normal to have irregular bleeding, and eventually lighter periods or no period at all."
How about patients who say after four months they are still having periods that last 15 days with implant or intrauterine contraception? The suggested response from a staff nurse would include the following: "When the bleeding starts, try taking 600 mg of ibuprofen three times a day with food for the next five to seven days. This can help cut down how long the bleeding lasts. It may take three days before you notice a decrease in bleeding."
For women who still experience irregular bleeding with the implant or intrauterine contraception and have tried approaches mentioned above, clinicians may look at the following prescription options:
- naproxen, 500 mg tablet, one by mouth twice a day for 5-7 days;
- estrogen supplementation options: Conjugated estrogen,1.25 mg tablet, one by mouth daily for 7-14 days; or micronized estradiol, 2 mg tablet, one by mouth daily for 7-14 days, or transdermal estrogen patch: 0.1 mg patch for 7-14 days;
- mefenamic acid, 500 mg tablet, twice a day for 5-7 days;
- tranexamic acid, 500 mg tablet, twice a day for 5-7 days;
- doxycycline, 100 mg tablet, one by mouth twice a day for 7 days.2
In prescribing such options, explain to women that while such methods will help stop the bleeding, there is no proven method to keep the bleeding from returning. The bleeding might stay away permanently, stay away several months, or return at the completion of the medication.2
- Association of Reproductive Health Professionals. New developments in contraception: the single-rod implant. Accessed at core.arhp.org.
- Contraceptive CHOICE Project. Frequently asked questions - implant. Accessed at http://bit.ly/MgN0U0.
The 2013 Contraceptive Technology Update (CTU) Contraception Survey monitors contraceptive trends and family planning issues among readers. Results were tallied and analyzed by AHC Media, LLC in Atlanta, publisher of CTU and dozens of medical newsletters and sourcebooks. The survey was mailed in December 2013 to 835 subscribers with 61 responses, for a response rate of 7.3%.
Fifty-two percent of responses came from nurse practitioners, with physicians representing about 40% of respondents. About 82% of respondents identified themselves as care providers, with 10% involved in administration and about 3% identifying themselves as faculty/teacher/student.
About 49% work in public health facilities, with about 28% listing private practice. About 12% listed employment in other settings; about 7% work in hospitals
When it comes to location of their employment, 43% said they work in a rural area location. About 27% said they are employed in a suburban area, with about 25% listing an urban setting.