Why I talk about all Long Term Reversible Contraception (LARC)

Author

Konia Trouton BSc MD MPH FCFP (biography and disclosures)

Disclosures: Dr. Trouton has received honoraria from Bayer, Organon, and Searchlight for being on advisory boards. She has received honoraria from Bayer and Organon for teaching engagements. She is a medical consultant to Linepharma. Products of these companies are discussed in this article. To mitigate that bias, only published trial data is presented. Recommendations are consistent with the SOGC and CPS published guidelines, and consistent with current practice patterns.

What I did before

When I first started practice, I would explain all the contraceptive options to a patient, starting with the ones that people use most often. I made sure I reviewed the contraindications to estrogen, believing that I was most likely to end up prescribing the pill.

Practicing in sexual and reproductive health led me to ask first about people’s risk tolerance for pregnancy, and what option would fit best with their lifestyle-using daily, weekly, monthly, or longer term — “set and forget”. The World Health Organization and The Society of Obstetricians and Gynaecologists of Canada (SOGC) produced posters on Tiered Effectiveness Counselling, encouraging clinicians to talk about the most effective options first.

Patient satisfaction and continuation rates are very well documented for various contraceptives in Canada. Among the combined hormonal contraceptives ⁠— the pill, patch, and ring ⁠— only 50% of people are still using them after a year, despite all efforts to improve compliance and reduce side effects. In contrast, over 80% of people are still using long-acting and reversible IUDs a year later.

Copper and levonorgestrel IUDs were the only effective reversible option in Canada until recently. Over the last decade, they are used by more and more Canadians. I worked on best approaches to insert these successfully and with minimal pain. My practice became streamlined to allow for several IUD clinics weekly, and my workshops are focussed on tips and tricks for insertion and management. They still work really well and I continue to use them.

I started working in abortion care during residency and ever since. When an unexpected pregnancy occurs, and the current contraception fails, people are strongly motivated to reconsider which contraceptive they are using, and this provides an opportunity to review contraception methods. I was able to offer IUDs at the same time as surgical abortion, but only 2–4 weeks after the medication abortion, because the uterus needs to be empty before placement.

In my abortion practice there continues to be a growing interest in the medication option, but the longer time between the abortion and the start of contraception leads to a loss of motivation. While the same percentage of people expressed interest in an IUD, fewer people having medication abortion ended up coming back to have one placed.

Over the last decade, there is growing interest in IUDs as the main effective non-pill option and it is recommended as the first and safest contraception for adolescents. There is clear support from the SOGC and the CPS for use. While people gravitate to the concept of long-term contraception, some people opted for short-term contraception because they didn’t like the idea of something placed in the uterus. Others had a strong aversion to a pelvic examination. A few had two or more expulsions of the IUD despite best efforts at good placement. We needed an additional option.

What changed my practice

In May 2020, another long-acting reversible contraception was approved in Canada — the sub-dermal implant (SDI). This etonogestrel-containing device is inserted under the skin and over the triceps, sub-dermally, and left in place for 3 years. It is placed in the non-dominant arm, after infiltration with xylocaine. It is 4cm and 2mm wide, with a rate-controlling flexible membrane, and a small amount of barium sulfate is mixed with the etonogestrel to make it radio-opaque. Placement requires only exposure of the upper arm, and skin closures are left in place over the tiny insertion window for a few days. It can easily be felt through the skin throughout use by palpating over the triceps.

Progesterone is the only hormone that is needed to prevent conception. It comes in many synthetic forms; a daily pill, an injection every 90 days, a subdermal implant, and an intrauterine system. Progesterone works by keeping the uterine lining too thin for implantation (endometrial decidualization) and thickens the cervical mucus making a barrier for sperm. At slightly higher concentrations, progesterone completely inhibits ovulation.

If the etonogestrel implant is inserted during the period, or in the first week after, it is effective within 24 hours, as is the levonorgestrel IUD. No backup method is needed. If it is inserted at other times, backup is recommended for 7 days. Switching from the pill, patch, or ring can be done without overlap if it is at the end of the month, or with a 7-day overlap at other times.

What most people notice is the change in bleeding with any of the LARCs. Copper IUDs are likely to make the periods heavier, up to 10–20% heavier, or another day of bleeding. This may settle back to the pre-IUD level for some, but not for most people. The levonorgestrel IUDs and the SDI reduce bleeding, and in many cases, stop periods, so it is important to set expectations early.

The good news is that fertility after an implant is removed is immediate, although tracking ovulation will require 1–2 cycles. Pregnancy can happen within 8–14 days, because the etonogestrel levels drop quickly, and can be as fast as 24 hours. Ovulation resumes after removal of the implant, so this mechanism differs from the IUD where ovulation continues throughout use.

While over 80% of people are satisfied with their LARC a year later, there is an adjustment period. The most common complaint is the change in bleeding patterns. For those with a copper IUD, there is less commonly breakthrough bleeding, but more of a prolonged period, possibly with clots. Those with either of the levonorgestrel IUDs typically have irregular spotting and/or bleeding that can be interruptive and unsettling, and continue for 2–3 months. Those with the etonogestrel implant may have irregular bleeding that lasts longer, 3–6 months. Irregular bleeding is the most common reason for discontinuation of the method, in under 20% of people. This is far less than those on the short-acting pill, patch, or ring, who are 50% likely not to be using the method a year later.

Placement of any of the LARCs is extremely safe, and complications are rare. IUD placement can be done by a trained clinician in less than 5 minutes, with the patient experiencing a sharp pinch (for the tenaculum placement) and cramp (for the sounding and insertion). Risks include vaso-vagal reactions, cervical laceration, and rarely, perforation. Low-grade cramping may continue for up to a few days. SDI placement also requires training, particularly on appropriate and careful landmarking to ensure the device is placed over the triceps. Risks include local reactions to the anesthetic and dressing, and bruising or aching that may last 3-10 days. Very rarely, inappropriate but deep insertion can affect the underlying muscle, ulnar nerve, or lead to migration of the SDI into the basilic vein. Removal of the IUDs is usually straightforward, with a clinician grasping the thread at the cervix and slipping it out. Removal of the SDI involves infiltration with local anesthetic and creating a small incision through which the STI is teased out manually or with small forceps. A small scar will remain.

For those that are having a pregnancy termination, LARC can be inserted immediately. SDI can be inserted on the same day as mifepristone use, with negligible drop in efficacy, about 1–2%. This makes it much easier for someone who plans to have pregnancy termination with mifepristone in the clinic and then immediately have the implant inserted for ongoing and long-term contraception. Misoprostol is taken 24–48 hours later, and follow-up, 7–10 days later, is often done virtually. Even if the process fails or is delayed, the implant does not need to be removed. IUD can be inserted at the same time as any surgical pregnancy termination, even after the second trimester.

All LARCs are highly effective. The failure rate for both IUD and the implant is less than 1 in 100, and for the LARCs that contain progesterone, failure is less than 1 in 1000.  Both copper and levonorgestrel IUDs can be used as emergency contraception if placed within 5 days of unplanned intercourse. The levonorgestrel IUD does not completely suppress ovulation, but effectively creates the mucus plug in the cervix, and thins the uterine lining. Failure rates are 1–2 in 1000. The subdermal implant contains the progesterone etonogestrel. This hormone, once released, suppresses ovulation within 24 hours, and within 2 weeks is at maximum levels, lasting for 3 years. Failure rates are 0.5 in 1000.

What I do now

1. I continue to focus my discussion on risk tolerance for pregnancy and no longer discuss the pros and cons of each contraceptive with patients.
2. I do not ask patients about contraindications to estrogen unless they opt to use a short-term contraceptive.
3. If a long-term reversible method fits their plans, I ask about where they would prefer that method as a small flexible ‘toothpick’ in the inner upper arm, or in the uterus where they cannot feel it.
4. Whether they want the implant or the IUD, I book them into the LARC clinic as soon as possible.
5. When the initial motivation to seek care is for pregnancy termination, I ensure they have a chance to consider immediate LARC placement.

Resource PDFs

1. Which birth control method is right for you? Sex and U. sexandu.ca (View) Accessed June 21, 2022.
2. SOGC Sexual Health And Reproductive Equity (SHARE) Committee Statement – Revised and reaffirmed November 9, 2021. Contraception Consensus: Updated Guidance during Pandemics and Periods of Social Disruption. The Society of Obstetricians and Gynaecologists of Canada (SOGC) (View) Accessed June 21, 2022.
3. Intrauterine Contraception (IUC). Hormonal Contraception. Sex and U. sexandu.ca (View) Accessed June 21, 2022.
4. Contraceptive Implant. Hormonal Contraception. Sex and U. sexandu.ca (View) Accessed June 21, 2022
5. Intrauterine Contraceptives (IUCs). Non-Hormonal Contraception. Sex and U. sexandu.ca (View) Accessed June 21, 2022.

References

1. Peipert JF, et al. Continuation and Satisfaction of Reversible Contraception. Obstet Gynecol 2011;117(5):1105–13. (View)
2. Peipert JF, et al. Continuation of Reversible Contraception in Teenager and Young Women. Obstet Gynecol 2012;120(6):1298-305. (View)
3. Turok DK, et al. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med 2021;384(4):335-44. (View)
4. Black A, Guilbert E, Costescu D, et al. SOGC Clinical Practice Guideline. Canadian contraception consensus (part 1 of 4). J Obstet Gynaecol Can 2015;37(10):936-8. DOI: https://doi.org/10.1016/S1701-2163(16)30033-0 (View with CPSBC or UBC)

Please indicate how this article will change your practice:

Why I talk about all Long Term Reversible Contraception

• I disagree with this approach
• I will consider changing my practice, but need more information/time
• I will likely change my practice
• I will definitely change my practice
• I already do this

View Results

 Loading ...