Pediatric Annals

Feature 

LARC First: What the General Pediatrician Needs to Know about IUDs and Contraceptive Implants

Lawren D. Wellisch, MD; Julie Chor, MD, MPH

Abstract

Despite a steady decline during the past 20 years, teen pregnancy remains a significant public health issue in the United States, with approximately 750,000 pregnancies per year in girls aged 15 to 19 years, 80% of which are unintended.1,2 Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and contraceptive implants are the most effective methods of reversible contraception and are recommended as first-line contraception for teens by adolescent medicine and reproductive health specialists.3,4 The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria, a comprehensive summary of recommendations regarding contraceptive safety for a wide array of medical conditions, supports the use of IUDs and contraceptive implants for females younger than 20 years old.5 However, only 4.5% of teens who use birth control currently use a LARC method.6 Available data suggest that general practitioners who feel under-informed about LARC methods are less likely to counsel their patients about these options.7 The goal of this article is to provide a review of LARC methods to help increase general pediatricians’ comfort in discussing these highly effective methods during all contraception counseling sessions with their teen and young adult patients.

Three IUDs are currently available in the United States: Mirena (Bayer HealthCare Pharmaceuticals), Skyla (Bayer HealthCare Pharmaceuticals), and Paragard (Teva Women’s Health). The Mirena has been available in the United States since 2000 and is a small, T-shaped progesterone (levonorgestrel) releasing device that is inserted into the uterus by a trained provider. This method works via thickening of the cervical mucus, impairment of sperm and ovum migration, and through endometrial changes that prevent implantation. Skyla is a newer, slightly smaller, levonorgestrel-releasing IUD that was approved in the United States in 2013. The Mirena is approved for pregnancy prevention for up to 5 years and the Skyla is approved for up to 3 years. The Paragard, which was initially approved in the United States in 1984, is a non-hormonal, copper IUD that prevents pregnancy by damaging sperm and by creating an inhospitable intrauterine environment for embryos. The copper IUD is approved for pregnancy prevention for up to 10 years and can also be used as an emergency contraceptive method for up to 120 hours after unprotected intercourse.8,9

Any provider who has been trained in this procedure (usually gynecology, family medicine, or adolescent-medicine practitioners) can insert an IUD. IUDs can be inserted at any time of the month if a patient is not at risk of being pregnant (either using a reliable method of contraception or not recently sexual active), but patients are often asked to schedule an appointment during menses to rule out current pregnancy. Patients undergo a routine pelvic exam and, barring any anatomic uterine abnormalities or evidence of active infection, an IUD can be placed. IUDs come pre-packaged in thin plastic tubes that fold the “arms” of the T-shaped device flat so they can be inserted through a minimally dilated cervix. Once inside the cervix, the IUD is released from the tube and assumes its T-shape. A string is attached to the bottom of the IUD that extends through the cervix and into the vagina. Once the IUD is inserted, the string is cut below the cervix and usually coils in cervical mucous. Patients will often be asked to return approximately 6 to 12 weeks after insertion for a string check to ensure that the IUD is still in appropriate position. IUDs can be removed at anytime but must be taken out by 3, 5, and 10 years for Skyla, Mirena, and Paragard, respectively. Removal should always be performed by a trained provider and, if desired, another IUD can be placed…


Despite a steady decline during the past 20 years, teen pregnancy remains a significant public health issue in the United States, with approximately 750,000 pregnancies per year in girls aged 15 to 19 years, 80% of which are unintended.1,2 Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and contraceptive implants are the most effective methods of reversible contraception and are recommended as first-line contraception for teens by adolescent medicine and reproductive health specialists.3,4 The Centers for Disease Control and Prevention (CDC) Medical Eligibility Criteria, a comprehensive summary of recommendations regarding contraceptive safety for a wide array of medical conditions, supports the use of IUDs and contraceptive implants for females younger than 20 years old.5 However, only 4.5% of teens who use birth control currently use a LARC method.6 Available data suggest that general practitioners who feel under-informed about LARC methods are less likely to counsel their patients about these options.7 The goal of this article is to provide a review of LARC methods to help increase general pediatricians’ comfort in discussing these highly effective methods during all contraception counseling sessions with their teen and young adult patients.

Background of Birth Control Devices

Intrauterine Device (IUD) Systems

Three IUDs are currently available in the United States: Mirena (Bayer HealthCare Pharmaceuticals), Skyla (Bayer HealthCare Pharmaceuticals), and Paragard (Teva Women’s Health). The Mirena has been available in the United States since 2000 and is a small, T-shaped progesterone (levonorgestrel) releasing device that is inserted into the uterus by a trained provider. This method works via thickening of the cervical mucus, impairment of sperm and ovum migration, and through endometrial changes that prevent implantation. Skyla is a newer, slightly smaller, levonorgestrel-releasing IUD that was approved in the United States in 2013. The Mirena is approved for pregnancy prevention for up to 5 years and the Skyla is approved for up to 3 years. The Paragard, which was initially approved in the United States in 1984, is a non-hormonal, copper IUD that prevents pregnancy by damaging sperm and by creating an inhospitable intrauterine environment for embryos. The copper IUD is approved for pregnancy prevention for up to 10 years and can also be used as an emergency contraceptive method for up to 120 hours after unprotected intercourse.8,9

Any provider who has been trained in this procedure (usually gynecology, family medicine, or adolescent-medicine practitioners) can insert an IUD. IUDs can be inserted at any time of the month if a patient is not at risk of being pregnant (either using a reliable method of contraception or not recently sexual active), but patients are often asked to schedule an appointment during menses to rule out current pregnancy. Patients undergo a routine pelvic exam and, barring any anatomic uterine abnormalities or evidence of active infection, an IUD can be placed. IUDs come pre-packaged in thin plastic tubes that fold the “arms” of the T-shaped device flat so they can be inserted through a minimally dilated cervix. Once inside the cervix, the IUD is released from the tube and assumes its T-shape. A string is attached to the bottom of the IUD that extends through the cervix and into the vagina. Once the IUD is inserted, the string is cut below the cervix and usually coils in cervical mucous. Patients will often be asked to return approximately 6 to 12 weeks after insertion for a string check to ensure that the IUD is still in appropriate position. IUDs can be removed at anytime but must be taken out by 3, 5, and 10 years for Skyla, Mirena, and Paragard, respectively. Removal should always be performed by a trained provider and, if desired, another IUD can be placed immediately after removal. While no follow-up is necessarily required, providers should evaluate for IUD strings during routine gynecologic examinations.

Birth Control Implants

Nexplanon (Merck) is a small, thin progesterone (etonogestrel) releasing rod that is inserted just under the skin in a patient’s upper arm. Nexplanon replaces the previous contraceptive implant, Implanon. In contrast to Implanon, Nexplanon is radiopaque and therefore can be detected on X-ray if needed. Contraceptive implants work by slowly releasing a steady dose of progesterone that suppresses ovulation. Implanon and Nexplanon are both approved for pregnancy prevention for up to 3 years and can be removed at any time with return to fertility in 7 to 14 days.

In contrast to IUDs, which do not have such requirements, contraceptive implant providers must complete a formal training session through the manufacturer before being certified as an Nexplanon/Implanon provider. The contraceptive implant comes packaged in its own insertion device that is used to insert the implant subcutaneously after first providing local anesthesia. Patients and providers are both expected to palpate the implant after insertion to confirm placement before concluding the visit. No follow-up is specifically recommended after contraceptive implant placement.

Efficacy of Devices

Although other reversible contraceptive methods require frequent participation by the user and therefore are susceptible to user error, LARC methods are sometimes referred to as “forgettable contraception” because users need not tend to the device between insertion and removal.10 Therefore, unlike other methods that often have a substantial difference between perfect and typical use, LARC method perfect and typical failure rates are equivalent.11 The Paragard and Mirena IUDs have a yearly failure rate of 0.8% and 0.2%, respectively; implants have a failure rate of 0.05%.12 In contrast, the most commonly used reversible contraceptives, pills and condoms, have typical use failure rates of 9% and 18%, respectively.12 Furthermore, teens often stop using short-acting contraception and subsequently leave themselves vulnerable to unintended pregnancy. Teens using LARC methods have significantly higher continuance rates (81% at 12 months) than those using short acting methods such as pills, patches, or rings (44% at 12 months). The most common reasons for IUD discontinuation are irregular vaginal bleeding and cramping.13

Non-Contraceptive Benefits

Besides their superior efficacy, Mirena and Skyla offer some of the same benefits as other hormonal methods, including improvement in dysmenorrhea and menorrhagia.14 Approximately 90% of women will have significantly decreased menstrual bleeding within 3 to 6 months of insertion, and many will become amenorrheic after 1 year.15 Decreased bleeding and pain with menses may be a significant draw for many patients.16 The benefits of Paragard include its long-term effectiveness (10 years without need for removal) and its lack of hormones. Teens or parents who feel uncomfortable using a hormonal method may see a copper IUD as a more “natural” form of family planning. Nexplanon offers teens a long-acting method of birth control without the requirement of a pelvic exam for placement. It can also decrease menstrual bleeding and cramping. All LARC methods offer privacy rarely available with short-term reversible contraceptive methods. Once in place, LARC methods cannot be seen by others. While Nexplanon may be felt under the skin if palpated directly over the rod, the device is generally not visible to the naked eye.17

Disadvantages of LARC

Over time, LARC methods are much more cost-effective than other methods of contraception. However, the upfront cost for the device and its insertion may be higher than that of starting a shorter-term method, and insurance coverage for devices and/or insertion can be inconsistent.18,19 While IUD and implant insertions can be uncomfortable, most patients tolerate insertion well and the initial discomfort quickly resolves. The most common side effect experienced by hormonal IUD users is irregular vaginal bleeding after placement. Approximately 1 in 3 of those using these methods will develop amenorrhea after 1 year, but many will continue to have light, unpredictable spotting for the duration that the IUD is in place. With adequate counseling, most users find this an acceptable side effect. If menstrual irregularity is especially bothersome to a user, naproxen and low-dose oral contraceptive pills may help reduce unexpected bleeding.20 Because of a high systemic dose of progesterone, implant users can experience more side effects, including irregular bleeding, acne, and mood swings.21 Paragard users will usually continue to menstruate with the same frequency as before their IUD was inserted, but may notice increased flow and cramping with periods.

Contraindications for Use

Contraindications for the use of IUDs and implants are shown in the Sidebar.


Common Misconceptions about IUDS

IUDs are inappropriate for teens with multiple sexual partners due to risk of PID and infertility

As mentioned above, the CDC Medical Eligibility Criteria supports the use of IUDs in females aged younger than 20 years. In the 1970s, an IUD called the Dalkon shield had a tri-filament string that, when cut at insertion, allowed vaginal bacteria to seed into the uterus and caused multiple cases of pelvic inflammatory disease (PID). This led to a persisting myth that IUDs actually cause PID and infertility. Modern IUDs have a monofilament string that does not facilitate tracking of vaginal flora into the uterus.22 Based on a meta-analysis on the association between IUDs and PID, women with STIs at the time of insertion are at a slightly increased risk of uterine infection, but their absolute risk remains very low, 0%–5%.23

IUDs are not appropriate for females who have never had a pregnancy

Nulliparity is not a contraindication for IUD placement. A 2009 meta-analysis of available data comparing expulsion rates of IUDs in nulliparous vs. parous users demonstrated that the risk of IUD expulsion may be slightly higher in younger, nulliparous patients, but overall rates were comparable, around 5% of all users.24,25

Teens aren’t interested in IUDs

The CHOICE project was a study performed between 2007 and 2009 in which trained professionals counseled female participants on their contraceptive choices that included LARC devices. All contraceptive methods were offered for free to the patients with structured contraceptive counseling. After counseling, 69% of females aged 14 to 20 years chose to begin a LARC method.26,27

When Patients Choose a LARC Method

Teens interested in LARC methods should be referred as soon as possible to a LARC provider, such as an adolescent-medicine specialist, a gynecologist, or a local family planning clinic. It is important not to delay initiation of contraception for sexually active patients. If obtaining a LARC method is likely to take significant time, another contraceptive method should be initiated until the LARC is available.

Like all non-barrier contraceptives, IUDs and implants do not provide any protection against STIs. All patients who choose a LARC method for contraception should be counseled on their risk of STIs and risk-reduction strategies such as using condoms consistently, limiting number of partners, and routine STI screening for themselves and their partners.

Although contraception counseling should routinely be done in private, parental support can be of significant benefit for LARC methods given the discomfort with insertion and requirement of specialist appointments. Parents who are involved with their teens’ decisions regarding contraception should be offered counseling on the safety, efficacy, benefits, and side effects of LARC methods as well. Importantly, however, 26 states and the District of Columbia allow minors aged older than 12 years to consent for contraceptive services, and 20 additional states allow certain minors to consent to such services. Therefore, providers should afford teens confidentiality and an opportunity to discuss contraception privately with their physicians.28

Conclusion

LARC methods are an ideal method of birth control for sexually active teen and young adult females who do not desire a pregnancy within the next few years. IUDs and contraceptive implants are highly effective, safe, and well-tolerated by this population. For these reasons, LARC methods should be offered as a first-line contraception for all medically eligible patients seeking birth control.

References

  1. Kost K, Henshaw S. US Teenage Pregnancies, Births and Abortions, 2008: National Trends by Age, Race and Ethnicity. New York, NY: Guttmacher Institute; 2012. Available at: www.guttmacher.org/pubs/USTPtrends08.pdf. Accessed July 13, 2013.
  2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478–85. doi:10.1016/j.contraception.2011.07.013 [CrossRef]
  3. American Academy of Pediatrics. Committee on Adolescence. Contraception and adolescents policy statement. Pediatrics. 2007;120(5):1135–1148.
  4. ACOG Committee Opinion No. 392, Intrauterine device and adolescents. Obstet Gynecol. 2007;110(6):1493–5.
  5. Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Morb Mortal Wkly Rep. 2010;59;52–63.
  6. Finer L, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril. 2012;98(4):893–897. doi:10.1016/j.fertnstert.2012.06.027 [CrossRef]
  7. Kohn JE, Hacker JG, Rousselle MA, Gold M. Knowledge and likelihood to recommend intrauterine devices for adolescents among school-based health center providers. J Adolesc Health. 2012;51(4):319–324. doi:10.1016/j.jadohealth.2011.12.024 [CrossRef]
  8. Espey E, Ogburn T. Long-acting reversible contraceptives: intrauterine devices and the contraceptive implant. Obstet Gynecol. 2011;117(3):705–719. doi:10.1097/AOG.0b013e31820ce2f0 [CrossRef]
  9. Zhou L, Xiao B. Emergency contraception with Multiload Cu-375 SL IUD: a multicenter clinical trial. Contraception. 2001;64(2):107–112. doi:10.1016/S0010-7824(01)00231-1 [CrossRef]
  10. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397–404. doi:10.1016/j.contraception.2011.01.021 [CrossRef]
  11. Grimes DA. Forgettable contraception. Contraception. 2009;80(6);497–499. doi:10.1016/j.contraception.2009.06.005 [CrossRef]
  12. Centers for Disease Control and Prevention. Contraception. Available at: www.cdc.gov/reproductivehealth/UnintendedPregnancy/Contraception.htm. Updated April 26, 2013. Accessed Aug. 5, 2013.
  13. Rosenstock JR, Peipert JF, Madden T, Zhao Q, Secura GM. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120(6):1298–1305.
  14. ACOG Practice Bulletin: No. 110. Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206–218.
  15. Hidalgo M, Bahamondes L, Perrotti M, Diaz J, Dantas-Monteiro C, Petta C. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception. 2002;65(2):129–132. doi:10.1016/S0010-7824(01)00302-X [CrossRef]
  16. Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv. 2002;57(2):120–128. doi:10.1097/00006254-200202000-00024 [CrossRef]
  17. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long–acting reversible contraception. Am J Obstet Gynecol. 2010;203(2):115.e111–115.e117. doi:10.1016/j.ajog.2010.04.017 [CrossRef]
  18. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79:5–14. doi:10.1016/j.contraception.2008.08.003 [CrossRef]
  19. Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolesc Health. 2013;52(4):S59–S63. doi:10.1016/j.jadohealth.2013.01.012 [CrossRef]
  20. Madden T, Proehl S, Allsworth JE, Secura GM, Peipert JF. Naproxen or estradiol for bleeding and spotting with the levonogestrel intrauterine system: a randomized controlled trial. Am J Obstet Gynecol. 2012;206(2):129.e1–8. doi:10.1016/j.ajog.2011.09.021 [CrossRef]
  21. Mansour D, Korver T, Marintcheva-Petrova M, Frasier IS. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care. 2008;13(Suppl 1):13–28. doi:10.1080/13625180801959931 [CrossRef]
  22. Tatum HJ, Schmidt FH, Phillips D, McCarty M, O’Leary WM. The Dalkon shield controversy. JAMA. 1975;231(7):711–717. doi:10.1001/jama.1975.03240190015009 [CrossRef]
  23. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 2006:73(2);145–153. doi:10.1016/j.contraception.2005.08.007 [CrossRef]
  24. McNicholas C, Peipert JF. Long-acting reversible contraception for adolescents. Curr Opin Obstet Gynecol. 2012;24(5):293–298. doi:10.1097/GCO.0b013e32835686d5 [CrossRef]
  25. Lyus R, Lohr P, Prager S. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Contraception. 2010;81(5):367. doi:10.1016/j.contraception.2010.01.010 [CrossRef]
  26. Mestad R, Secura G, Allsworth JE, Madden T, Zhao Q, Peipert JF. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception. 2011;84(5):493–498. doi:10.1016/j.contraception.2011.03.001 [CrossRef]
  27. Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception. 2008;78(3):211–217. doi:10.1016/j.contraception.2008.04.119 [CrossRef]
  28. Boonstra H, Nash E. Minors and the Right to Consent to Health Care. Guttmacher Rep Public Policy. 2000;3(4):4–8.
  29. Paragard. Paragard prescribing information. Available at: www.paragard.com/images/ParaGard_info.pdf. Accessed Aug. 19, 2013.
  30. Mirena. Mirena prescribing information. Available at: http://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf. Accessed Aug. 19, 2013.

Sidebar.

Contraindications for Use of IUDs and Implants

IUDs
  • Sensitivity to a component of the IUD (ie, copper allergy or Wilson’s disease for Paragard)29,30
  • Known or suspected pregnancy
  • Structural anomalies of the uterus (ie, bicornuate uterus)
  • Active cervicitis
  • Active STI/PID/endometritis or within past 3 months (IUD insertion may take place at time of testing in a low-risk asymptomatic patient)


Implants
  • Known or suspected pregnancy
  • Hepatic malignancies
  • Known or suspected breast cancer or history of breast cancer

IUD = intrauterine device; PID = pelvic inflammatory disease; STI = sexually transmitted infection.

Authors

Lawren D. Wellisch, MD, is a Resident Physician, Department of Pediatrics, Comer Children’s Hospital, The University of Chicago. Julie Chor, MD, MPH, is an Assistant Professor, Department of Obstetrics and Gynecology, Section of Family Planning and Contraceptive Research, The University of Chicago Medical Center.

Address correspondence to: Lawren D. Wellisch, MD, 5721 S. Maryland Avenue, Chicago, IL 60637, email: Lawren.Wellisch@uchospitals.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20130823-13

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