Pediatric Annals

Healthy Baby/Healthy Child 

Long-Acting Reversible Contraception: A Primer for the Primary Care Pediatrician

Sabrina Fernandez, MD

Abstract

Long-acting reversible contraception (LARC) is the most effective method of preventing pregnancy in young women and adolescents. The two types of LARC methods are the intrauterine device and the implantable rod device. The success of these methods is demonstrable due to the “perfect use” and “typical use” failure rates being near identical. Pediatricians must be comfortable counseling patients, including adolescents, about LARC methods and how to access them. This primer provides some background about the types of LARC methods, details about their efficacy and side effects, and the role of the primary pediatrician. [Pediatr Ann. 2017;46(3):e79–e82.]

Abstract

Long-acting reversible contraception (LARC) is the most effective method of preventing pregnancy in young women and adolescents. The two types of LARC methods are the intrauterine device and the implantable rod device. The success of these methods is demonstrable due to the “perfect use” and “typical use” failure rates being near identical. Pediatricians must be comfortable counseling patients, including adolescents, about LARC methods and how to access them. This primer provides some background about the types of LARC methods, details about their efficacy and side effects, and the role of the primary pediatrician. [Pediatr Ann. 2017;46(3):e79–e82.]

Almost one-half of all high school students report ever having sexual intercourse, and every year the number of adolescent pregnancies in the United States is about 750,000.1–3 Most of these are unplanned pregnancies, indicating a need for effective, accessible contraception for adolescents.2,3 Pediatricians are trusted sources of information for adolescents, and should ask them about their sexual history in a confidential manner. Many states allow minors to consent for contraception, but confidentiality and consent laws vary from state to state. Twenty-one states explicitly allow minors to consent for contraception, 25 states allow minors to consent in certain circumstances, and 4 states have no explicit policy. These specific laws can be accessed by referencing the Guttmacher Institute's State Center4 or State Minor Consent Laws: A Summary.5 It is also important to note that in 2010, the Affordable Care Act was enacted and required private health plans to cover all US Food and Drug Administration-approved contraceptive methods without copay or deductible.6

Long-acting reversible contraception (LARC) methods are the most effective in preventing pregnancy in adolescents.7 The success of LARC methods is due to the “typical use” and “perfect use” failure rates being nearly identical. “Typical use” refers to the percentage of typical couples that initiate a contraceptive method and experience accidental pregnancy in the first year of use. “Perfect use” refers to the percentage of couples that use their contraceptive methods consistently and correctly and still experience accidental pregnancy. LARC methods do not require a daily, weekly, or monthly action on the part of the patient; therefore, they are easier for the patient to manage. Additionally, the typical use and perfect use failure rates for LARC methods are <1%.7 The typical use and perfect use failure rates for the oral contraceptive pill, by comparison, are 9% and 0.3%, respectively. In other words, for typical patients, 9 of 100 will become pregnant after 1 year on the pill, whereas <1 of 100 will become pregnant with a LARC method.

When counseling adolescents about contraception, it's ideal to discuss the most effective methods of contraception first. Despite this, some pediatricians may feel uncomfortable talking about LARC methods, and most are not trained in LARC insertion.8 This article is intended to increase familiarity and comfort of the primary care pediatrician in counseling and recommending LARC methods.

The Contraceptive CHOICE project was a prospective cohort study9 of almost 10,000 women, age 14 to 45 years, in which they were asked two questions: (1) if given information and access to contraception for free, which contraceptive method would they choose and (2) what happened in the 2 to 3 years after initiation. The findings were overwhelmingly positive toward LARC methods. More teens and young women chose LARC methods over other contraceptive options. More patients were satisfied with their choice in using the LARC method, and more patients were still using their LARC method after 1 year, compared to other short-acting options.9

Types of LARC Methods

Table 1 is not an exhaustive list of contraceptive options, but instead focuses on LARC methods and how they compare to other common contraceptive options, including oral contraceptive pills and male condoms. The two types of LARC methods are the intrauterine device (IUD) and the implantable rod device. There are two types of IUDs, the Copper T and levonorgestrel. The Copper T IUD is approved for use up to 10 years, and does not have a hormonal component. Copper ions inhibit sperm motility and fertilization enzymes. Women often have regular menstruation, although bleeding may be heavier, longer, and with more cramping in the first 6 months. Therefore, the Copper T IUD is most ideal for women who want regular periods, want a nonhormonal contraceptive method, and have no history of menorrhagia or dysmenorrhea. The Copper T IUD is also the only IUD approved for use as emergency contraception if inserted within 5 days after unprotected sex.10

�A;            Information on Selected Contraceptive Methods

Table 1.

Information on Selected Contraceptive Methods

There are four types of levonorgestrel IUDs,11–15 with dosages ranging from 14 to 20 mcg/day. These are progestin-only devices lasting for 3 to 5 years. Levonorgenstrel thickens cervical mucus and inhibits sperm motility.16 Therefore the mechanism of action for levonorgestrel IUDs is to prevent fertilization, rather than disrupt implantation. A common side effect of levonorgestrel IUDs is spotting or irregular bleeding. There are a few contraindications to IUDs, such as active pelvic inflammatory disease (PID), certain cancers, or uterine anatomical abnormalities. Prior history of PID, HIV infection, and immunodeficiency are not contraindications to IUD insertion.7

The implantable rod device is inserted into the inner side of the upper arm. It is a progestin-only product and therefore does not contain estrogen. It is effective for 3 years. Clinician training on insertion is required by the manufacturer before purchasing. Insertion time is approximately 1 minute. This product inhibits ovulation and thickens cervical mucous. Like IUDs, irregular bleeding/spotting may occur. Amenorrhea occurs in approximately 22% of women.17 This option may be ideal for women who desire a highly effective, discrete birth control method and do not want intrauterine insertion. In the Contraceptive CHOICE project, of those age 14 to 20 years who desired a LARC method, more 14- to 17-year-old participants choose the implantable rod device over IUDs, compared to their 18- to 20-year-old counterparts.9

LARC Myths

Pelvic Inflammatory Disease

A common LARC misconception is its relationship to PID. The incidence of PID in women using a LARC method is similar to that of the general population.18 The risk is mostly in the first month after insertion, and is related to a preexisting infection, rather than the IUD causing PID. Therefore, women at risk for PID should be screened for sexual transmitted infections (STIs) at the time of insertion. Although it is ideal to have a recent negative STI screen at the time of insertion, waiting for a negative test prior to insertion is not a necessity. When at all possible, LARC insertion should occur on the day of counseling.6

Infertility

There is also concern about whether there is a potential link between IUDs and infertility. However, studies have shown that a prior history of chlamydia is the culprit, rather than the IUD itself and women with IUDs are not more likely to have infertility compared to their gravid counterparts, with an odds ratio of 0.9.19,20

IUD Use in Nulliparous Women

Another common concern is expulsion rates in nulliparous women compared to parous women. Studies conflict on this issue, with some studies showing no difference in the two groups, and others showing slightly greater rates of expulsion.6 Despite this potential small difference, IUDs are an effective, generally well-tolerated method of contraception in nulliparous women.6

See Table 2 for take-home points about LARC methods in adolescents.

�A;            Take-Home Points

Table 2.

Take-Home Points

References

  1. Martinez G, Copen CE, Abma JC. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006–2010 national survey of family growth. Vital Health Stat 23. 2011;31:1–35
  2. Kost K, Henshaw S, Carlin L. US Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute; 2010.
  3. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478–485. doi:10.1016/j.contraception.2011.07.013 [CrossRef]
  4. Guttmacher Institute. Minors' access to contraceptive services. www.guttmacher.org/statecenter/spibs/spib_MACS.pdf. Accessed February 20, 2017.
  5. Center for Adolescent Health & the Law. State Minor Consent Laws: A Summary. 3rd ed. Chapel Hill, NC: Center for Adolescent Health and the Law; 2010.
  6. Eliscu AH, Burstein G. Updates in contraceptive counseling for adolescents. J Pediatr. 2016;175:22–26. doi:10.1016/j.jpeds.2016.05.007 [CrossRef]
  7. Ott MA, Sucato GSCommittee on Adolescents. Contraception for adolescents. Pediatrics. 2014;134:e1257–e1281. doi:10.1542/peds.2014-2300 [CrossRef]
  8. Greenberg KB, Makino KK, Coles MS. Factors associated with provision of long-acting reversible contraception among adolescent health care providers. J Adolesc Health. 2013;52:S372–374. doi:10.1016/j.jadohealth.2012.11.003 [CrossRef]
  9. Secura G, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371:1316–1323. doi:10.1056/NEJMoa1400506 [CrossRef]
  10. Teva Women's Health website. Paragard. http://hcp.paragard.com/Default.aspx. Accessed February 20, 2017.
  11. Bayer website. Mirena. http://hcp.mirena-us.com/index.php. Accessed February 20, 2017.
  12. Bayer website. Skyla. http://hcp.skyla-us.com/index.php. Accessed February 20, 2017.
  13. Allergan website. Lilleta. https://www.lilettahcp.com. Accessed February 20, 2017.
  14. Creinin MD. Levonorgestrel release rates over 5 years with the Liletta® 52-mg intrauterine system. Contraception. 2016;94(4):353–356. doi:10.1016/j.contraception.2016.04.010 [CrossRef]
  15. Bayer website. Kyleena. https://hcp.kyleena-us.com. Accessed February 20, 2017.
  16. Jonsson B, Landgren BM, Eneroth P. Effects of various IUDs on the composition of cervical mucus. Contraception. 1991;43:447–458. doi:10.1016/0010-7824(91)90135-3 [CrossRef]
  17. Merck website. Nexplanon. https://www.merckconnect.com/nexplanon/overview.html. Accessed February 20, 2017.
  18. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339:785–788. doi:10.1016/0140-6736(92)91904-M [CrossRef]
  19. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmán-Rodríguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345:561–567. doi:10.1056/NEJMoa010438 [CrossRef]
  20. Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subsequent fertility--follow-up after participation in a randomized clinical trial. Contraception. 2007;75:88–92. doi:10.1016/j.contraception.2006.09.010 [CrossRef]

Information on Selected Contraceptive Methods

Long-Acting Reversible Contraception Method No. of Years Approved for Use % Failure Ratea % Still Using at 1 Year Special Notes
Typical Use Perfect Use
Intrauterine devices
Copper T: Paragard (Teva, North Wales, PA) 10 0.8 0.6 78 May be used for emergency contraceptionb
Levonorgestrel 20 mcg/day: Mirena (Bayer, Whippany, NJ) 5 0.2 80 Irregular bleeding/spotting is common in the first 3–6 months. ∼18% experience amenorrhea
Levonorgestrel 14 mcg/day: Skyla (Bayer, Whippany, NJ) 3 0.4 Slightly smaller in size compared to other levonorgestrel IUDs
Levonorgestrel ∼15 mcg/day: Liletta (Allergan, Irvine, CA) 3 0.55 May be approved for 5 or more years in the future
Levonorgestrel 17.5 mg/day initially, decreasing to 7.4 mcg/day after 5 years: Kyleena (Bayer, Whippany, NJ) 5 0.16 Became FDA approved in September 2016
Implantable rod devices
Etonogestrel: Nexplanon (Merck, Whitehouse Station, NJ) 3 0.05 84 Prior version was Implanon (Merck, Whitehouse Station, NJ). Needs training from the manufacturer before purchasing
Other contraceptive methods
Oral contraceptive pill (combined pills and progestin-only pills) N/A 9 0.3 67 Combined pills contain estrogen and progestin
Male condom N/A 18 2 43 Also protects against sexually transmitted infections
No method N/A 85 85 N/A --

Take-Home Points

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LARC methods are the most effective form of birth control, and the main two types are IUDs and implantable rod devices. Besides sterilization, these methods have the highest rates of continuation after 1 year, and studies support a high rate of satisfaction among patients

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When counseling patients about contraception, pediatricians are encouraged to talk about the LARC methods first, because these are the most effective form of contraception

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When possible, offer LARC insertion on the day of counseling to eliminate the need for a future visit. If insertion is not immediately available, one may bridge the patient with a short-acting method until their LARC insertion appointment

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The Copper T IUDs are the only LARC methods approved as emergency contraception if used in the first 5 days after unprotected sex

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Adolescents should be screened for sexually transmitted infections at the time of counseling and/or insertion, and pediatricians need not wait for negative test results prior to insertion in an asymptomatic patient

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Pediatricians should counsel patients that with all LARC methods, irregular bleeding/spotting can occur, but generally improve after the first several months of use

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Authors
Sabrina Fernandez, MD
 

Sabrina Fernandez, MD, is a Primary Care Pediatrician, University of California San Francisco, Benioff Children's Hospital; and an Assistant Professor of Pediatrics, Department of Pediatrics, University of California San Francisco.

Address correspondence to Sabrina Fernandez, MD, via email: sabrina.fernandez@ucsf.edu.

Disclosure: The author has no relevant financial relationships to disclose.

The author gives special thanks to Tonya Chaffee, MD, (University of California, San Francisco and Zuckerburg San Francisco General Hospital), in helping with this article.

10.3928/19382359-20170220-03

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