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Use of long-acting reversible contraceptives to reduce the rate of teen pregnancy

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ABSTRACTLong-acting reversible contraceptives (LARCs) are safe for use in adolescents and do not rely on compliance or adherence for effectiveness. Continuation rates are higher and pregnancy rates are lower for adolescent users of LARCs compared with short-acting methods such as oral contraceptives. Similarly, repeat pregnancy rates are lower when LARCs are used compared with other forms of contraception. Myths and misconceptions about LARCs and other contraceptives remain a barrier to their use. Health care providers are in a unique position to provide confidential care to adolescents, and should provide education to them about the various contraceptive options, especially LARCs.


 

References

Adolescents who are at risk of unintended pregnancy need access to highly effective contraceptives. Using a case study format, this article addresses the myths, misconceptions, and barriers to effective use of contraceptives, focusing on long-acting reversible contraceptives (LARCs) and suggesting ways to overcome these barriers.

CASE 1: TEEN WITH DYSMENORRHEA

Jessica is a 15-year-old girl presenting with complaints of severe cramps, causing her to miss school and other activities 3 to 4 days each month. She has had six sexual partners and believes that contraception would be a good idea. She also states that she hates shots and doesn’t swallow pills well. She asks you to help. What are her/your options?

In this case, options include chewable oral contraceptives, a contraceptive patch, the etonogestrel/ethinyl estradiol vaginal ring (NuvaRing), depot medroxyprogesterone acetate (DMPA; progestin-only, injectable, lasts 3 months), and LARCs, which are intrauterine systems (IUS), intrauterine devices (IUDs), and implants. If she can remember a chewable pill every day, that would be one option. The patch requires her to remember to change it weekly. The vaginal ring requires ability and motivation to insert and remove it vaginally each month. She has stated that she does not want shots, so DMPA is not a viable option.

In contrast, LARCs constitute “forgettable” contraception in that they are not dependent on daily or monthly investment of time and energy to use. With her dysmenorrhea, use of an LARC that contains a progestin to thin out her lining and/or induce amenorrhea has some additional advantages.

The Institute of Medicine has declared that expanding access to LARCs for young women is a national priority.1 In 2009, the American College of Obstetricians and Gynecologists encouraged implants and IUDs for nulliparous women and adolescents.2 The following review describes currently available LARCs.

Intrauterine systems (IUS)

The levonorgestrel-releasing IUS (Mirena) was approved by the US Food and Drug Administration (FDA) in 2000. It maintains efficacy for 5 years and has a failure rate of 0.2%. Contraception is reversible with its removal. The system consists of a small T-shaped frame with a steroid reservoir that releases 20 µg/day of levonorgestrel, resulting in high endometrial levels and low plasma levels of levonorgestrel. An alternate brand available in the US is Skyla, notable for its slightly smaller size, slightly higher expulsion rate, and similar side effect profile to Mirena.

The copper in the levonorgestrel-releasing IUS acts as a spermicide. The progestin thickens the cervical mucus and thins the endometrial lining to cause a marked reduction in uterine bleeding. Between 20% and 80% of recipients experience amenorrhea by 1 year.3–5 It is considered safe and effective, it provides prolonged relief of menstrual problems including menometrorrhagia. Because it contains only progestin, it can be used while breastfeeding. One drawback is the skill needed to insert the device, necessitating insertion by a clinician. Side effects include early spotting and rare instances of perforation of the uterus.3

Intrauterine devices (IUD)

The copper IUD (Paragard) was FDA approved in 1989 for 10 years of use, but it has been used off label for up to 12 years continuously. It is preferred by women who want to avoid hormones while achieving similar results as the levonorgestrel-releasing IUS, including reductions in menstrual bleeding. The copper IUD can be used in women with a history of ectopic pregnancy. Fertility returns after removal of the device. Its use has been associated with a reduction in the risk of endometrial cancer,6 which may be related to prevention of human papillomavirus infection. Insertion of the copper IUD is a relatively simple office procedure.

Implants

The etonorgestrel single-implant system (Implanon, Nexplanon) is a single rod containing 68 mg of the progestin etonorgestrel, which is the biologically active metabolite of desogestrel. The single rod eases implantation and removal compared with previous systems that contained six rods. The implant was FDA approved in 2006 but has been marketed worldwide since 1998. Nexplanon contains a single, radiopaque rod that is easier to localize and remove.

The duration of contraceptive efficacy for Nex­planon is 3 years. Etonorgestrel levels are undetectable within a few days of reversal. Breakthrough bleeding can occur, and depression and mood swings are potential side effects that are manageable with close follow-up. The implants can be removed at any time.

If breakthrough bleeding occurs while on progestin-only methods, an intermittent solution is to add estrogen by pill or patch for 3 weeks and then withdraw the estrogen until bleeding again occurs. This practice is usually not necessary by 12 months after implantation.

Implant use can reduce the repeat pregnancy rate among adolescents. In one study, researchers found that teenage mothers who chose a contraceptive implant during their first year postpartum, including the 37% who discontinued use, had a 2-year repeat pregnancy rate of 12% versus 46% among mothers using no method or other methods of contraception.7

Barriers to LARC use

Among adolescents attending an integrated prenatal and postpartum maternity clinic, 75% indicated intent to use LARCs postpartum. Approximately one-third chose an implant, one-third chose an IUS, and one-third chose either DMPA, oral contraceptives, a contraceptive patch, or a contraceptive ring. After 6 months, only 50% had received an LARC, leaving one-third at risk for rapid repeat pregnancy.8

Unfortunately, the safety, side effects, and efficacy of LARCs may be misunderstood by both clinicians and teens. A negative personal experience may dominate one’s thinking and act as a barrier to use. The adolescent may not be mature enough to understand the chance of pregnancy or its consequences. Use of an IUD or IUS requires planning, a visit to a clinic that can insert the device, and a substantial up-front expenditure, even though the average cost per year compares favorably to use of DMPA or oral contraceptives.

Lack of awareness of LARCs is another barrier to their use. Between 50% and 60% of young women have never heard of an IUD and 90% have no awareness of contraceptive implants.9–12 Of those who knew about them, only 25% knew that they were eligible to use LARCs.13

In addition, many practitioners still mistakenly believe that current IUDs can cause pelvic inflammatory disease (PID), despite there being no association between modern IUDs and PID after the first 20 days following insertion.14–16

Physicians may also be unaware of the medical eligibility criteria (MEC) for contraceptive use established by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC).15,16 Conditions affecting eligibility for the use of each contraceptive method are classified under four categories (Table 1).

Overall efficacy

The effectiveness of LARC use in young women has been established. In one large study,17 4,167 females aged 15 to 45 were offered contraception at no cost for 3 years. Of those who chose an LARC, the 12-month continuation rate was 86% compared with 55% among those choosing an oral contraceptive. Satisfaction rates reflect the continuation rates with more than 80% of LARC users being satisfied compared with 54% of oral contraceptive users being satisfied. The pregnancy rate was 22 times greater in women using short-acting contraceptives compared with LARC users. In women younger than 20, pregnancy rates were twice as high among oral contraceptive users.4,18

Case conclusion

Jessica chooses an IUS, and her adolescent-medicine physician inserts Mirena at her next visit. She has some irregular bleeding during the first 3 months, but by 1 year, she is having periods only every 5 to 6 months. She manages cramps with ibuprofen 400 mg orally every 6 hours and is careful not to miss ibuprofen doses when she starts cramping or bleeding. She has not had sexual activity since the insertion, but she plans to always use condoms when she chooses to have sex. At her 3-month visit after insertion, when considering whether to remove or continue with her IUS despite her initial unscheduled bleeding, she discusses the flexibility of IUS to allow her to change her mind: “It’s like changing my hairstyle; I can just come back and change it in 3 months or even sooner if it is really bothering me. I don’t have to think of it as permanent, just less of a daily bother.” She is pleased with her choice of LARC and plans to return in 6 months for follow-up.

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