› Suggest long-acting reversible contraception (LARC), including intrauterine devices (IUDs), as a first-line method of contraception to most women, including adolescents and nulliparous women. A
› Offer immediate post-placental insertion of LARC when counseling women who have barriers to seeking contraception at a postpartum visit or are unlikely to return for a postpartum visit. B
› Treat sexually transmitted infections in most cases without removing an IUD that is already in place. Consider removing the IUD, however, if there is no clinical improvement after 2 to 3 days of antibiotics. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The number of women using long-acting reversible contraception (LARC) in the United States has been increasing, with current use accounting for approximately 18% of reversible contraception, according to the National Survey of Family Growth.1,2 LARC includes any method of contraception that lasts ≥3 years, is easily reversed, and does not rely on the user to maintain efficacy. Five LARC devices are available in the United States: 4 intrauterine devices (IUDs) and one subdermal implant.
The number of women using LARC is surprisingly low, given that it is considered a first-line contraceptive method for most women and adolescents,3 and when compared with other forms of reversible contraception, is more efficacious,4-6 has higher satisfaction rates,7-9 and higher rates of continuation.9 In fact, the Contraceptive CHOICE Project—a St. Louis community-based research program promoting and enabling access to reversible contraceptive methods—has shown that when appropriate counseling is provided and cost barriers are removed, up to 79% of women choose LARC as their preferred method of contraception.10
CASES › Jenny, who is 16 years old, comes to your office with her mother to discuss contraceptive options. She is nulliparous, has regular menses, and, aside from a body mass index (BMI) of 28, has no medical problems. Her mother is concerned about Jenny becoming pregnant while she is still in high school.
Maria D, a 32-year-old G2P1, comes in for a prenatal visit with her husband. She tells you that after delivery she is interested in a long-acting contraceptive, but is planning on breastfeeding and does not want anything to interfere with that.
What LARC options do these and other patients have?
The 4 IUDs and one implant approved for use are all viable options depending on a patient’s preference and comorbidities (TABLE 1).3-9,11-15 The copper IUD is the oldest method of LARC available and the only one that is nonhormonal. It is approved by the Food and Drug Administration (FDA) for use up to 10 years,11 but studies support its effectiveness for up to 12 years.16
The remaining IUDs (Skyla, Liletta, Mirena) contain varying amounts of the progestin levonorgestrel (LNG), released by each device at a slightly different rate that declines over time. Skyla releases a significantly lower dose of hormone than Liletta or Mirena.12-14 Skyla and Liletta are FDA-approved for up to 3 years of use,12,13 and Liletta is currently undergoing trials to gain approval for use up to 5 years. Mirena is FDA-approved for use up to 5 years,14 but studies have shown that it can be effective for 7 years.4,16
The only implant available in the US is Nexplanon, a plastic rod containing 68 mg of etonorgestrel. It is inserted subdermally and is FDA-approved for use up to 3 years.15
Through systemic hormonal effects, the primary mechanism of action of the implant is prevention of ovulation. Additionally, the implant has been shown to inhibit endometrial proliferation and cervical mucus thickening, both of which may contribute to the implant’s overall effectiveness.17 In contrast, both the copper IUD and the LNG-IUDs work primarily by preventing fertilization. The LNG-IUDs also exhibit local hormonal effects (endometrial atrophy and thickened cervical mucus) that contribute to their effectiveness.17
Who is eligible for LARC?
LARC is suitable for the vast majority of women of reproductive age. For most multiparous women ≥20 years, all LARC devices are classified as category 1 (use without restriction) in the Centers for Disease Control and Prevention’s (CDC) US Medical Eligibility Criteria (US MEC).3 For women <20 years, the implant is also considered category 1, but IUDs in this age group are classified as category 2 (recommended with the caution that advantages usually outweigh risks) because of concerns about an increased risk of IUD expulsion and the increased prevalence of sexually transmitted infections (STIs) in adolescents.3 Contraindications to use of LARC vary depending on the method chosen (TABLE 1).3