Clinical Review

Your teenage patient and contraception: Think “long-acting” first

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Skyla is another LARC option for womenseeking an LNG-IUS for contraception. It provides highly effective contraception for at least 3 years through the release of 13.5 mg of levonorgestrel over time. Skyla’s reduced levonorgestrel content, as compared with Mirena and Liletta, means that fewer users will experience amenorrhea (13% vs 25%).

Paragard is a nonhormonal IUD that uses copper for contraceptive efficacy. The device contains a total of 380 mm of copper. Possible mechanisms of action include interference with sperm migration in the uterus and damage to or destruction of ova. It is FDA-approved for at least 10 years of use. The lack of any hormone in Paragard IUDs may make them attractive to women who do not wish to experience amenorrhea.

Nexplanon is a subdermal implant containing 68 mg of etonogestrel; it is approved for at least 3 years of use. It is the only LARC method that does not require a pelvic examination. Providers are required to complete a training course offered by the manufacturer to ensure proper placement and removal technique.

LARC should be a first-line birth control option
The primary indication for LARC is preg-nancy prevention. Because LARC methods are the most effective reversible means to prevent pregnancy—apart from complete abstinence from sexual intercourse—they should be offered as first-line birth control options to patients who do not wish to conceive. The ability to discontinue LARC methods is an attractive option for women who may want to become pregnant in the future, such as the patient in the opening vignette.

Efficacy rates are high
Because LARC methods do not require users to take action daily or prior to intercourse, they carry a risk of pregnancy of less than 1% (TABLE 1)4-7—equal to or better than rates seen with tubal sterilization. In comparison, the OC pill has a typical use contraceptive failure rate of about 8%.

LARC still has a low utilization rate
It is unfortunate that barriers to LARC methods remain in the United States (see, for example, “National organization identifies barriers to LARC,” above). As recently as 2011 to 2013, only 7.2% of US women aged 15 to 44 years used a LARC method.8 Provider inexperience and patient fears surrounding LARC use remain major barriers. In the past, nulliparity and young age were thought to be contraindications to IUD use. Research and experience have demonstrated, however, that IUDs and contraceptive implants are safe for use in young women and those who have not had children.

Cost barriers also have significantly limited the use of LARC methods. Over time, however, these contraceptives have become less costly to patients, and most insurance providers routinely cover LARC devices and insertion fees. The contraceptive mandate of the Affordable Care Act ensures coverage of contraception, including LARC, for interested women. These trends suggest continued improvement in women’s access to LARC.

National organization identifies barriers to LARC

In 2014, the National Committee for Quality Assurance (NCQA), with support from Bayer Healthcare, organized a meeting of key opinion leaders to discuss ways to eliminate barriers to the most effective contraceptive methods, better known as long-acting reversible contraception (LARC). The resultant issue brief, Women’s Health: Approaches to improving unintended pregnancy rates in the United States, identified a number of key barriers:

  • Financial and logistical obstacles. The consensus attendees agreed that LARC methods should be offered to all women not planning a pregnancy in the next 2 years, but acknowledged that operational or administrative process issues sometimes interfere with this goal. One of the most prominent of these issues was the lack of opportunity for same-day insertion of LARC. Other issues included the cost to stock LARC methods, a lack of understanding of billing and reimbursement for LARC, reimbursement policies that prohibit billing for the visit and placement on the same day, and an overabundance of paperwork.
  • Timing of the contraceptive counseling session. Many women fail to return for the 6-week postpartum visit—the visit typically set aside for counseling about contraception.
  • Lack of a quality measure that would “motivate change in clinical practice.”1 One option: Treat family planning as a “vital sign” that needs to be addressed during the annual visit. “This would lead to stronger evidence for effecting change,” the report notes.1
  • Lack of adequate communication skills by the provider. According to the NCQA report, “There are strong positive relationships between a health care team member’s communication skills and a patient’s willingness to follow through with medical recommendations.”1 The establishment of a “current counseling approach” that emphasizes the efficiency and effectiveness of LARC methods as well as the tremendous impact an unintended pregnancy would have on a woman’s whole life course would help improve provider-patient communication and increase the likelihood of LARC methods being utilized.1
  • Lack of receptivity among some patients. For some women, the person delivering the message is as important as the message itself, depending on social and cultural norms. Sensitivity of health care providers to these nuances of communication can help enhance patient receptivity to the key message. As the NCQA report notes, “Physicians and the health care system are not always the most trusted source of information, and understanding disparities in contraception care will be important in changing patient behavior.”1
  • Basic issues such as cost and access to care.1 Not all women are covered by insurance, particularly in states that opted against expanding access to Medicaid. For these women, the cost of LARC methods and insertion may be prohibitive.


1. Women’s health: Approaches to improving unintended pregnancy rates in the United States. National Committee for Quality Assurance. Issue Brief. 2014. Accessed August 18, 2015.

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