LONG-ACTING REVERSIBLE CONTRACEPTION

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ABSTRACT (ABSTRACT)
It's essential to give women information about bleeding patterns.7 Implanon (implanted etonogestrel) causes
amenorrhoea in 20% of users in the first year. A further 26% experience erratic bleeding, which may settle. POIC
comprises depot injections of either medroxyprogesterone acetate (DMPA, Depo-Provera) or norethisterone
enantate. POIC has higher 'no bleeding' rates than Implanon.

FULL TEXT
 
Note: Levonorgestrel; Implanon (implanted etonogestrel); Medroxyprogesterone acetate; DMPA; Depo-Provera;
Norethisterone enantate; Mirena

Sexual health GPSI Dr Meg Thomas offers tips on LARC promotion, use as emergency contraception and bone
health

1 Take the chance to promote LARC when a young woman wants to go on the pill as she may be unaware of the
option. This includes copper intrauterine devices (IUCDs), the levonorgestrel intrauterine system (LNG/IUS),
progestogen-only implants (POSDI) and injectables (POIC).

LARC is oestrogen-free and very safe - the risks of complicated migraine and thromboembolism are insignificant.
Failure rates lie between 0.05 and 0.3 pregnancies per 100 women per year (PHWY) - equivalent to vasectomy and
better than female sterilisation.

But uptake is low despite NICE guidance1 and this needs to be addressed as the 'actual' failure rates of oral
contraception and condoms are eight and 16 pregnancies PHWY respectively.2

Giving more information on convenience, reversibility and women's positive experiences may improve
acceptability3.

2 A request for emergency contraception (EC) is another good opportunity to promote LARC.

Offer the IUCD to all woman who request EC - it is very effective, especially after 24 hours. Discuss its low failure
rate compared with hormonal EC, and its potential for use as an ongoing method.4

Some 60% of women requesting abortion were 'using' contraception at the time they became pregnant.5 Present
LARC in a positive light, while obviously remaining sensitive to the immediate needs of the patient.

3 Copper IUCDs are the best way to protect women's reproductive and general health.

There are few serious problems. Pelvic inflammatory disease (PID) is uncommon at 0.16 cases per PHWY,

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although a sixfold increase in risk occurs in the 20 days after insertion.6 Screen women at risk of sexually
transmitted infection - for example, those under 25 or with a new partner - before insertion and consider
prophylaxis.6

Further information is available from the Royal College of Obstetricians and Gynaecologists' Faculty of Sexual and
Reproductive Healthcare website at www.ffprhc.org.uk.

4 Progestogen-only contraception is not first choice for women who like regular periods.

It's essential to give women information about bleeding patterns.7 Implanon (implanted etonogestrel) causes
amenorrhoea in 20% of users in the first year. A further 26% experience erratic bleeding, which may settle. POIC
comprises depot injections of either medroxyprogesterone acetate (DMPA, Depo-Provera) or norethisterone
enantate. POIC has higher 'no bleeding' rates than Implanon.

The LNG-IUS (Mirena) leads to initial erratic bleeding. By six months, bleeding is reduced, hence the popularity of
the method. The best way to control bleeding is to use the combined pill, if it is not contraindicated. See
www.ffprhc.org.uk.

5 Discuss bone health with potential POIC users.

Prolonged use leads to a reversible decline in bone mineral density. The Medicines and Health Care Products
Regulatory Agency issued advice on this in 2004.8 Adolescents may use DMPA first line only after other methods
have been discussed and considered unsuitable, and this fits in with the advice to always discuss all methods.
DMPA remains an excellent contraceptive for the young, as a result of its overall safety and efficacy.

Re-evaluate the risks and benefits for all ages after two years of use. When there are risk factors for osteoporosis,
consider other methods.8

6 Discuss future fertility intentions when women are considering an injectable as it's not the ideal method for
family spacing. On average, ovulation does not occur till the ninth month after the last injection, although it has
been known as early as 14 weeks and as late as 16 months. There is no permanent effect on fertility.

7 Follow LARC insertion schedules carefully to avoid overlooking an early pregnancy. Product licences restrict
insertion to the first few days of the cycle. In practical terms this can be problematic, especially for more
vulnerable groups. For guidance on the use of LARC outside of the licence,9 see www.ffprhc.org.uk. LARC can be
started at any time in the cycle if there is no pregnancy risk. Pregnancy testing is only helpful three weeks or more
since last intercourse.

The IUCD can be fitted in cycles with risk up to five days post ovulation. For further information, including how to
switch methods, go to www.ffprhc.org.uk and search for 'UK selected practice recommendations for contraceptive
use'.

8 Insertion regimes can be relaxed for perimenopausal women. Women who have a copper IUCD fitted after 40
years of age can keep it until they are postmenopausal. LNG-IUS users who have their device fitted at 45 or over
may keep it for seven years.

9 If a woman repeatedly turns up late for injections, suggest she use a longer-acting alternative such as an implant

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or IUCD. If there is any risk of pregnancy - when the woman is more than 14 days late - do a pregnancy test. If it is
negative, the woman should be advised to use effective contraception or abstain from sex for 14 days. Repeat the
test and if it is still negative, give the injection with a barrier method for seven more days. This is an off-licence use
but recommended in RCOG Faculty of Sexual and Reproductive Healthcare guidance.

10 Reassure women about the risk of minor side-effects. Mood change and loss of libido are not associated with
LARC. DMPA is the only method associated with weight gain. All progestogenic methods can exacerbate acne.

Dr Meg Thomas is a GP in Newbury, Berkshire, with a special interest in sexual health

Competing interests None declared

References

1 JE Edwards. Women's knowledge of, and attitudes to, contraceptive effectiveness and adverse effects. Br J Fam
Plann 2000;26:73-80

2 Trussell J. Contraceptive efficacy. Contraceptive Technology 2004: 18th edition. Ardent Media

3 Hairon N. Increasing use of long-acting reversible contraception. Nursing Times 2008;104:23-4

4 Emergency contraception. J Fam Plann Reprod Health Care 2006;32:121-8

5 BBC Online www.bbc.co.uk October 1999. Search for: UK abortion seekers 'used contraception'

6 FSRH guidance. Intrauterine contraception. November 2007 www.ffprhc.org.uk

7 Rees M. Bleeding problems and progestogen-only contraception. J Fam Plann Reprod Health Care 2002;28:178

8 MHRA guidance on Depo-Provera. FFPRHC 2004 www.ffprhc.org.uk

9 The use of contraception outside the terms of the product licence. J Fam Plann Reprod Health Care 2005;31:225-
42

Copyright: CMP Information Ltd.

DETAILS

Subject: Sexual health; Ovulation; Pregnancy; Womens health; Fertility; Methods; Transplants
&implants; Abortion; Birth control; Health care

Publication title: Pulse; London

First page: 35

Publication year: 2009

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 Publication date: Jan 14, 2009

Dateline: GB United Kingdom, EU

Publisher: Briefing Media Ltd.

Place of publication: London

Country of publication: United Kingdom, London

Publication subject: Medical Sciences

ISSN: 00486000

Source type: Trade Journal

Language of publication: English

Document type: News

ProQuest document ID: 233402579

Document URL: https://www.proquest.com/trade-journals/long-acting-reversible-

contraception/docview/233402579/se-2?accountid=13771

Copyright: (Copyright : 2009 CMP Information Ltd.)

Last updated: 2022-10-23

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