Long-Acting Reversible Contraceptives

 In today’s society, women have many methods of contraception to choose from, ranging in effectiveness. Long-acting reversible contraceptives, or LARC’s, are some of the most effective methods, second to sterilization, and fertility returns within days of the device being removed. These methods include the copper intrauterine device (IUD), levonorgestrel IUD, and the etonogestrel implant. Despite their high efficacy, a low percentage of adolescent and young adult women choose this option: in Houston, a nine year study found that less than 10% of women aged 15-25 chose LARC’s over other contraceptive methods (Patel, Albacan, & Smith, 2019). There are several significant barriers to access of this method, and addressing and overcoming these could allow a higher percentage of women to have access to effective contraception, thus reducing the adolescent, as well as unplanned pregnancy rates.  

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 While there are three categories of LARC’s, each differs slightly in terms of mechanism of action and hormonal component. IUD’s are divided into hormonal and non-hormonal categories. There are three hormonal IUD’s, differing in size, releasing levonorgestrel in concentrations of 52 mg, 19.5 mg, and 13.5 mg respectively, lasting anywhere from 3-5 years. These have two mechanisms of action: the presence of the device thickens cervical mucous, inhibiting motility of the sperm, as well as thinning the endometrium due to the locally released hormone, levonorgestrel. The thinned endometrium can lead to side effects such as hypomenorrhea or amenorrhea beginning around a year after insertion. A study performed in 2019 by Goldthwaite and Creinin showed that women with the 52 mg IUD experienced amenorrhea more frequently and reported less irregular bleeding, compared to women who have the lower dose devices. The copper IUD works to prevent fertilization by creating a toxic environment for sperm. It also decreases the possibility for an embryo to be formed, because copper is toxic to embryos, as well. A unique feature of this contraceptive method is that it can be used as effective emergency contraception if inserted 6-14 days after unprotected intercourse, as evidenced by a study in 2017 by Thompson et al. After insertion, this LARC option is effective for up to ten years. The American Journal of Obstetrics and Gynecology published a study in 2017 comparing continuation rates of copper and levonorgestrel IUD’s in over one thousand women. Researchers found that “at 4 years, continuation rates were 45.1% for levonorgestrel [IUD] and 32.6% for copper [IUD]” (Phillips et al., 2017). These statistics show a higher percentage of women with the levonorgestrel IUD following through with their choice of contraception than the copper IUD, which could be related to satisfaction. A study by Deidrich et al. in 2015 on the correlation between short-term bleeding/cramping and LARC satisfaction showed that >65% of levonorgestrel IUD and implant users reported decreased or no cramping at three months post-insertion, while 63% of copper IUD users reported increased menstrual cramping. They also found that over half of levonorgestrel IUD and implant users experienced lighter bleeding, while only 8% of copper IUD users experienced lighter bleeding. While the copper IUD is still an effective means of contraception, users seem to be more satisfied with the levonorgestrel IUD. While the IUD’s are used for contraception, they have many non-contraceptive benefits, as well. A study by Bahamondes et al. in 2015 found that “use of the levonorgestrel-releasing [IUD] also controls heavy menstrual bleeding, anemia, and endometrial hyperplasia and cancer, reduces rates of endometrial polyps in users of tamoxifen, and alleviates pain associated with endometriosis and adenomyosis… and users of the copper intrauterine device have reduced rates of endometrial and cervical cancer.” The etonogestrel implant is rod-shaped and is inserted under the skin in the forearm. It works by preventing ovulation, thickening cervical mucous, and thinning the endometrium, and manufacturers suggest it is effective up to three years after insertion. A study performed in 2017 showed the etonogestrel implant to be 100% effective for up to five years in over 500 women (Ali et al., 2017). Those additional two years of effective contraception could reduce patient costs and increase continuation rates.

 Patient misinformation and fears are among the greatest barriers to access of LARC usage. In the 21st century, people often turn to the Internet before they go to the doctor, a practice that has negatively affected use of IUD’s: “women who are aware of the actual effectiveness of various contraceptive methods are more likely to choose the IUD. Conversely, women who are misinformed about the safety of IUDs may be less likely to use this method” (Madden, 2016). Madden’s 2016 study discovered that “only 30% of sites explicitly indicated that IUDs are safe. Fifty percent of sites contained inaccurate information about the IUD… 44% stated that a mechanism of IUDs is prevention of implantation of a fertilized egg… 3% of web sites incorrectly stated that IUDs are an abortifacient, [and] more than a quarter of sites listed an inaccurate contraindication to the IUD.” In light of this trend, providers need to be diligent in providing factual information to their patients about all contraceptive methods, so the patient’s decision can be backed by evidence-based practice. A qualitative analysis of LARC in women taking oral contraceptive pills (OCP) found that “participants described a sense of unease about methods perceived as "alien." These women underestimated the risks of oral contraceptive pills and overestimated the risks of long-acting reversible contraception, including infertility. The myth of perfect use emerged as participants wanted to be in control by taking “the pill” every day; however, many described imperfect adherence” (Sundstrom, 2015). Patient education would be meaningful in this situation: taking the time to explain how “perfect use indicates the method is used correctly and consistently every time, while typical use relates to the average correct and consistent use of the method,” (Turner, 2019) and that there are two different efficacy rates, respectively. In comparison to OCP’s, LARC’s have significantly less rigorous requirements constituting ‘perfect use,’ making them easier to use and allowing less room for user error. Providers could provide patients with studies similar to Peipert et al. 2011 study of over five thousand women’s satisfaction and continuation rates of their chosen method of contraception, which found that “long-acting reversible contraception users had higher 12-month continuation rates (86%) than OCP users (55%), the two IUDs had the highest 12-month continuation rates, [and that] more than 80% of users were satisfied with the IUD compared with 54% satisfied with OCPs.” Then, providers should explain the positives and negatives to the insertion procedure, as well as what to expect in the days/weeks/months following insertion to dispel any fears and refute any misinformation. The IUD insertion process can be painful for some, but providers can educate about “supportive measures, such as the use of a paracervical block or nonsteroidal anti-inflammatory medication [that] can reduce pain experienced during IUD insertion” (Turner, 2019). Nursing interventions to reduce stress and improve patient outcome during and after device insertion include “demonstrating clinical expertise, creating a trustful environment, giving reliable information, acknowledging the significance of anxiety and providing reassurance and distraction” (McCarthy, 2018). One teaching point providers need to stress is the fact that LARC devices do not prevent STI’s, so condom use is still necessary, but it further increases contraceptive efficacy: “using a LARC and condom together provides nearly 100% prevention against pregnancy and STIs” (Turner, 2019). Cost is also a significant barrier to access of LARC’s: “the price of obtaining a LARC can range from $500 to $1000, not including the provider’s insertion fee or cost of follow-up visits. However, over a period of 3-10 years, the cost becomes comparable to what would have been spent on other reversible methods” (Turner, 2019). Financial counseling about potential aid programs and ways to afford the device and insertion can help remove the cost barrier, and “when cost barriers are removed, an adolescent female will select more effective and long-acting contraceptive methods” (Turner, 2019).

 While LARC devices are among the most effective methods of contraception, patients who choose them still remain in the minority. LARC’s require little responsibility on the patient’s part, and allow for little, if any, user error. The main barriers to access include misinformation, patient fears, lack of education of contraceptive options, and cost. By increasing quality of provider/patient education about LARC’s, it has been shown that they will be chosen more often than other contraceptive methods, which may lead to a decrease in the unplanned and adolescent pregnancy rates.

References

• Ali, M., Akin, A., Bahamondes, L., Brache, V., Habib, N., Landoulsi, S., … WHO study group on subdermal contraceptive implants for women (2016). Extended use up to 5 years of the etonogestrel-releasing subdermal contraceptive implant: comparison to levonorgestrel-releasing subdermal implant. Human reproduction (Oxford, England), 31(11), 2491–2498. doi:10.1093/humrep/dew222
• Bahamondes, L., Bahamondes, M. V., & Shulman, L. P. (2015). Non-contraceptive benefits of hormonal and intrauterine reversible contraceptive methods. Human Reproduction Update, 21(5), 640-651. doi:10.1093/humupd/dmv023
• Diedrich, J. T., Desai, S., Zhao, Q., Secura, G., Madden, T., & Peipert, J. F. (2015). Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. American journal of obstetrics and gynecology, 212(1), 50.e1–50.e508. doi:10.1016/j.ajog.2014.07.025
• Goldthwaite, L. M., & Creinin, M. D. (2019). Comparing bleeding patterns for the levonorgestrel 52 mg, 19.5 mg, and 13.5 mg intrauterine systems. Contraception, 100(2), 128-131. doi:10.1016/j.contraception.2019.03.044
• Madden, T., Cortez, S., Kuzemchak, M., Kaphingst, K. A., & Politi, M. C. (2016). Accuracy of information about the intrauterine device on the Internet. American journal of obstetrics and gynecology, 214(4), 499.e1–499.e6. doi:10.1016/j.ajog.2015.10.928
• McCarthy, C. (2017). Intrauterine contraception insertion pain: Nursing interventions to improve patient experience. Journal of Clinical Nursing,27(1-2), 9-21. doi:10.1111/jocn.13751
• Patel, P. R., Abacan, A., & Smith, P. B. (2019). Trends of Contraceptive Choices Among Young Women in Inner City Houston. Journal of Pediatric and Adolescent Gynecology. doi:10.1016/j.jpag.2019.05.001
• Peipert, J. F., Zhao, Q., Allsworth, J. E., Petrosky, E., Madden, T., Eisenberg, D., & Secura, G. (2011). Continuation and satisfaction of reversible contraception. Obstetrics and gynecology, 117(5), 1105–1113. doi:10.1097/AOG.0b013e31821188ad
• Phillips, S. J., Hofler, L. G., Modest, A. M., Harvey, L., Wu, L. H., & Hacker, M. R. (2017). Continuation of copper and levonorgestrel intrauterine devices: a retrospective cohort study. American journal of obstetrics and gynecology, 217(1), 57.e1–57.e6. doi:10.1016/j.ajog.2017.03.005
• Sundstrom, B., Baker-Whitcomb, A., & DeMaria, A. L. (2015). A qualitative analysis of long-acting reversible contraception. [Abstract]. Maternal and Child Health Journal, 19(7), 1507-1514. doi:10.1007/s10995-014-1655-0
• Thompson, I., Sanders, J. N., Schwarz, E. B., Boraas, C., & Turok, D. K. (2019). Copper intrauterine device placement 6–14 days after unprotected sex. Contraception. doi:10.1016/j.contraception.2019.05.015
• Turner, J. H. (2019). Long-acting reversible contraceptives. The Nurse Practitioner, 44(5), 23-30. doi:10.1097/01.npr.0000554671.24579.73