ACOG issues recommendations for long-acting reversible contraception

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The practice bulletin provides information for appropriate patient selection and evidence-based recommendations for intrauterine devices and contraceptive implants.
The practice bulletin provides information for appropriate patient selection and evidence-based recommendations for intrauterine devices and contraceptive implants.

The American College of Obstetricians and Gynecologists (ACOG) has released a new practice bulletin regarding long-acting reversible contraception (LARC).

ACOG's practice bulletin provides information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. Long-acting reversible contraceptives have few contraindications and should be offered routinely as safe and effective contraceptive options for most women, according to the authors.

The recommendations were developed by the Committee on Practice Bulletins—Gynecology and the Long-Acting Reversible Contraception Work Group in collaboration with Eve Espey, MD, MPH, and Lisa Hofler, MD, MPH, MBA.

The following recommendations are based on good and consistent scientific evidence (Level A):

  • Insertion of an intrauterine device (IUD) immediately after first-trimester uterine aspiration should be offered routinely as a safe and effective contraceptive option.
  • Insertion of the contraceptive implant on the same day as first-trimester or second-trimester–induced or spontaneous abortion should be offered routinely as a safe and effective contraceptive option.
  • Routine antibiotic prophylaxis is not recommended before IUD insertion.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

  • Intrauterine devices and the contraceptive implants should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents.
  • Insertion of an IUD or an implant may occur at any time during the menstrual cycle as long as pregnancy may be reasonably excluded.
  • Insertion of an IUD immediately after confirmed completion of first-trimester medication-induced abortion should be offered routinely as a safe and effective contraceptive option.
  • Immediate postpartum IUD insertion (ie, within 10 minutes after placental delivery in vaginal and cesarean births) should be offered routinely as a safe and effective option for postpartum contraception.
  • Immediate postpartum initiation of the contraceptive implant (ie, insertion before hospital discharge after a hospital stay for birth) should be offered routinely as a safe and effective option for postpartum contraception, regardless of breastfeeding status.
  • Women who have not undergone routine screening for STIs or who are identified to have an increased risk of STIs based on medical history should receive CDC-recommended STI screening at the time of a single visit for IUD insertion. Intrauterine device insertion should not be delayed while awaiting test results. Treatment for a positive test result may occur without removal of the IUD.
  • Intrauterine devices may be offered to women with a history of ectopic pregnancies.

The following recommendations are based primarily on consensus and expert opinion (Level C):

  • LARCs have few contraindications and should be offered routinely as safe and effective contraceptive options for most women.
  • The copper IUD should be offered routinely to women who request emergency contraception and are eligible for IUD placement.
  • To improve LARC method satisfaction and continuation, patient counseling should include information on expected bleeding changes and reassurance that these changes are not harmful.
  • Endometrial biopsy, colposcopy, cervical ablation or excision, and endocervical sampling may all be performed with an IUD in place.
  • Actinomyces on cytology is considered an incidental finding. In the absence of symptoms, no antimicrobial treatment is needed, and the IUD may be left in place.
  • Intrauterine device removal is recommended in pregnant women when the strings are visible or can be removed safely from the cervical canal.
  • There is no compelling evidence for the removal of an IUD or implant before its expiration date in menopausal women.

Reference

Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: Long-acting reversible contraception: Implants and intrauterine Devices. Obstet Gynecol. 2017 Nov;130(5). doi: 10.1097/AOG.0000000000002400.

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