Long-acting reversible contraceptives: a review

Contraceptive counseling

Counseling about contraception is a crucial part of providing reproductive health care to patients. Charts can be used to demonstrate the most effective and least effective methods.¹⁷ It is important to discuss how contraceptive methods are used, and providers also need to counsel patients about possible side effects. Many patients are concerned about the effect that a contraceptive method will have on their menstrual cycle, so it is important to counsel them regarding any bleeding that may occur.¹⁸ The nonhormonal IUD is often associated with an increase in the amount and duration of bleeding, which may diminish over the first year. Menstrual bleeding and pain were the most common reasons that women chose to discontinue the nonhormonal IUD. Although 11.9% of women experienced bleeding and pain during the first year of use, this percentage decreased to 3.7% at year 10 (Table 2).¹⁹

With the levonorgestrel IUDs, patients may expect to have irregular bleeding and spotting, especially during the first 3 to 6 months. With some hormonal IUDs, patients may experience reduced bleeding or even amenorrhea after 1 year of use.¹⁸ The amount of levonorgestrel affects the side effect profile of the hormonal IUDs. In Tables 3 and 4, the side effects of Mirena, which contains 52 mg of levonorgestrel, and of Skyla, which has 13.5 mg of levonorgestrel, are provided. With Skyla, 6% of women stop having menstrual cycles after 1 year.10 With Mirena, 20% of women have amenorrhea after using the device for 1 year.¹⁰ 

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Common side effects of the implant include headaches, weight gain, vaginitis, acne, abdominal pain, and breast pain.¹⁰ Irregular bleeding is also a common side effect of the implant, which can be concerning to patients. Patients should be advised of this possible occurrence before placement of the device.¹⁷ Irregular bleeding is the most common reason why women request removal of the implant (Table 5).¹⁰

Common side effects of LARCs should be discussed, including headaches, nausea, depression, and breast tenderness. With IUDs, there is a small possibility of expulsion (5%) or perforation of the uterus (1 per 1000 insertions), and an increased risk for pelvic inflammatory disease during the first 3 weeks (1%). Additionally, if pregnancy occurs with an IUD or the implant, there is a slightly increased risk for an ectopic pregnancy.¹⁷

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The provider should also ensure that patients understand what is being discussed. The teach-back method should be used in the counseling process. Healthcare providers should use written materials at the appropriate literacy level and in the correct language.¹⁷ In one study, shared decision aids for low-literacy patients resulted in an increase in the rate of LARC use when they were combined with a shared decision-making approach.²⁰ Smartphone or tablet apps may be another way to enhance counseling, and in one study, patients’ knowledge of and interest in the implant improved after the use of apps.³ It is important to answer all questions and allow patients to hold models or devices if possible. In a shared decision-making approach, it is important always to allow patients to make their own contraceptive choice without coercion.¹⁷ 

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Because of the high number of unintended pregnancies in the United States and the effectiveness of LARCs, they should be considered as a first-line contraceptive option for most women. It is important to use the US MEC, which are evidence-based, when contraceptive methods are being considered. Counseling is an important aspect of providing contraceptive methods, including LARCs, and should be offered in a shared decision-making approach to promote patients’ satisfaction and continuation of their chosen method.

Tracy P. George, DNP, APRN-BC, CNE, is an assistant professor of nursing and coordinator of the Bachelor of General Studies Program, Francis Marion University, in Florence, South Carolina.

References

1. Parks C, Peipert JF. Eliminating health disparities in unintended pregnancy with long-acting reversible contraception (LARC). Am J Obstet Gynecol. 2016;214:681-688. doi:10.1016/j.ajog.2016.02.017
2. Trussell J, Henry N, Hassan F, Prezioso A, Law A, Filonenko A. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception. 2013;87:154-161. doi:10.1016/j.contraception.2012.07.016
3. Gilliam ML, Martins SL, Bartlett E, Mistretta SQ, Holl JL. Development and testing of an iOS waiting room “app” for contraceptive counseling in a Title X family planning clinic. Am J Obstet Gynecol. 2014;211:481.e1-e8. doi:10.1016/j.ajog.2014.05.034
4. Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee opinion no. 642: increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015;126, e44-e48. 
5. Levine L. The IUD rumor mill: common misconceptions. Clinical Advisor. http://www.clinicaladvisor.com/features/iud-intrauterine-device-contraception-smisconceptions/article/444722/. Published October 13. 2015. Accessed December 15, 2017.
6. LARC options expand with new intrauterine device. Contracept Technol Update. 2016;37:121-124. 
7. Use effective counseling skills when counseling on choosing LARC methods. Contracept Technol Update. 2016;37:101-103. 
8. Raphaelides L. New addition to long-acting reversible contraception. 
9. J Nurse Pract. 2015;11:377-378.
10. Allergan. Liletta. Important safety information. https://www.lilettahcp.com/about/liletta?slide=2. © 2017. Accessed December 14, 2017.
11. Merck Connect. Nexplanon. https://www.merckconnect.com/nexplanon/overview.html. Accessed December 15, 2017.
12. Update on contraceptive implant ¬– what family planners need to know. Contracept Technol Update. 2016;37:76-77.
13. Curtis KM, Tepper MK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016:65(No. RR-3):1-104. https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm?s_cid=rr6503a1_w. Updated September 21, 2017. Accessed December 14, 2017.
14. Curtis KM, Jatlaoui TC, Tepper MK, et al. U.S. selected practice recommendations for contraceptive use. MMWR Recomm Rep. 2016:65(No. RR-4):1-66. https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm?s_cid=rr6504a1_w. Updated June 16, 2017. Accessed December 14, 2017.
15. Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group. The American College of Obstetricians and Gynecologists. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012;120:983-988 (reaffirmed 2016).
16. Rodriguez MI, EvansM, Espey E. Advocating for immediate postpartum LARC: increasing access, improving outcomes, and decreasing cost. Contraception. 2014;90:468-471. doi:10.1016/j.contraception.2014.07.001
17. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee opinion no. 670: immediate postpartum long-acting reversible contraception. Obstet Gynecol. 2016;128:e32-e37.
18. Association of Reproductive Health Professionals. Clinical Minute transcript: counseling young women about long-acting reversible methods. https://www.arhp.org/uploadDocs/IUC-Clinical-Minute.pdf. Accessed December 14, 2017.
19. Short-term bleeding and cramping with LARC method satisfaction eyed. Contracept Technol Update. 2014;35:121-123. 
20. Teva Women’s Health. ParaGard prescribing information. http://hcp.paragard.com/Pdf/ParaGard-PI.pdf. Updated September 2014. Accessed December 15, 2017.
21. George TP, DeCristofaro C, Dumas BP, Murphy PF. Shared decision aids: increasing patient acceptance of long-acting reversible contraception. Healthcare (Basel). 2015;3:205-218. 
22. Bayer HealthCare Pharmaceuticals. Mirena prescribing information. https://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf. Updated June 2017. Accessed December 14, 2017.
23. Bayer HealthCare Pharmaceuticals. Skyla prescribing information. http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf. Updated March 2017. Accessed December 14, 2017. 

From the February 01, 2018 Issue of Clinical Advisor