Managing Adverse Effects

Managing adverse effects of LARC methods begins with managing patient expectations through comprehensive pre-insertion counseling that includes anticipatory guidance about likely and possible adverse effects.6,10-15,23,24

Almost all patients using a LARC method will experience some change to their menstrual cycle. These changes can range from heavier bleeding and cramping, often experienced with the copper IUD, to unscheduled or even continuous irregular bleeding, associated with ENG implants and LNG IUDs, to amenorrhea, often associated with the higher-dose LNG IUDs.6,24

During pre-insertion counseling, providers should ensure that patients understand they will not have a regular menstrual cycle while taking progestin-only LARC methods. Explore beliefs and myths about the menstrual cycle and not having a monthly period and reinforce the proven quick return of fertility after removal of LARC.25 In addition, patients often need to be reassured that irregular or unscheduled bleeding does not decrease the efficacy of the method.24

Bleeding changes are cited commonly as a reason for LARC discontinuation26; patients should be counseled to return to the provider to explore management options if bleeding changes are bothersome. When the patient is motivated to continue the method, managing heavy and/or unscheduled bleeding can improve satisfaction and continuation.


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Table 3 lists various regimens to manage menstrual bleeding changes commonly associated with LARC.19,23,24 The table is based on studies of specific regimens, and what is used in practice may vary. For example, ibuprofen is not listed as a treatment for LNG IUD-related irregular bleeding but is a common first-line nonsteroidal anti-inflammatory drug (NSAID) used in practice, following the same regimen listed for copper IUD-related heavy bleeding. It is important to note that secondary amenorrhea caused by a contraceptive method does not require medical intervention.19

Discomfort During and Immediately After IUD Insertion

Pain during and in the days immediately after IUD insertion generally can be managed with NSAIDs. A prophylactic dose of an NSAID is helpful before insertion. Also consider providing a heating pad for the patient to hold over their abdomen during insertion. A cervical block can be used during the insertion process, but research is mixed as to its effectiveness.27

Another consideration to ease a patient’s anxiety and potential discomfort is to allow the patient to have a chosen support person in the room during insertion. It is standard procedure at some adolescent practices to have a trained staff member available to provide patients with a hand to hold, a helpful distraction, and guidance on coping techniques.

While heavy cramping may decrease over time for some patients, in others it may persist.28 Patients should be counseled on how to appropriately treat painful or debilitating cramps, with NSAIDs being first line treatment after assuring correct placement of the device and no other underlying problem.19

Acne

Acne caused or worsened by a progestin-containing LARC should be treated the same as acne due to other causes. Treatment of moderate to severe acne should include combination therapy with a topical retinoid and a topical antimicrobial that contains benzoyl peroxide. Consider adding a daily oral antibiotic for the shortest duration necessary (no more than 3-4 months). Alternative adjunctive therapies include spironolactone and/or combined hormonal oral contraceptives.29

Uncommon Adverse Effects

Less common adverse effects and complications of IUD use in adolescents include expulsion, perforation, infection, and ectopic pregnancy, but occurrence rates for each of these are low. Although IUD expulsion is more common in younger and nulliparous patients, rates are still relatively low, approximately 6% in patients aged 13 to 19 years.30

The risk for PID secondary to IUD insertion also is quite low: 0% to 2% in the absence of cervical infection and 0% to 5% with an unknown cervical infection.31 Evidence does not definitively indicate a higher risk for PID in adolescents compared with older patients.32 Similarly, perforation, seen in about 0.1% of all insertions, does not seem to be more common in adolescents compared with older patients.32

The ability to calculate the risk for ectopic pregnancy in IUD users is limited by low pregnancy rates among IUD users. It is important to note that IUDs do not cause ectopic pregnancy. Even though the percentage of pregnancies that are ectopic is higher in IUD users compared with the percentage among all pregnancies, because IUD failure is so rare, the absolute risk for ectopic pregnancy is significantly lower in patients with an IUD than in the general population.33

In general, clinicians should help teens manage adverse effects of LARC methods, determining what is reasonable for them, and always remove a device at the patient’s request, regardless of how long they have had it.

Conclusion

The COVID-19 pandemic has magnified preexisting health inequities in access to health care.34 Clinics serving adolescents have closed and others are conducting most visits via telehealth. Challenges for teens seeking contraception include lack of access to smartphones or laptops, lack of consistent Wi-Fi or cell phone access, and crowded living conditions. The use of headphones, asking yes-or-no questions, and using the chat function can help protect patient confidentiality.35 

Maintaining and increasing access to LARC and other contraceptive methods during these challenging times will require creativity on the part of clinics, providers, and patients to ensure that adolescents can make autonomous decisions about their sexual health.

To learn more about the current threats to adolescent confidentiality and contraceptive access, click here.

Tiffany Lambright, MPH, MS, RN, CPNP-PC, is a pediatric nurse practitioner and assistant clinical professor at the University of California, San Francisco, with expertise in the intersection of adolescent development and sexual/reproductive health. Naomi A. Schapiro, PhD, RN, CPNP-PC, is a professor emeritus of family health care nursing at the University of California, San Francisco, and a pediatric nurse practitioner at La Clinica de la Raza, providing primary and sexual/reproductive health care to adolescents and young adults in school-based settings.

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