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.
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 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.
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.
- Ventura SJ, Hamilton BE, Matthews TJ. National and state patterns of teen births in the United States, 1940-2013. Natl Vital Stat Rep. 2014;63(4):1-34.
- Lindberg L, Santelli J, Desai S. Understanding the decline in adolescent fertility in the United States, 2007-2012. J Adoles Health. 2016;59(5):577-583.
- Sherin M, Waters J. Long-acting reversible contraceptives for adolescent females: a review of current best practices. Curr Opin Pediatr. 2019;31(5):675-682.
- American College of Obstetrics & Gynecology. ACOG Committee Opinion No. 735: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2018;131(5):e130-e139.
- Menon S, Committee on Adolescence. Long-acting reversible contraception: specific issues for adolescents. Pediatrics. 2020;146(2):e2020007252.
- Itriyeva K. Use of long-acting reversible contraception (LARC) and the Depo-Provera shot in adolescents. Curr Probl Pediatr Adolesc Health Care. 2018;48(12):321-332.
- Dehlendorf C, Ruskin R, Grumbach K, et al. Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status. Am J Obstet Gynecol. 2010;203(4):319.e1-8.
- Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-1256.
- Society for Adolescent Health and Medicine. Improving knowledge about, access to, and utilization of long-acting reversible contraception among adolescents and young adults. J Adolesc Health. 2017;60(4):472-474.
- Nexplanon [package insert]. Whitehouse Station, NJ: Merck & Co., Inc; 2019.
- Mirena [package insert]. Whippany, NJ: Bayer HealthCare; 2020.
- Lilletta [package insert]. Irvine, CA: Allergan USA; 2019.
- Kyleena [package insert]. Whippany, NJ: Bayer HealthCare; 2018.
- Skyla [package insert]. Whippany, NJ: Bayer HealthCare; 2018.
- Paragard [package insert]. Trumbull, CT: CooperSurgical, Inc; 2020.
- Rosenstock JR, Peipert JF, Madden T, Zhao Q, Secura GM. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120(6):1298-1305.
- Nelson AL. Contraindications to IUD and IUS use. Contraception. 2007;75(6 suppl):s76-s81.
- Hardeman J, Weiss BD. Intrauterine devices: an update. Am Fam Physician. 2014;89(6):445-450.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. US selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(4):1-66.
- Bayer LL, Hillard PJA. Use of levonorgestrel intrauterine system for medical indications in adolescents. J Adolesc Health. 2013;52(4 suppl):s54-s58.
- Guss CE. Intrauterine devices in gender minority youth: an option to decrease dysphoria and unintended pregnancies. J Adolesc Health. 2019;65(1):3-4.
- Fitzgerald S, DiVasta A, Gooding H. An update on PCOS in adolescents. Curr Opin Pediatr. 2018;30(4):459-465.
- Villavicencio J, Allen RH. Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates. Open Access J Contracept. 2016;7:43-52.
- Friedlander E, Kaneshiro B. Therapeutic options for unscheduled bleeding associated with long-acting reversible contraception. Obstet Gynecol Clin North Am. 2015;42(4):593-603.
- Sangraula M, Garbers S, Garth J, Shakibnia EB, Timmons S, Gold MA. Integrating long-acting reversible contraception services into New York City school-based health centers: quality improvement to ensure provision of youth-friendly services. J Pediatr Adolesc Gynecol. 2017;30(3):376-382.
- Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception. 2007;76(4):267-272.
- Hillard PJA. Practical tips for intrauterine device counseling, insertion, and pain relief in adolescents: an update. J Pediatr Adolesc Gynecol. 2019;32(5s):s14-s22.
- Diedrich JT, Desai S, Zhao Q, Secura G, Madden T, Peipert JF. Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. Am J Obstet Gynecol. 2015;212(1):50.e1-8.
- Zaenglein AL. Acne vulgaris. N Engl J Med. 2018;379(14):1343-1352.
- Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-Lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014;123(3):585-592.
- Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 2006;73(2):145-153.
- Jatlaoui TC, Riley HEM, Curtis KM. The safety of intrauterine devices among young women: a systematic review. Contraception. 2017;95(1):17-39.
- Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). J Adoles Health. 2013; 52(4 Suppl):S14-S21.
- Yancy CW. COVID-19 and African Americans. JAMA. 2020; April 15. doi: 10.1001/jama.2020.6548.
- Barney A, Buckelew S, Mesheriakova V, Raymond-Flesch M. The COVID-19 pandemic and rapid implementation of adolescent and young adult telemedicine: challenges and opportunities for innovation. J Adolesc Health. 2020;67(2):164-171.