Long-acting reversible contraceptives

Last updated
Long-acting reversible contraceptives (LARC)
Background
TypeVarious (includes hormonal and non-hormonal options)
First use?
Pregnancy rates (first year)
Perfect use?
Typical use?
Usage
ReversibilityYes
User reminders?
Advantages and disadvantages
STI protectionNo

Long-acting reversible contraceptives (LARC) are methods of birth control that provide effective contraception for an extended period without requiring user action. They include hormonal and non-hormonal intrauterine devices (IUDs), and subdermal hormonal contraceptive implants. They are the most effective reversible methods of contraception because their efficacy is not reliant on patient compliance. The failure rates of IUDs and implants is less than 1% per year.

Contents

LARCs are often recommended to people seeking convenient and cost effective contraception. [1] In one study, LARC users saved thousands of dollars over a five-year period compared to those who buy condoms and birth control pills. [2] LARCs can generally be safely and effectively used by people of any body weight, [3] adolescents, [4] and people who have not yet had children. [5] [6]

In 2008, the American College of Obstetrics and Gynecologists (ACOG) launched The Long-Acting Reversible Contraception Program with the intention to reduce rates of unintended pregnancy by promoting LARCs, often referred to as a "LARC-first" model. [7] Rates of LARC use in the United States rose steadily in that time frame, from 3.7% in 2007 [7] to 10% in 2019. [8] LARC methods are most popular amongst people in their late teens and early twenties. [9] LARC use varies globally, with different regions reporting different use rates. [10] [11] An estimated 161 million people of reproductive age use an IUD and an additional 25 million use an implant; this is 19.4% of the estimated global population of women of reproductive age. [12]

Methods

Copper IUD IUD with scale.jpg
Copper IUD

LARC methods include IUDs and the subdermal implant. [13]

IUDs, also sometimes referred to as IUS (intrauterine system) or IUC (intrauterine contraception), can come in hormonal or nonhormonal varieties.

Medical use

Contraception

LARCs have higher rates of efficacy than do other forms of contraception. [15] This difference is likely due to the difference between "perfect use" and "typical use". Perfect use indicates complete adherence to medication schedules and guidelines. Typical use describes effectiveness in real-world conditions, where patients may not fully adhere to medication regimens. LARC methods require little to no user action after insertion; therefore, LARC perfect use failure rates are the same as their typical use failure rates. LARC failure rates are comparable to those of sterilization. [15] LARCs and sterilization differ in their reversibility.

The implant has a 0.05% failure rate in the first year of use, the levonorgestrel (hormonal) IUD has a 0.1% failure rate in the first year of use, and the copper IUD has a 0.8% failure rate in first year of use. [16] These rates are comparable to those of permanent sterilization procedures, leading to conclusions that LARCs should be offered as "first-line contraception." [16]

Additional Uses

LARCs can also be used to treat other conditions, primarily by regulating or stopping the bleeding portion of a user's menstrual cycle. [17] LARCs may be used to treat endometriosis [18] and heavy menstrual bleeding. [19] They can also be useful in treating painful menstruation. [20]

Additionally, a copper IUD can be used as emergency contraception if inserted within five days of unprotected sex. This timeframe may be extended if the date of ovulation is known; the copper IUD must be inserted within 5 days of ovulation. [21]

Side effects and risks

Side effects and risks for LARCs vary by type of LARC, with hormonal IUDs, non-hormonal IUDs, and implants all entailing different side effects and risks.

Side effects

Hormonal IUDs have similar side effects to other forms of hormonal contraception, such as combined and progesterone only oral contraceptives. Hormonal IUDs most frequently cause irregular menstrual bleeding. Other side effects include acne, breast tenderness, headaches, nausea, and mood changes. [22] [23]

The most common side effects of non-hormonal or copper IUDs are increased pain and heavy bleeding during menstruation, and spotting between menstruation. Impacts on menstruation may decrease over the lifespan of the IUD, but spotting between menstruation may become more frequent over time. For some users, these side effects lead them to discontinue use. [24]

The most common side effect of the contraceptive implant is irregular bleeding, which includes both reduced and increased levels of bleeding. [25] Other side effects include mood changes and mild insulin resistance. [22]

Risks

IUD use caries some additional risks. Both hormonal and non-hormonal IUDs may lead to developing non-cancerous ovarian cysts. [22] [26] It is also possible that an IUD may be expelled (fall out) from the uterus. [27] The IUD may also perforate (tear) the uterine wall. This is extremely rare and a medical emergency. [28]

Society and culture

Cost and benefit

LARC methods traditionally have a higher up-front cost, between $800 and $900 in the United States, [29] than methods such as pills, patches and vaginal rings, but are more cost-effective in the long run. [30] Like all contraceptive methods, access to LARC methods can reduce the rate of unintended pregnancy and result in significant cost savings to publicly funded health systems. [30] Women switching from short-acting reversible contraceptive to long-acting intrauterine systems are likely to generate cost savings from unplanned pregnancy-related expenses and long term savings in contraceptive costs. [31] Regardless, the initial out of pocket cost is still too high for many patients and is one of the biggest barriers to LARC use. Two recent studies done in California and St. Louis have shown that rates of LARC usage are dramatically higher when the costs of the methods are either covered or removed. [32] [33] [34] A program geared toward increasing use of LARC among adolescents in Iowa demonstrated a significant decrease in the unintended pregnancy and abortion rate in that state along with a projected savings of $17.23 for every dollar spent on contraception for 14- to 19-year-olds. [35]

The Colorado Family Planning Initiative (CPFI), a six-year $23 million privately funded program to expand access to LARCs, decreased unplanned adolescent pregnancies in the state by about 40% and returned $5.85 in savings for each dollar spent. There was a similar decline of unplanned pregnancies in unmarried women under 25 who have not finished high school, another at risk group. Use of LARC methods by children of child-bearing age in the state increased to 20% during the 2009–2014 period. [29] A 2017 study found that CPFI "reduced the teen birth rate in counties with clinics receiving funding by 6.4 percent over five years. These effects were concentrated in the second through fifth years of the program and in counties with relatively high poverty rates." [36]

Promotion

LARC usage [37]
Russia32%
France27%
Austria23%
Georgia23%
Bulgaria18%
Germany11%
Romania10%
United States10%
Australia7%

The United Kingdom Department of Health has actively promoted LARC use since 2008, particularly for young people; [38] following on from the October 2005 National Institute for Health and Clinical Excellence guidelines, which promoted LARC provision in the United Kingdom, accurate and detailed counseling for women about these methods, and training of healthcare professionals to provide these methods. [39] Giving advice on these methods of contraception has been included in the 2009 Quality and Outcomes Framework "good practice" for primary care. [40]

The use of long-acting reversible contraceptives in the United States has increased nearly fivefold from 1.5% in 2002 to 7.2% in 2011–2013. [41] Increasing access to long-acting reversible contraceptives was listed by the Centers for Disease Control and Prevention as one of the top public health priorities for reducing teen pregnancy and unintended pregnancy in the United States. [42] One study of female family planning providers showed that they were significantly more likely to use LARCs than the general population (41.7% compared to 12.0%) suggesting that the general population has less information or access to LARCs. [43]

Guidelines released in 2009 by the American Congress of Obstetricians and Gynecologists state that LARC methods are considered to be the first-line option for birth control in the United States, and are recommended for the majority of women. [44] According to the CDC Medical Eligibility Criteria for Contraceptive Use, LARC methods are recommended for the majority of women who have had their first menstruation, regardless of whether they have had any pregnancies. [45] The American Academy of Pediatrics (AAP) in a policy statement and technical report [46] published in October 2014 recommended LARC methods for adolescents. [47]

Related Research Articles

<span class="mw-page-title-main">Copper IUD</span> Birth control and emergency contraceptive device

A copper intrauterine device (IUD), also known as an intrauterine coil or copper coil or non-hormonal IUD, is a type of intrauterine device which contains copper. It is used for birth control and emergency contraception within five days of unprotected sex. It is one of the most effective forms of birth control with a one-year failure rate around 0.7%. The device is placed in the uterus and lasts up to twelve years. It may be used by women of all ages regardless of whether or not they have had children. Following removal, fertility quickly returns.

<span class="mw-page-title-main">Emergency contraception</span> Birth control measures taken after sexual intercourse

Emergency contraception (EC) is a birth control measure, used after sexual intercourse to prevent pregnancy.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Family planning</span> Planning when to have children

Family planning is the consideration of the number of children a person wishes to have, including the choice to have no children, and the age at which they wish to have them. Things that may play a role on family planning decisions include marital situation, career or work considerations, financial situations. If sexually active, family planning may involve the use of contraception and other techniques to control the timing of reproduction.

<span class="mw-page-title-main">Levonorgestrel</span> Hormonal medication used for birth control

Levonorgestrel is a hormonal medication which is used in a number of birth control methods. It is combined with an estrogen to make combination birth control pills. As an emergency birth control, sold under the brand names Plan B One-Step and Julie, among others, it is useful within 72 hours of unprotected sex. The more time that has passed since sex, the less effective the medication becomes, and it does not work after pregnancy (implantation) has occurred. Levonorgestrel works by preventing ovulation or fertilization from occurring. It decreases the chances of pregnancy by 57–93%. In an intrauterine device (IUD), such as Mirena among others, it is effective for the long-term prevention of pregnancy. A levonorgestrel-releasing implant is also available in some countries.

Male contraceptives, also known as male birth control, are methods of preventing pregnancy that are used by males or people who produce sperm. The main forms of male contraceptives available today are condoms, vasectomy, and withdrawal, and these methods combined make up less than one-third of global contraceptive use.

<span class="mw-page-title-main">Hormonal intrauterine device</span> Intrauterine device

A hormonal intrauterine device (IUD), also known as an intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel into the uterus. It is used for birth control, heavy menstrual periods, and to prevent excessive build of the lining of the uterus in those on estrogen replacement therapy. It is one of the most effective forms of birth control with a one-year failure rate around 0.2%. The device is placed in the uterus and lasts three to eight years. Fertility often returns quickly following removal.

Progestogen-only pills (POPs), colloquially known as "mini pills", are a type of oral contraceptive that contain synthetic progestogens (progestins) and do not contain estrogens. They are primarily used for the prevention of undesired pregnancy, although additional medical uses also exist.

<span class="mw-page-title-main">Hormonal contraception</span> Birth control methods that act on the endocrine system

Hormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, although in India one selective estrogen receptor modulator is marketed as a contraceptive. The original hormonal method—the combined oral contraceptive pill—was first marketed as a contraceptive in 1960. In the ensuing decades, many other delivery methods have been developed, although the oral and injectable methods are by far the most popular. Hormonal contraception is highly effective: when taken on the prescribed schedule, users of steroid hormone methods experience pregnancy rates of less than 1% per year. Perfect-use pregnancy rates for most hormonal contraceptives are usually around the 0.3% rate or less. Currently available methods can only be used by women; the development of a male hormonal contraceptive is an active research area.

<span class="mw-page-title-main">Etonogestrel</span> Chemical compound

Etonogestrel is a medication which is used as a means of birth control for women. It is available as an implant placed under the skin of the upper arm under the brand names Nexplanon and Implanon. It is a progestin that is also used in combination with ethinylestradiol, an estrogen, as a vaginal ring under the brand names NuvaRing and Circlet. Etonogestrel is effective as a means of birth control and lasts at least three or four years with some data showing effectiveness for five years. Following removal, fertility quickly returns.

<span class="mw-page-title-main">Beginning of pregnancy controversy</span> Cultural-linguistic, not scientific question

Controversy over the beginning of pregnancy occurs in different contexts, particularly as it is discussed within the debate of abortion in the United States. Because an abortion is defined as ending an established pregnancy, rather than as destroying a fertilized egg, depending on when pregnancy is considered to begin, some methods of birth control as well as some methods of infertility treatment might be classified as causing abortions.

<span class="mw-page-title-main">Comparison of birth control methods</span>

There are many methods of birth control that vary in requirements, side effects, and effectiveness. As the technology, education, and awareness about contraception has evolved, new contraception methods have been theorized and put in application. Although no method of birth control is ideal for every user, some methods remain more effective, affordable or intrusive than others. Outlined here are the different types of barrier methods, hormonal methods, various methods including spermicides, emergency contraceptives, and surgical methods and a comparison between them.

<span class="mw-page-title-main">Contraceptive implant</span> Implantable medical device used for birth control

A contraceptive implant is an implantable medical device used for the purpose of birth control. The implant may depend on the timed release of hormones to hinder ovulation or sperm development, the ability of copper to act as a natural spermicide within the uterus, or it may work using a non-hormonal, physical blocking mechanism. As with other contraceptives, a contraceptive implant is designed to prevent pregnancy, but it does not protect against sexually transmitted infections.

<span class="mw-page-title-main">Birth control</span> Method of preventing human pregnancy

Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unintended pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth control only became available in the 20th century. Planning, making available, and using human birth control is called family planning. Some cultures limit or discourage access to birth control because they consider it to be morally, religiously, or politically undesirable.

Unintended pregnancies are pregnancies that are mistimed, unplanned or unwanted at the time of conception.

Sex after pregnancy is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. Injury to the perineum or surgical cuts (episiotomy) to the vagina during childbirth can cause sexual dysfunction. Sexual activity in the postpartum period other than sexual intercourse is possible sooner, but some women experience a prolonged loss of sexual desire after giving birth, which may be associated with postnatal depression. Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's body image.

<span class="mw-page-title-main">Intrauterine device</span> Form of birth control involving a device placed in the uterus

An intrauterine device (IUD), also known as intrauterine contraceptive device or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are one form of long-acting reversible birth control (LARC). One study found that female family planning providers choose LARC methods more often (41.7%) than the general public (12.1%). Among birth control methods, IUDs, along with other contraceptive implants, result in the greatest satisfaction among users.

<span class="mw-page-title-main">Prevalence of birth control</span> Overview article

Globally approximately 45% of those who are married and able to have children use contraception. As of 2007, IUDs were used by about 17% of women of child bearing age in developing countries and 9% in developed countries or more than 180 million women worldwide. Avoiding sex when fertile is used by about 3.6% of women of childbearing age, with usage as high as 20% in areas of South America. As of 2005, 12% of couples are using a male form of contraception with rates of up to 30% in the developed world.

Contraceptive use is important to slow population growth as well as a reduction in neonatal mortality, maternal mortality and adverse perinatal outcomes. In Bangladesh, an estimated 60% of married women currently use a method of contraception.

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

References

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    Summarised at
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  44. ↑ ACOG Committee Opinion 450 (December 2009). "Increasing the Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy". American Congress of Obstetricians and Gynecologists. Archived from the original on 2 May 2012. Retrieved 28 June 2012.{{cite web}}: CS1 maint: numeric names: authors list (link)
  45. ↑ "U.S. Medical Eligibility Criteria for Contraceptive Use, 2010" (PDF). Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 28 May 2010.
  46. ↑ Mary A. Ott, Gina S. Sucato, Committee ON. Adolescence (1 October 2014). "From the American Academy of Pediatrics Technical Report Contraception for Adolescents" (Text and PDF). Pediatrics. 134 (4). American Academy of Pediatrics: e1257–e1281. doi: 10.1542/peds.2014-2300 . PMID   25266435 . Retrieved 7 July 2015. For adolescents who need highly effective contraception that is user- and coitus-independent, the implant is an outstanding choice.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  47. ↑ Mary A. Ott and Gina S. Sucato, lead authors for the Committee on Adolescence (1 October 2014). "From the American Academy of Pediatrics Policy Statement Contraception for Adolescents". Pediatrics. 134 (4). American Academy of Pediatrics (AAP): e1244–e1256. doi:10.1542/peds.2014-2299. PMC   1070796 . PMID   25266430. LARC methods should be considered first-line contraceptive choices for adolescents.
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