LARCs - Long-Acting Reversible Contraceptives

IUDs and Nexplanon

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Long-Lasting Reversible Contraception (LARCs). Photo © 2014 Dawn Stacey

Long-acting reversible contraceptives (also known as LARCs) include IUDs -- ParaGard, Mirena, and Skyla as well as the implant, Nexplanon (formerly known as Implanon). The American College of Obstetricians and Gynecologists (ACOG) explain that LARC methods are the best contraceptive method available to fight against unintended pregnancies.

The major advantage is that after insertion, LARCs work without having to do anything else.

These methods do not require ongoing effort on the part of the user for long-term and effective use. They are also completely reversible. This means that you can have them removed at any time, and then your fertility will quickly return. When compared to the pill, typical-use failure rates are lower for women using LARCs and continuation rates are higher. In fact, IUDs and Nexplanon are the most effective forms of reversible birth control available. Over the long term, LARCs are about 20 times more effective than birth control pills, the patch, or NuvaRing.

Almost all women are eligible candidate for long-acting reversible contraceptives. The U.S. Medical Eligibility Criteria for Contraceptive Use (evidence-based medical eligibility criteria developed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization):

  • Classifies IUD use in women who have never given birth (i.e., nulliparous) and teenagers as a Category 2 -- meaning that the advantages of use generally outweigh the risks.
  • Assigns a Category 1 rating (no restriction) to the use of Nexplanon by nulliparous women and adolescents.

In 2005, FDA-approved changes were made to the package insert of ParaGard and language suggesting IUD candidates be limited to those having one or more children was removed. Mirena’s label still recommends that it be used by women who have given birth to at least one child; however, the reason Mirena is not specifically approved for nulliparous women is because the clinical-trial research provided for FDA approval was only conducted on women who had at least one child.

Skyla, known as the mini-IUD, was purposely designed for women who have never had children.

The use of long-acting reversible contraceptive methods has significantly increased. Between 2002 and 2009, LARC use increased from 2.4% to 8.5%. In teens, ages 15–19, LARC use increased from less than 1% to 4.5%. The majority of these women used an IUD (with only 1% of women using the implant and only 0.5% of teenagers). That being said, the overall use of LARCs is still low and many young women and teenagers claim that they hardly know anything about these methods. There are several reasons why this may be the case:

  • Historically, IUDs have gotten a bad rap because of the Dalkon shield -- an IUD that was taken off the market after being linked to infertility and pelvic inflammatory disease. Even though IUDs and Nexplanon are safe and effective contraceptive options, it seems many medical providers still mistakenly associate the IUD with infection risks, so they may be unwilling to offer this method to their patients, especially teenagers/young women.
  • Until recently, it was suggested that only women who had given birth and who were at low risk for sexually transmitted infections should be considered as routine candidates for IUD insertions. But in 2012, the ACOG revised these recommendations in a new Practice Bulletin. Currently, both the ACOG and CDC recommend that LARCs are appropriate for adolescents as well as nulliparous women. Despite previous guidelines, some doctors and teaching hospitals have been inserting IUDs in these populations for years, so the newer recommendations basically reflect what has been actually going on in the real population.

In terms of effectiveness, there is essentially very little possibility of user error with Nexplanon and IUDs. Once inserted, nothing needs to be done, so there is no need to remember to take a pill every day or change a patch once-a-week. Once Nexplanon or ParaGard/Mirena/Skylar is in place, these devices prevent pregnancy for years. Because of this, LARC use can greatly decrease the number of unexpected pregnancies in the teenage population. The ACOG suggests that counseling about LARCs should occur at all health care provider visits with sexually active adolescents, and that teenagers who use LARCs should also be advised to consistently use condoms for the prevention of STIs. Increasing teenage access to long-acting reversible contraceptives is a clinical and public health opportunity for the medical community.

“With top-tier effectiveness, high rates of satisfaction and continuation, and no need for daily adherence, LARC methods should be first-line recommendations for all women and adolescents” -- American College of Obstetricians and Gynecologists

Sources:

American College of Obstetricians and Gynecologists, Committee on Adolescent Health Care, Long-Acting Reversible Contraception Working Group, Committee Opinion No. 539. "Adolescents and long-acting reversible contraception: Implants and intrauterine devices.” Obstetrics & Gynecology, 2012, 120(4):983–988. Accessed via private subscription.

American College of Obstetricians and Gynecologists. "Practice Bulletin #121 - Long-Acting Reversible Contraception: Implants and Intrauterine Devices." Obstetrics & Gynecology, 2011, 118(1):184-196. Accessed via private subscription.

Centers for Disease Control and Prevention. "U.S. selected practice recommendations for contraceptive use 2013." Morbidity and Mortality Weekly Report, 2013, 62(5):1–60. Accessed Feb. 22, 2014.

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