Long-acting reversible contraception - Highly efficacious, safe, and underutilized

Each year, 43 million women, nearly 70% of all reproductive-aged females in the United States, are at risk for unplanned pregnancy. These women are candidates for contraceptive counseling and services. Unplanned pregnancies are associated with increased risks of maternal and child morbidity and mortality and socioeconomic costs to families and society. Nearly half of all US pregnancies are unplanned. Increasing access to long-acting reversible contraception (LARC) is a critical strategy for decreasing the US rate of unplanned pregnancy. LARC includes intrauterine devices (IUDs) and the subdermal implant.

LARC is highly efficacious and associated with high rates of continued contraception. The majority of patients are medically eligible for LARC use. LARC is underutilized (14.3% of all contraceptive use) vs sterilization (28.2%) and hormonal contraception requiring user involvement (31.8%).4 Barriers to LARC include expense, misunderstanding about safety, and inadequate counseling.3 In 2016, the National Quality Forum endorsed LARC as one of several metrics for high-quality contraceptive care, underscoring the need for widespread patient-centered LARC counseling and access.

Debunking Misunderstanding of LARC

Misunderstanding about LARC safety contribute to its underutilization. Concerns that women who are nulliparous, unmarried, or adolescents are at higher risk for pelvic inflammatory disease and infertility from using FDA-approved IUDs are not supported by current literature. Any risk of pelvic infection associated with IUD insertion is very low (0.5%) and limited to several weeks postinsertion. IUD users have a lower absolute risk of ectopic pregnancy than non-IUD users, but in the rare event that IUD users become pregnant, the relative risk of ectopic pregnancy is elevated. Patients concerned about devices getting lost should be informed that uterine perforation from IUDs is rare (1/1000 insertions) and distant migration of properly placed subdermal implants is rare (case reports). Upon removal of LARC, baseline fertility rapidly returns. Requirements that LARC only be inserted during menses unnecessarily delay access; LARC can be inserted anytime pregnancy has been reasonably ruled out, based on history and urine pregnancy testing.

Noncontraceptive Benefits Associated With LARC Use

Noncontraceptive benefits of LARC can improve health outcomes. Levonorgestrel-containing IUDs can treat menstrual-related disorders. By decreasing menses, levonorgestrel-containing IUDs can improve anemia and prevent surgical interventions to treat fibroids and endometriosis. Progestin-containing LARCs can alleviate symptoms related to other menstrual-related conditions, such as dysmenorrhea and migraine headaches. Because progestins suppress endometrial proliferation, the levonorgestrel-containing IUD has been used to treat atypical endometrial hyperplasia.

Special Circumstances

The Centers for Disease Control and Prevention provides evidence-based resources that summarize patient eligibility for different contraceptive methods based on selected patient characteristics and medical conditions. LARC is well suited for patients with medical problems that pose contraindications to estrogen use, including poorly controlled diabetes or hypertension, current or past venous thromboembolism, migraines with aura, and cigarette smokers (aged ≥35 years). All LARC devices can be placed right after birth or abortion, providing immediate contraception. The copper IUD will not interfere with lactogenesis. Multiple randomized clinical trials and observational studies have failed to demonstrate any negative effects of progestin-containing contraceptives (shot, implant, progestin only pills) on the quality of maternal lactation or first-year infant growth.

Selecting a contraceptive is a highly preference-sensitive decision, such that more than 1 treatment option is acceptable. Shared decision-making is a patient-centered counseling method that has been associated with decreased decisional conflict and better contraceptive outcomes. During this process, clinicians and patients work together to decide what method reflects patients’ values and preferences. Clinicians should respect patient preferences and decisions in a noncoercive manner, which may include prioritizing patient-desired method attributes over duration of action or contraceptive effectiveness and not choosing a clinician-recommended method (eg, declining a copper IUD because of concerns about worsening menses) or not choosing a method at all.

There are 6 FDA-approved LARC devices: 5 IUDs (1 copper, 4 levonorgestrel-containing) and 1 subdermal progestin implant. LARC has excellent efficacy (>99%), high continuation rates, and multiple noncontraceptive benefits, yet is underutilized in the United States. Use of an IUD alone does not increase the long-term risk of pelvic infection or infertility. LARC use decreases the absolute risk of ectopic pregnancy. Adolescents and nulliparous women can safely use IUDs. Noncontraceptive benefits of the levonorgestrel-containing IUD include decreased blood loss and protection from endometrial proliferation. LARC provides excellent options for patients with medical conditions that preclude the use of estrogen. Counseling about LARC should be noncoercive via shared decision-making and within the context of patient preferences and medical history.