Understanding LARC and hormonal options
The two types of IUDs are an levonorgestrel IUD and a copper-T IUD. The levonorgestrel IUD contains progestin only, released at 20 mcg per day, and is effective up to 3-7 years. Most patients have light spotting initially, lasting 6 months in about 25% of patients and up to a year in 10%. By 6 months, 44% don’t have periods, which increases to 50% by 1 year (“Contraceptive Technology,” 19ed. [London: Ardent Media, 2007]).
The copper-T IUD contains copper ions but no hormones and is effective up to 12 years, starting immediately. Women have regular periods, but they may be heavier, longer, or with more cramps for the first 6 months.
Both IUDs and implants are safe in nulliparous, postpartum, and breastfeeding teens as well as those with obesity, cervical intraepithelial neoplasia, diabetes, HIV, depression, stroke/myocardial infarction/deep vein thrombosis/pulmonary embolism, pelvic inflammatory disease, and sexually transmitted infections.
Dr. Phelps reviewed insertion for both IUDs and the implant, but also said providers can refer teens for LARCs using http://larc.arhp.org to find someone. She also recommended the Managing Contraception pocket-sized book, available at www.managingcontraception.com and free for medical students and residents. Further, the U.S. Medical Eligibility Criteria provides all necessary information on contraindications and is available as a mobile app.
All the hormonal options, including the levonorgestrel IUD, become effective 1 week after starting. The implant, costing $300-$600, contains only progesterone, is effective up to 4 years and works by inhibiting ovulation. Just over one in five girls (22%) have no period, 34% have infrequent light bleeding, and 11% discontinue it because of frequent bleeding.
Depo-Provera contains progestin only and involves an injection every 12-14 weeks; irregular bleeding is initially common, after which most patients experience amenorrhea.
Patients using the patch, containing both estrogen and progestin, should change it once a week for 3 weeks and then take 1 week off for their period. Providers should advise teens to stick the patch directly on clean, dry skin of the arm, torso, buttocks, or stomach, but not to their breasts.
The ring similarly contains estrogen and progestin and has 1 off week after 3 weeks of use, but it is changed out monthly. Patients pinch the ring and place it into the vagina in any location, going deeper if it is uncomfortable.
Emergency contraception
Of the two emergency contraception options, ulipristal acetate – prescription only as 30 mg used up to 120 hours after unprotected sex – is always more effective than levonorgestrel – over-the-counter as 1.5 mg used up to 72 hours after unprotected sex. Both, however, are less effective in those with obesity (ulipristal acetate if BMI great than 30 and levonorgestrel if BMI greater than 25), Dr. Phelps said. If the patient had unprotected sex 3-5 days earlier and/or has a higher BMI, ulipristal acetate is preferred. Ideally, teens should be provided emergency contraception ahead of time, thereby increasing earlier use and use overall when it’s needed without increasing risk-taking behavior.
Common misconceptions
Dr. Phelps also reviewed some of the key myths that providers and teens often believe about LARCs and other contraceptive methods.
“When providers or patients hold misperceptions about the risks associated with contraception, teens’ choices are unnecessarily limited,” she said.
Key facts to know about IUDs are that even nulliparous teens can use them, teens can tolerate IUD placement, and IUDs do not increase the risk of pelvic inflammatory disease or infertility. Even teens with multiple partners and/or a history of sexually transmitted infections, pelvic inflammatory disease, or ectopic pregnancy can use IUDs, Dr. Phelps emphasized.
Although Depo-Provera can lead to 3%-5% bone loss, similar to pregnancy and breastfeeding, in the first 1-2 years, the loss is temporary and reversible. No research has shown Depo-Provera to increase risk of fracture or other negative clinical outcomes, no limits to its duration of use exist, and measuring bone mass density is not recommended.
Although Depo-Provera does cause excessive weight gain in 25% of users – an average 15 pounds over 3 years – the risk of increase is evident at 6 months. All other hormonal options – IUDs, the implant, pill, patch, or ring – do not cause weight gain. Finally, obesity does not decrease the effectiveness of IUDs, the implant, patch, pill, or ring.
No funding was used for this presentation. Dr. Phelps reported having done clinical training and speaking for Merck.