Long-acting Reversible Contraceptives
13th Dec

2017

Long-acting Reversible Contraceptives

Long-acting reversible contraceptives (LARCs) are options which last for long periods of time and don’t need to be remembered on a daily basis but are completely reversible. There are a number of such options on the market currently, including a rod which is injected under the skin of the upper arm, intra-uterine devices (either progesterone releasing or the copper IUD with no hormones) and the 3-monthly progesterone depot injection. We will not be focussing on the depot injections in this blog as they are less long-acting and require regular GP visits for injection so do not have as many of the advantages as the other LARCs.

In general, LARCs have a number of functions and the hormonal options are used both as contraceptive devices as well as helping many women control bleeding and pain symptoms associated with their periods. There are a number of advantages to these devices over traditional contraceptives like the oral contraceptive pill (OCP). As with any prescription medicine these options all have potential risks and side effects which need to be considered prior to use, but overall they are very well tolerated and have a high continuation use rate which is evidence of their acceptability in the general population.

1. LARCs are the most effective contraceptives

The following table is adapted from a paper published in 2011 and shows the difference in effectiveness when comparing different types of contraceptives. (Trussell J, Contraceptive failure in the United States, Contraception 2011).

When women use no contraception there is an 85% chance of conceiving in the first year. One of the important things shown in the table is the comparison of ‘perfect use’ versus ‘typical use’. Anyone who has been on any medication would know how easy it is to forget to take a pill at times, or to have unexpected vomiting or even interactions with medications like antibiotics, all of which affect how well the contraceptive works. Typical OCP use is only 91% effective. The benefit of the LARCs is that they are as good regardless of human and day-to-day factors. And they are very effective -between 99.8-99.9% which means that women have full control over their pregnancy options and there are no unexpected surprises! It is not surprising that countries that have high use of LARCs have very low rates of termination of pregnancy.

Contraceptive type Typical use Perfect use Continuation at 3 years
No method 85% 85%
OCP 9% 0.3% 67%
Progesterone rod 0.05% 0.05% 84%
IUD (copper) 0.8% 0.6% 78%
IUD (progesterone) 0.2% 0.2% 80%
Depot injections 6% 0.2% 56%
Condoms 18% 2% 43%
Withdrawal 22% 4% 46%
Tubal ligation 0.5% 0.5% 100%
Vasectomy 0.15% 0.10% 100%

2. LARCs are well tolerated and acceptable to most women

The last column in the above table looks at continuation rates after 3 years with the highest rates seen in the LARCs. While some women will decide to change their contraceptive due to side effects or wanting to start a family, they are more likely to stick with one of the LARCs than other types of contraception which is evidence of their low rate of side effects and acceptability for most women.

3. LARCs are cheaper than using the OCP over 12 months

When comparing the cost of LARC contraception vs the OCP, the OCP expenditure over the course of the year is higher. When you consider that most LARCs are effective for 3-5 years, then that makes it a very cost effective option for many women.

4. LARCs are completely reversible and do not have an impact on fertility

Once LARCs are removed your fertility potential returns to normal. This is the fastest with the IUDs as neither the progesterone releasing IUD, nor the copper IUD result in a cessation of ovulation while they are in use. This means it is possible to conceive on the first cycle after removal. The progesterone rod stops you from releasing eggs (ovulation) but after removal of the rod it is expected that ovulation will return in a short space of time. Even women whose periods stop completely while using LARCs do not have a reduction in fertility when they are removed.

5. LARCs can be used in women regardless of age and despite many health conditions which may prevent them from using the OCP

LARCs can be used in the teenage years right through to the menopause. For the prevention of teenage pregnancy they are the most effective option available (see the above regarding ‘typical use’ of the OCP which is worse in teenagers!).

In addition, some women who are unable to use the OCP due to clotting disorders, migraines, and other health conditions can use the LARCs without increased risk.

6. LARCs help to treat gynaecological conditions

LARCs are frequently one of the first line options to help with abnormally heavy or painful periods.
Women who used the progesterone rod were found to have resolution of their period pain in 77% of the cases and in >50% of women have infrequent or no period bleeding. The progesterone IUD has consistently been found to be associated with a reduction in heavy menstrual bleeding and a reduction in the need for hysterectomy. There are many studies showing that when used for bleeding or pain there are high satisfaction rates and improved quality of life. At Alana Healthcare for Women, we frequently use these methods as treatments for endometriosis as the research supports a reduction in pain and bleeding with an improvement in symptoms for women with endometriosis using progesterone releasing LARCs.

7. So what are the risks and downsides of the LARC methods of contraception? And how do these compare to the OCP?

Here is a summary of some of the more common and pertinent side effects associated with each LARC.

Type of contraception Risks and Side effects Rate of complication
Progesterone rod Irregular bleeding 11.3% of women discontinue use because of bleeding side effects
No periods (amenorrhoea) while inserted 22%
Infrequent bleeding 33%
Mood disturbance 30%
Progesterone IUD Perforation (where the IUD passes through the wall of the uterus) 1.6/1000 women

 

Irregular bleeding Very common in first 3-6 months
No periods (amenorrhoea) while inserted 20-80% reported by 12 months
Expulsion (where the IUD is pushed out by the uterus) 6%
Ectopic pregnancy 0.02-0.2/100
Breast tenderness and bloating 40%
Mood disturbance 13%
Copper IUD Perforation (where the IUD passes through the wall of the uterus) 1.6/1000 women

 

Heavy menstrual bleeding Increases by about 50%
Expulsion (where the IUD is pushed out by the uterus) 6%
Ectopic pregnancy 0.1-0.8/100

8. I’ve heard that women who use LARCs are more likely to get PID…

There is a common misconception that all LARCs are associated with pelvic inflammatory disease and therefore infertility. So what are the facts?

  • Women who use the progesterone rod are as likely to get PID as women without the rod. The message is use a condom to prevent against STIs if you are engaging in casual intercourse or don’t know the status of your partner.
  • Women using IUDs have been found to have a slight increase in the number of infections in the first 3 weeks after insertion (likely related to asymptomatic sexually transmitted infection like chlamydia which was already present). After this initial spike, rates of PID are the same in users of the IUD as women without it. Again, use a condom if you are at risk!

So, our message from Alana Healthcare for Women is to not be taken in by alarmist journalism reporting on two cases of women who have experienced issues with LARCs. Talk to your doctor about the pros and cons of all contraceptive options and make an informed decision that is best for you.

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Dr Erin Nesbitt-Hawes is an Obstetrician, Gynaecologist and Laparoscopic Surgeon at Alana Healthcare for Women, Royal Hospital for Women and UNSW.

For more information about our services, please visit our Gynaecology, Obstetrics and Fertility main pages.

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