Long Acting Reversible
Contraceptive Options for
College Women
A new era of contraception
Beth Kutler FNP
Gannett Health Services
Cornell University
BK82@Cornell.edu
The purpose of this activity is to enable the learner to
counsel effectively about long acting contraceptive methods
(Intrauterine devices and implantable rods) as well as learn
new insights for effective placement and management of
potential side effects
The presenter has no financial conflicts to disclose
2013 ACHA National College Health Assessment :
o 49.2% of females had vaginal sex in the 30 days prior to the survey
o 1.9 % of college students who had vaginal intercourse within the last 12 months reported
experiencing an unintentional pregnancy in that time frame
o 18.8 % reported using EC within the last 12 months
7.9%
61.6%
61.7%
2013 ACHA survey
31%
Percentage of Women Experiencing
Unintended Pregnancy in First Year
* Standard Days Method: 5%, Two Day Method: 4%
Hatcher RA. Contraceptive Tech. 19th ed. 2007.
Increased use of LARC*
has the potential to lower unintended
pregnancy rates among adolescents
*LARC = Long-Acting Reversible Contraception
Get It
And Forget It !
Contraceptive Cohort Study
• Recruited 10,000 participants over 4 years
– 60 % age 14-25
– 47% nulliparous
– No cost contraception for 3 yrs
– Counseled in all methods, starting
with top tier methods
– Participant choice
www.choiceproject.wustl.edu
LARC Acceptance
Percentage
LNG-IUS
CuT380A
Implant
DMPA
Pills
Ring
Patch
Other
46.0%
11.9%
16.9%
6.9%
9.4%
7.0%
1.8%
<1.0%
75%
10
Method Choice ages 14-20
60
50
40
30
United States
20
Choice
10
0
% of all contraceptive users 2010
% of 4,167 Choice sample
www.choiceproject.wustl.edu
Intrauterine Contraception in Nulliparous Women
a Prospective Observational Study
Study Objectives:
 Assess nulliparous women’s satisfaction with the IUD as a method of contraception
 Identify any medical history that may predict satisfaction or dissatisfaction with this
method
 Quantify the rates of discontinuation and/or complications for IUD use among nulliparous
women
117 women currently enrolled in ongoing study. Receive surveys at 1 ,6, 12 and 18 months
following placement
What, if any, symptoms did you feel related to the IUD placement ?
#
Question
None
Mild
Moderate
Severe
Response
Average
Value
1
Nausea from the pre-medication
80
6
3
3
92
1.23
2
Cramping from the pre-medication
69
14
6
2
91
1.35
3
Pain and cramping during the IUD insertion procedure
1
23
32
37
93
3.13
4
Light-headedness, nausea, and/or sweating during procedure
49
18
22
4
93
1.80
5
Pain and cramping in the first hour after insertion
2
25
35
31
93
3.02
6
Pain and cramping in the first 24 hours after insertion
4
33
37
19
93
2.76
7
Pain and cramping 24-72 hours after insertion
23
40
18
12
93
2.20
8
Pain and cramping after one week had passed
57
18
14
4
93
1.62
How well informed did you feel prior to your IUD placement ?
#
Answer
Bar
Response
%
1 Very well informed
80
86.02%
2 Fairly well informed
12
12.90%
3 Neutral
0
0.00%
4 Not well informed
1
1.08%
5 Very poorly informed
0
0.00%
93
100.00%
Total
How likely are you, at this point (6mo) are you to
recommend the IUD to a friend ?
#
Answer
Bar
Response
%
1
Very Likely
68
79.07%
2
Likely
11
12.79%
3
Neutral
6
6.98%
4
Unlikely
0
0.00%
5
Very Unlikely
1
1.16%
86
100.00%
Total
But what about…?
•
•
•
•
Multiple sexual partners
Nulliparity
Future fertility
Placement trouble
IUDs Do Not Cause Infertility
• Infertility is not more likely after IUD
discontinuation compared to other
reversible methods
• No evidence that IUD use is associated
with subsequent infertility
• Chlamydia, not previous IUD use, is
associated with infertility
Safety: IUD Does Not Cause
Infertility
• IUD is not related to infertility
• Chlamydia is related to infertility
Odds Ratio
10
1
0.1
Hubacher D, et al. NEJM. 2001.
Tubal infertility by previous
copper T IUD use and
presence of chlamydia
antibodies, nulligravid women
Fertility Rates in Parous Women After
Discontinuation of Contraceptive
100
Pregnancies (%)
80
IUC
6060
OC
Diaphragm
40
Other methods
20
0
0
12
18
24
30
Months After Discontinuation
Vessey MP, et al. Br Med J. 1983.
Andersson K, et al. Contraception. 1992.
Belhadj H, et al. Contraception. 1986.
36
42
Ectopic Pregnancy
• IUDs may be offered to women with a history of ectopic
pregnancy (MEC cat. 1)
• IUD use does not appear to increase absolute risk
o Ectopic rate with IUD= 0.5/1,000 women-years
o Ectopic rate with no contraception= 3.25-5.25/1,000 women- years
o However, if pregnancy does occur with an IUD in place, the pregnancy
is more likely to be ectopic
Sivin I. Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception. Obstet
Gynecol 1991;78:291–8.
Ectopic Pregnancy
Levonorgestrel IUS
0.20*
Copper IUD
0.34*
No method
1.20-1.60*
*Ectopic pregnancies per 1,000 woman-years
Andersson et al. Contraception 1994;49:56.
Sivin. Stud Fam Plann 1983;14:57-63.
Safety: IUDs Do Not Cause PID
• PID incidence for IUD users is
similar to that of the general
population
• Risk is increased only during the
first month after insertion
• Preexisting STI at time of insertion,
not the IUD itself, increases risk
Svensson L, et al. JAMA. 1984.
Sivin I, et al. Contraception. 1991.
Farley T, et al. Lancet. 1992.
Rate of PID by Duration
of IUD Use
Rate per 1,000 woman years
N = 20,000 women
9.25
1.6
<21 days of use
Adapted from Farley T, et al. Lancet. 1992.
21 days - 8 years of use
Screening: Poor Candidates for
Intrauterine Contraception
•
•
•
•
•
•
Known or suspected pregnancy
Puerperal sepsis
Immediate post septic abortion
Unexplained vaginal bleeding
Cervical or endometrial cancer
Uterine fibroids that interfere with
placement
• Current purulent cervicitis, chlamydia,
or gonorrhea
WHO. Medical Eligibility Criteria for Contraceptive Use.
Copper IUD
• ParaGard polyethylene wrapped with
copper wire
• Approved for use up to 10 years (probably
more)
• Mechanisms of action:
 Inhibition of sperm migration and
viability
 Change in ovum transport speed
 Damage to or destruction of ovum
 Damage to or destruction of fertilized
ovum
 All effects occur before implantation
• Highly effective
LNG IUS
• Mirena LNG IUS releases 20 mcg
levonorgestrel/day
• Approved for use up to 5 years (probably
more)
• Mechanisms of action:

Similar effects as copper IUD

Also causes endometrial suppression
and changes in cervical mucus

All effects occur before implantation
• Highly effective
New LNG IUS
3.3 cm sq
2.8 x 3 cm
Insertion tube
o.5 cm
Insertion tube
0.4cm
• Skyla LNG IUS releases 14 mcg levonorgestrel/day
• Approved for use up to 3 years
• Highly effective
IUD Placement
Screening for STI chlamydia and gonorrhea
57,728 IUD insertions:
• 47% unscreened
• 19% screened on day IUD was inserted
• Overall PID risk within 90 days= 0.54%
• No difference in PID regardless of screening
Suffrin et al OB. Gyn 2012 120: 1314-21
Screen at risk women through most convenient process
• Pre placement counseling essential
• 800 mg Ibuprofen 1 hour prior to
placement
±
•
•
•
•
•
•
Anxiolytics
50 mg Tramadol
Topical and/or instilled lidocaine
Cervical blocks
Misoprostol
Menses
Post-Abortion Insertion
• Insertion of an IUD immediately after abortion or
miscarriage is safe and effective
– Significantly reduces the risk of repeat abortion
– Increases rates of use
– Adolescents should be counseled regarding risk of
expulsion
Copper IUD as EC
• Most effective method of emergency
contraception
• Can be inserted up to 5 days after
unprotected intercourse to prevent
pregnancy
Efficacy of Emergency contraception
Glasier A, et. all. Contraception. 2011;84:363‐7
.
Bleeding Concerns
Fertility and Sterility
Volume 97, Issue 3, March 2012, Pages 616–622.e3
Copper T related bleeding can decrease over time
Side effects from the copper IUD: do they decrease over time? David Hubacher⁎,
Pai-Lien Chen, Sola Park. Contraception 79 (2009) 356–362
Managing Bleeding Concerns
• Anticipatory guidance and reassurance
• Treat with NSAIDs
• Cycle with oral contraceptives
• 70% experience oligomenorrhea or amenorrhea within
2 years of insertion of Mirena
• These numbers likely to be lower with Skyla
3 most common reasons for requesting removal before 6 months of use
Obstet Gynecol 2013;122:1214–21)
Nexplanon
Convenient
Long acting reversible method. Discrete. Effective for 3 years
Effective
0.5 to 1 pregnancy /1,000 users
Reversible
After implant is removed, most women (94%) ovulate by 3 months; the
majority ovulate within 3 weeks. Drug level is undetectable one week after
removal. Funk S, Contraception. 2005 May;71(5):319-26.
Safe
Progesterone only. MEC 1 or 2 where estrogen is contraindicated. Inhibits ovulation
No evidence of long-term effects such as deep vein thrombosis or anemia. Studies
regarding bone mineral density have been conflicting. BeerthuizenR, Hum Reprod.
2000;15:118-122.
Easy Placement
•
•
•
•
Insertion in <1 min
Removal 3-5 min
1% complications related to insertion
1.7% related to removal
•
•
Can be placed anytime pregnancy reasonably excluded
Back up method for 7 days unless :
•
inserted within 5 days of menses
•
immediately post-abortion
•
Immediately upon switching from another hormonal method
Bleeding patterns with etonogestrel implant
Contraception
Volume 71, Issue 5, May 2005, Pages 319–326
Bleeding Patterns with Implant
First 2 Years
Frequent
Prolonged
Amenorrhea
Infrequent
Percentage of
90– day
intervals
6.1%
16.9%
21.4%
33.3%
Managing Bleeding Concerns
• Common strategies include short courses of
combined OCs or NSAIDs
– No published placebo controlled trials to support use
of these treatments
• Limited data suggest decreases in bleeding
episode length with:
– Mefenamic acid
– Mifepristone in combination with ethinyl estradiol or
doxycycline
– Doxycycline alone
Weight Changes with LARC Methods
Contraception 88 (2013) 503–508
Thank You !
Questions ?
Beth Kutler
BK82@cornell.edu
LARC Online Resources
www.acog.org/goto/larc
www.jahonline.org
www.arhp.org
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htm
Selected practice recommendations for contraceptive use, (SPRC, 2013)
http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm
Medical Eligibility Guidelines for Contraception (MEC, 2010)
www.bedsider.org