Are you up with the LARCs?
Dr Christine Roke
National Medical Advisor,
Family Planning
March 2011
Long Acting Reversible
Contraception - LARC
• Action less often than monthly
• All less than 1% failure rate
Long Acting Reversible
Contraception - LARC
• Depo Provera injection
• Intrauterine contraception
• Implants
Longacting contraception
Why?
• Methods that require something with every act of
sexual intercourse or need to be taken every
day have higher user failure rates
• Combined pill has about 3% failure rate per year
in every day use and 8% in first year of use
• Women have first baby in NZ at about 30
• So average woman has more than 10 years
contraceptive use before first baby
• About 1 in 3 may therefore have an unintended
conception in that time
• Average woman has less than 2 children
• So many years of contraception required
when family complete with possible
contraceptive failure
Depo Provera
• Problem with women returning on time for
subsequent injections
• Now internationally recommended that
“late” injection is more than 14 weeks
since last injection
• Still schedule next appointment for 12
weeks
Possible side effects
• Most don’t put on weight
• Most don’t have mood changes
Depo Provera and bone density
• Depo Provera may reduce bone density by
5 – 7% over the first 2 years of use – it
then plateaus
• Caused by suppression of oestrogen
• When Depo Provera discontinued, regain
this loss of bone density over next few
years
Bone density
• Maximum increase in bone mass age 1114, some sites reach peak bone mass by
18, others later
• Reduced in anorexia nervosa, exerciseinduced amenorrhoea etc
• Increased in Maori and Pacific nation
people
Depo Provera use
• Can be used by adolescents if other
methods unsuitable, especially if 18 or
older
• All ages - review at 2 years – risks and
benefits
– UK Faculty of Family Planning and
Reproductive Health care, WHO
Intrauterine
contraception
• Now clear that STIs cause infection not IUDs
beyond the initial insertion phase
• Ideal to exclude STIs before insertion
• If asymptomatic chlamydia found, can treat and
insert IUD if reinfection not likely
• If STI or PID diagnosed while IUD in situ, treat
and only remove if not settling
• IUDs can be used by nulliparous women
(although they do have higher expulsion rate)
Intrauterine
contraception
• Fertility declines in 40s
• Copper IUDs – if inserted when 40 or older,
can stay until postmenopausal if no problems
• Mirena - if inserted when 45 or older for
contraception, can stay until postmenopausal if
no problems
Implant
Jadelle
• Progestogen-releasing rods
• 2 rods of levonogestrel - lasts 5 years
• inserted subdermally into upper arm under
local anaesthetic by trained clinician
• Subsidised from 1st August 2010
• Available on individual prescription (obtain
trochar from Bayer NZ)
Action
Slow release of progestogen which works by
• Inhibiting ovulation for first year or so
• Thickening cervical mucus
• Oestrogen levels remain above threshold
for loss of bone density
Jadelle efficacy
Women 60kg
or more
Year 1
Annual
pregnancy
rate
0.1
Year 2
0.1
0.2
Year 3
0.1
0.3
Year 4
0.0
0.0
Year 5
0.8
1.1
0.2
Side effects
• Main side effect is change in bleeding
pattern
• Can have other hormonal side effects
but lower hormonal levels than POP –
headache, weight gain, acne
• Scar for insertion and removal occasionally local wound problem
Jadelle bleeding pattern
• Irregular bleeding and amenorrhoea common
• Settles to long term pattern over first 3 - 6 months
• Bleeding less likely to settle with time than Depo Provera
or Mirena
• Bleeding problems are commonest reason for
discontinuation
• Spotting and irregular bleeding common – 14% (1 in 7)
discontinue for this reason:
– 5% for prolonged episodes of vaginal bleeding and
spotting
– 4% for irregular bleeding
– 3% for heavy bleeding
Bleeding
• Discussion of possible bleeding problems essential
before insertion
• Bleeding pattern possibly related to weight – lighter
women more likely to have amenorrhoea, heavier
women more likely to have more numerous bleeding
days
• Management of irregular bleeding
– COC as long as oestrogen not contraindicated
– NSAIDs 5 -10 days
Advantages
•
•
•
•
Rapid return of fertility when removed
Lower PID rates
Less dysmenorrhoea
Low ectopic pregnancy rate
Insertion
• By day 7 or reliable contraception
• Contraceptively effective immediately if inserted by day
5, otherwise 7 days
• Contraindicated if breast cancer within last 5 years
• Should not be used by those on enzyme inducing
medication
• Otherwise suitable for all ages provided able to manage
possible bleeding problems
• Superficial placement essential
Continuation and
removal
• Jadelle continuation rate at 2 years >80%
• At 5 years 40%
• Do not attempt removal if implants impalpable
• Refer to interventional radiologist
New ways of taking COC
• Tricycling = taking 3 packets of pills in a
row without a break
• Continuous = no breaks
• Less risk of contraceptive failure
• Less breakthrough bleeding with time but
some women will find this spotting a
problem – take 7 day break
• No known medical concerns