Long Acting Reversible Contraceptive Options for

College WomenA new era of contraception

Beth Kutler FNPGannett Health ServicesCornell UniversityBK82@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% 31%

2013 ACHA survey

Percentage of Women Experiencing Unintended Pregnancy in First Year

Hatcher RA. Contraceptive Tech. 19th ed. 2007. * Standard Days Method: 5%, Two Day Method: 4%

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

10

LARC Acceptance

Percentage

LNG-IUS 46.0%CuT380A 11.9%Implant 16.9%DMPA 6.9%Pills 9.4%Ring 7.0%Patch 1.8%Other <1.0%

75%

DMPA Ring Patch BCP Implant IUD0

10

20

30

40

50

60

United StatesChoice

Method Choice ages 14-20

% 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

# 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

What, if any, symptoms did you feel related to the 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%

Total 93 100.00%

How well informed did you feel prior to your IUD placement ?

# 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%

Total 86 100.00%

How likely are you, at this point (6mo) are you to recommend the IUD to a friend ?

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

Tubal infertility by previous copper T IUD use and presence of chlamydia antibodies, nulligravid women

Hubacher D, et al. NEJM. 2001.

Series30.1

1

10

Od

ds

Rat

io

Fertility Rates in Parous Women After Discontinuation of Contraceptive

Pre

gnan

cies

(%

)

Months After Discontinuation

0

20

40

6060

80

100

0 12 18 24 30 36 42

IUC

OC

Diaphragm

Other methods

Vessey MP, et al. Br Med J. 1983.Andersson K, et al. Contraception. 1992.Belhadj H, et al. Contraception. 1986.

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*

Andersson et al. Contraception 1994;49:56.Sivin. Stud Fam Plann 1983;14:57-63.

*Ectopic pregnancies per 1,000 woman-years

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

Adapted from Farley T, et al. Lancet. 1992.

1.6

9.25

<21 days of use 21 days - 8 years of use

Rate per 1,000 woman yearsN = 20,000 women

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

• Skyla LNG IUS releases 14 mcg levonorgestrel/day

• Approved for use up to 3 years

• Highly effective

2.8 x 3 cm

Insertion tube0.4cm

3.3 cm sq

Insertion tubeo.5 cm

IUD Placement

Suffrin et al OB. Gyn 2012 120: 1314-21

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

Screen at risk women through most convenient process

Screening for STI chlamydia and gonorrhea

• 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 SterilityVolume 97, Issue 3, March 2012, Pages 616–622.e3

Side effects from the copper IUD: do they decrease over time? David Hubacher , ⁎Pai-Lien Chen, Sola Park. Contraception 79 (2009) 356–362

Copper T related bleeding can decrease over time

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

Obstet Gynecol 2013;122:1214–21)

3 most common reasons for requesting removal before 6 months of use

ConvenientLong acting reversible method. Discrete. Effective for 3 years

Effective0.5 to 1 pregnancy /1,000 users

ReversibleAfter 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.

SafeProgesterone 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.

Nexplanon

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

ContraceptionVolume 71, Issue 5, May 2005, Pages 319–326

Bleeding patterns with etonogestrel implant

Bleeding Patterns with Implant First 2 Years

Infrequent

Amenorrhea

Prolonged

Frequent

33.3%

21.4%

16.9%

6.1% Percentage of 90– day intervals

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

Contraception 88 (2013) 503–508

Weight Changes with LARC Methods

Thank You !

Questions ?

Beth KutlerBK82@cornell.edu

LARC Online Resources

www.acog.org/goto/larc

www.jahonline.org

www.arhp.org

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USSPR.htmSelected practice recommendations for contraceptive use, (SPRC, 2013)

http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htmMedical Eligibility Guidelines for Contraception (MEC, 2010)

www.bedsider.org