In a new clinical update in JAMA, Justine Wu, M.D., M.P.H., assistant professor, and co-authors from the University of Michigan, offers updated guidelines for long-acting reversible contraception, or LARC. Wu was interviewed for a corresponding JAMA podcast that details the history of LARC in American life and debunks some of the misconceptions surrounding intrauterine devices (IUDs). LARC has long been a topic of interest among patients and their providers. And these devices could benefit many more patients than are currently using them.
These birth control options include several types of IUDs and an implant inserted in the upper arm.
- Hormonal IUDs release a progestin hormone (levonorgestrel) into the uterus, causing thickening of the cervical mucus to inhibit sperm from reaching or fertilizing the egg. The devices may also prevent the ovaries from releasing eggs. Hormonal IUDs are approved by the Food and Drug Administration for use for up to five years, although there is good science to support using them for up to seven years.
- Hormone-free copper IUDs (ParaGard) prevent sperm from reaching and fertilizing the egg. Because this device also will prevent implantation of a fertilized egg, it can be used as emergency contraception. It is approved by the FDA for use for up to 10 years, although there is science to support use for up to 12 years.
- An implantable rod (Nexplanon) is the current option in the U.S. for a contraceptive implant. The size of a matchstick, it is approved by the FDA for use for up to three years, although it has proved effective for up to four years.
No maintenance is required from the recipient. “An IUD or implant lets you set it and forget it for years, essentially,” Wu says.
Still, some may fear pain during LARC insertion or possible side effects afterward.
It’s why Wu and several University of Michigan colleagues wrote a clinical update about LARC benefits and common misunderstandings about LARC safety.
They state that the contraception is safe and effective, that wider adoption could help reduce unplanned pregnancies and that it could be used even in adolescents and in women who have never been pregnant.
Benefits of LARC
For patients who can’t take estrogen, such as those with a history of blood clots or breast cancer, the widely known oral contraceptive (the pill), a contraceptive patch or vaginal ring may not be safe. These methods put patients at a higher risk of stroke or cardiovascular events.
Nor are they foolproof: “The pill is still something you have to remember to take every day,” Wu says. “The pill’s effectiveness varies depending on adherence to daily use.”
More patients are choosing the long-acting reversible methods. Among women who use birth control, LARC use has risen from 1 percent to 12 percent over the past 18 years, Wu says. Oral contraception, at 25 percent of birth control users, remains the most-used option.
Besides LARC being more effective than the pill (99 percent vs. 91 percent), there are noncontraceptive benefits.
“For those who use the hormonal IUD, they can have lighter, shorter periods or none at all,” says co-author Allison Ursu, M.D., a clinical lecturer in family medicine at U-M. “The cramps and migraines associated with periods can also become much less intense.”
LARC can be reversed at any time, and a patient’s fertility is regained immediately upon removal.
“We can take out the IUD or implant whenever the woman doesn’t want it anymore,” says co-author Michelle Moniz, M.D., M.Sc., an assistant professor in obstetrics and gynecology at U-M.
Easing fears, encouraging choice
Patients may worry about the discomfort or complicated process of getting an IUD, but it takes only a few minutes during an office visit to insert the device, Moniz says.
Fears surrounding these contraceptive methods could first develop online.
“It can be hard to tell what sources are reputable,” Ursu says. “It’s also more common for someone with a bad experience to publicize it, compared to a great experience.”
Contraceptive manufacturers have to publish all recorded symptoms, she adds. Some women might view the symptoms as a deterrent, even if LARC isn’t necessarily the cause.
Patients should feel comfortable having an honest and open dialogue about contraception with their doctors — and those providers must respect their patients’ wishes, the U-M authors say.
“We know that when people feel like their preferences and values are heard, they’re more satisfied by the counseling they get from the provider and more likely to make a choice they stick with,” Wu says. “No one should be talked into anything.
“Shared decision-making is the recommended standard of care.”
Whether by LARC or other means, taking steps together to avoid unwanted pregnancy is crucial. Nearly half of all births in the U.S. are unplanned, with high costs to mothers-to-be and society, the U-M report notes.
“In 2010 alone, it cost more than $662 million statewide in medical expenses for unplanned pregnancies,” Ursu says. “Those pregnant may also leave their jobs for maternity leave or take a pause on academic obtainments.”
Women who have a chronic medical condition or take certain medications must also have careful discussions with their providers about how to safely proceed.
“If someone wants to get pregnant, we should do everything we can to optimize their health before conception. Getting good control of chronic conditions prior to conception can have a huge impact on pregnancy outcomes, as well as on the mom and baby’s well-being,” Moniz says.
As a patient’s reproductive wants change, meanwhile, “we as providers can provide tools that’ll help meet their goals,” she adds. LARC is one option to consider.
Find coverage of the JAMA clinical updates on Michigan Medicine's Health blog
Article Citation: Wu JP, Moniz MH, Ursu AN. Long-acting Reversible Contraception—Highly Efficacious, Safe, and Underutilized. Jama. 2018;320(4):397. doi:10.1001/jama.2018.8877.
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