Today’s LARC: Not Your Mother’s LARC

CDC currently estimates that 41 states are in the range of Aedes aegypti or Aedes albopictus mosquitoes that can transmit the Zika virus. Infected pregnant women can pass this along to their developing fetuses. One important aspect of preventing complications of the Zika virus such as microcephaly and other severe fetal brain defects is encouraging the use of effective methods of contraception among teens and women that do not want to become pregnant.  According to the most recent data, approximately 45% of pregnancies in the US are unintended.

This is simply staggering in the era of highly effective, long-acting reversible contraception (LARC). LARC includes implants and intrauterine devices.  Studies have shown these to be 20 times more effective at preventing pregnancy than oral contraceptive pills, transdermal patches or rings.  Unfortunately, according to the CDC, the majority of women and teens at risk for unintended pregnancy in potential Zika areas are using less effective methods or no method at all.

LARC methods are extremely safe, and most women tolerate them quite well.  Until recently, they were costly for many women, but because of The Affordable Care Act, signed by President Obama in 2010, most insurance plans cover them.  Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have strongly encouraged the use of LARC, even for teens and for women who have never given birth.  In fact, for AAP, LARC is their first-line recommendation for teens not choosing to remain abstinent.

Sadly, clinicians and patients have been slow to embrace these methods in the U.S.  Many formed negative opinions about IUDs after an early version known as the Dalkon Shield resulted in many serious infections. It was released in 1971 and taken off the market in 1974.  Experts speculate that the its unique multifilament tail string probably facilitated ascent of bacteria into the uterus, causing PID.

To help overcome misconceptions and provide the best care, two documents should serve as the basis for counseling any patient about contraception.  CDC recently updated both of them:

  1.  U.S. Selected Practice Recommendations for Contraceptive Use, 2016 (MMWR)
  2. United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016 (MMWR)

LARC Methods available in the U.S. include two types:

I. IUDs (4 varieties in US)

Copper IUD (Cu-IUD) ParaGard® T 380A Intrauterine Copper Contraceptive.  This is a hormone free method approved for 10 years of use.  The copper interferes with sperm movement, fertilization and possibly implantation. Women may experience increased cramping or bleeding with this method, but these often diminish with time.

Levonorgestrel-releasing IUDs (LNG-IUD) Mirena® (52 mg levonorgestrel, approved for 5 years of use), Skyla® (13,5 mg levonorgestrel and approved for three years of use) and Liletta® (52 mg levonorgestrel – currently approved for three years of use).  All of these thicken cervical mucus and block sperm.  These tend to decrease cramping and bleeding with many women becoming amenorrheic over time.  This is certainly viewed as a feature, not a bug on my campus.

II. Implants (1 in U.S.)

Etonogestrel implant, Nexplanon® (68 mg of etonorgestrel, approved for three years). This device, inserted in the upper arm, prevents ovulation and thickens cervical mucus.  It is associated with unpredictable bleeding but the pattern varies.

*Keep in mind that none of these methods prevent sexually transmitted infections (including Zika!), so don’t forget to encourage condom use.

The CDC also has some great free tools you can use to counsel patients:

  1. Effectiveness of Family Planning Methods I strongly recommend using a chart like this as it really clarifies the idea of effectiveness for many patients. Also check out Bedsider.org for additional resources and infographics.
  2. When to Start Contraceptive Methods and Routine Follow-up

Unplanned pregnancies and severe birth defects don’t help anyone. Nurses have shown over and over again they play a crucial role in preventing both.

Julie Richards, President

American Travel Health Nurses Association