Are you up with the LARCs?

Dr Christine RokeNational Medical Advisor,

Family PlanningMarch 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 contraceptionWhy?

• 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 11-14, some sites reach peak bone mass by 18, others later

• Reduced in anorexia nervosa, exercise-induced 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

Annual pregnancy rate

Women 60kg or more

Year 1 0.1 0.2

Year 2 0.1 0.2

Year 3 0.1 0.3

Year 4 0.0 0.0

Year 5 0.8 1.1

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