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10/2/2018
1
LARCS Update: A Reproductive Justice Perspective ADENA BARGAD, PHD, CNM
Objectives1) Identify LARC methods currently available in US
2) Review US MEC and SPR for LARCS
4) Discuss approaches to LARC problem management
5) Apply a Reproductive Justice Framework to Examine the LARC 1st approach
http://www.huffingtonpost.com/2013/10/09/birth-control_n_4070949.htmlhttp://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000003461/2013%20ACNM%20Contraception%20Survey%20-%20Executive%20Summary.pdf
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<1
6
9
22‐24
28
18
12
12‐24
9
Adapted from https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf
Copper IUD
•Brand Name: Paragard®
•MOA: Inhibits fertilization and implantation•Approved for nullips and parous women•Effective for 10 yrs (12)•Efficacy: <1% failure rate •Most effective method of EC
DeviceCopper (mm2)
Duration
Copper‐sleeved devices:
TCu380SRecommended first choice for all women opting for Cu IUCD.
380 10
TT 380® SlimlineMarketed as a replacement for the Ortho Gynae® T380 which is no longer available in the UK.
380 10
TCu380A QuickLoad®Replacement for the TCu380A (T‐Safe® 380A) which is no longer available in the UK.
380 10
Mini TT 380® SlimlineCan be used when the uterine cavity is less than 6.5 cm on sounding.
380 5
Flexi‐T® 380There are limited data on the Flexi‐T®. Unlike other banded devices, it therefore cannot be recommended for 10 years of use.
380 5
Copper in stem only:
Ancora® 375 Cu 375 5Cu‐Safe® T300 300 5
Load® 375 375 5
Neo‐Safe® T380 380 5
UT 380 Short®Can be used when the uterine cavity is less than 6.5 cm on sounding.
380 5
Nova‐T® 380 380 5
Novaplus T 380® Cu (mini and normal sizes) 380 5Novaplus T 380® Ag (mini and normal sizes) 380 5
Neo‐Safe® T380 380 5
Multiload® Cu375Can be used when the uterine cavity is less than 6.5 cm on sounding.
375 5
Multi‐Safe® 375 375 5
Multi‐Safe® 375 Short StemCan be used when the uterine cavity is less than 6.5 cm on sounding.
375 5
Flexi‐T® 300Can be used when the uterine cavity is less than 6.5 cm on sounding.
300 5
Flexi‐T® 380 380 5
Frameless copper devices:
GyneFix®Can be used when the uterine cavity is less than 6.5 cm on sounding.
330 5
Gynefix ®
For <6.5cm uterus
Multisafe ®
2 sizes
Types of Copper IUDs Available in UK
https://patient.info/doctor/intrauterine‐contraceptive‐device‐pro
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Levonorgestrel IUD: 4 AvailableBrand Name
Size Inserter Diameter
Mg Years Effective FDA (empirical)
Parity FDA (empirical)
Non‐ContraceptiveUseFDA (off label)
Mirena®
Liletta®32 X 32mm
4.4mm 52 5 (7)3 (7)
Parous (Any)
Menorrhagia(endometrial hyperplasia; menopausal HT)
*Kyleena® 30 X 28mm
3.8 19.5 5 Any
*Skyla® 30 x 28mm
3.8 13.5 3 Any
Implant •Brand name: Nexplanon®
•Solid, single rod; 2x 40mm
•Contains etonogestrel 68mg (progesterone only)
•Effective for 3 years (4)
•MOA: Inhibits ovulation
Implant: Insertion and Removal
https://www.youtube.com/watch?v=ug7q_1RUMio https://www.youtube.com/watch?v=LUfc3XZnb9c
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How long until protection from pregnancy after initiation?
Immediately:Copper‐T IUD
LNG IUSImplant
1 week:If >5d since 1st day of cycle:
Adapted from: Association of Reproductive Health Professionals www.arhp.org
Immediate Post Partum LARC•Of 2000 surveyed, 90% midwives had never done PPIUD or PP Nexplanon
•Reimbursement and inadequate training
•NY State Medicaid Reimbursement for PP LARC ; ACOG Resource Digest
•https://www.acog.org/‐/media/Departments/LARC/NYSmidwifereimbursement.pdf?la=en&hash=AA91E19B2D2EF6AB5E3D0AAAF426A5E76602314B
https://www.acog.org/‐/media/Departments/LARC/IPPLARCResourceDigestReplaceable.pdf?dmc=1ts=20160819T1326385264
Moniz, M., Roosevelt, L., Crissman, H., et al. (2017) Immediate postpartum contraception: A survey needs assessment of a national sample of midwives. JMWH, 62 ( 5 ), 538–544.
US Medical Eligibility Criteria for Contraceptive Use (CDC Contraception US MEC/US SPR, 2016)
• Contraceptive method
• Patient characteristics (age, smoking status, etc.)
• Preexisting conditions (hypertension, epilepsy, etc.)
• Initiating v. Continuing
https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
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US Medical Eligibility Criteria
https://www.ncbi.nlm.nih.gov/pubmed/29322856#
US Selected Practice Recommendations for Contraceptive Use (CDC US SPR,2016)
•When to start•Missed pills
•Bleeding problems•Exams and tests
•Follow‐up•How to be reasonably certain that a woman is not
pregnanthttps://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html
STI testing for IUDsWt/BMI for HC
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Problem Management: IUD Insertion Pain
•Allis Clamp v. Tenaculum
•Ibuprofen• Anesthetic options:1) None
2) benzocaine gel 20%
3) 5‐10 cc of 1% lidocaine injection (cervix)
4) Paracervical Block (nullips)
Allis Clamp
Hatcher, R.A., Zieman, M., Allen, A., Lathrop, E. Haddad, Let al. (2017‐2018). Managing contraception, 14th Ed. Tiger, Georgia: Bridging the Gap Foundation .
Problem Management: Vasovagal Reaction/Syncope (Fainting)
•Excessive pooling in extremities
•Prodromal Symptoms
•Screen for risk
•Watch patient for signs of impending vasovagal reaction
•Intervention:•Contract extremities!•Anticipatory guidance
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Problem Management: Heavy/Late Bleeding IUD Implant
R/O pregnancy, infection, lesion/fibroid, anemia
R/O pregnancy, infection, lesion/fibroid, anemia
R/O Expulsion/ Displacement (sono, x‐ray) R/O Expulsion/Displacement (sono, x‐ray)
Mngmt: • Ibuprofen 800mg PO TID during
bleeding episodes• COCs 1‐3 cycles
Mngmt: • Ibuprofen 800mg PO TID• Estrogen QD x 21 d (CCEE .0625‐2.5mg,
EE 1‐2mg)• COCs x 1 cycle
Removal prn Removal prn
Hubacher D, Chen P-L, Park S. Side effects from the copper T IUD: do they decrease over time? Contraception. 2009;79(5):356-62.Sivin I. Utility and drawbacks of continuous use of a copper T IUD for 20 years. Contraception. 2007;75(suppl):S70-5.
http://www.obgmanagement.com/index.php?id=21603&cHash=071010&tx_ttnews[tt_news]=177032
Problem Management: Missing Strings
or remove with ring forceps
or remove with ring forceps w/tenaculum
Problem Management:Pregnancy with IUD in Place
• R/O ectopic • Remove IUD if strings are accessible• Removal decreases risk of:
– Spontaneous abortion– PROM, PTL/B– Chorioamnionitis
ParaGard PI. 2013; Mirena PI. 2013; Skyla PI. 2013; UK Family Planning Research Network. Br J Fam Plann. 1989; Foreman H. Obstet Gynecol. 1981; Atrash HK. 1994.
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Implant: Problem Management SITE COMPLICATION NONPALPABLE
Bleeding: steri strips and pressure dressing
Infection: Dicloxacillin 500mg PO QIDCephalexin 500mg PO QIDWarm CompressesF/U 72 hrsRemove prn
X‐RayMRIMerk testing for Etonegestrellevel, prn
CHOICE Project• 75% Chose LARC
• Continuation/Satisfaction at 1 yr: 86% LARC v. 55% SARC
• Continuation/Satisfaction 2 & 3 yrs: 72% LARC v. 39% SARC
Rates of Unintended Pregnancy
http://www.choiceproject.wustl.edu/
Clin Obstet Gynecol. 2014 Dec; 57(4): 635–643.doi: 10.1097/GRF.0000000000000070
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Colorado Family Planning Project2009 to 2014:
LARC users increased from 6.4 percent to 30.5 percent.Teen birth rate was nearly cut in half.Teen abortion rate was nearly cut in half.Second and higher order births to teens were cut by 57 percent.Birth rate among young women ages 20‐24 was cut by 20 percent.Costs avoided: almost 70 million dollars.
http://www.brownpoliticalreview.org/2015/11/birds‐bees‐and‐iuds‐why‐colorados‐successful‐experiment‐with‐long‐term‐contraception‐is‐poised‐to‐fail/
https://www.colorado.gov/pacific/sites/default/files/PSD_TitleX3_CFPI‐Report.pdf
All Women
White Hispanic Black
All Women
Unintended pregnancy rate per 1000 women 15‐44
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Percentage of people in US without health insurance in the United States from 2010 to 2016
Source: CDC; NCHS ID 200970
Note: United States
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%
National average
Hispanic (of any race)
Asian
Black
White (not Hispanic)
Share of population
2016 2015 2014 2013 2012 2011 2010
Further information regarding this statistic can be found on page 8.
Contraceptive use at last sex by Race/Ethnicity
93
85
90
Grady, C. D., Dehlendorf, C., Cohen, E. D., Schwarz, E. B., & Borrero, S. (2015). Racial and Ethnic Differences in Contraceptive Use Among Women Who Desire No Future Children, 2006–2010 National Survey of Family Growth. Contraception, 92(1), 62–70. http://doi.org/10.1016/j.contraception.2015.03.017
61
55 55
20 2019 19
2527
NSFG 2006‐2010: 2624 heterosexually active women, who do not desire future children at last intercourse
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Contraceptive Preferences
•No method is a 100% match with any woman’s or groups preferences
•WOC report a greater number of features to be extremely important
•WOC have preferences that most closely matched low or moderate efficacy methods •Desire for self‐control over initiating and discontinuing method
• Immediate return to fertility
•No interference with menstrual cycles
•Use only w/sex •STI protection
History of Lived Experiences
Slavery 1900‐1940s BC as Genocide 1960s‐1980s Incentive
Programs
1600s‐1800s Eugenics 19602‐70s Forced
Sterilization 1990s
Reproductive Justice: Foundational Principle
“The human rights of women include their right to have control over and decide freely and
responsibly on matters related to their sexuality, including sexual and reproductive health, free of
coercion, discrimination, and violence.” (Office of the High Commissioner for Human Rights, 2014)
Ross, L.J. (2017). Reproductive Justice as Intersectional Feminist Activism. Souls, 19 (3), 286–314 .
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Reproductive Justice: Tenets(1) The right to have a child
(2) The right not to have a child
(3) The right to parent children in safe and healthy environments free from violence perpetrated by the state, corporate entities, or individuals
(4) Systemic inequality—past and present racism, sexism, classism/poverty‐‐‐exert influence on a person’s or a group’s exercising these rights
(5) Safe fertility control, childbirth, and parenting are impossible without human rights protections (Civil; Political; Economic; Social; Cultural; Environmental; Developmental; Sexual)
LARC First: “Celebration Meets Caution” (Higgins, 2014)
Higgins, J.A. (2014). Celebration meets caution: LARC's boons, potential busts, and the benefits of a reproductive justice approach. Contraception, 89 (4), 237 – 241.
• LARC alone can’t address relational, social, and cultural factors that undermine contraceptive use.
• What role can it play?
• Unfair to place burden of social change on women and contraceptive behaviors. • What is the role of individual responsibility?
• Efficacy is not only consideration. • How important a consideration should it be?
• Role of providers is unbiased, individualized counseling. • Do we have a role in reducing public expenditures? Ensuring all people use most effective
methods?
https://www.your‐life.com/en/contraception‐methods/which‐contraception‐is‐right‐for‐me/
Choosing BC: Individualized Counseling
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LARCS: Coming soon….?
Veracept Levocept
FDA: Accepted for Review Phase III Clinical Trials US
Intrauterine Ball3 sizes5 yrs
Contraceptive ChipLevonorgestrelRemote Controlled16 yrs LARC for Men!
Testosterone1 yr
Nestorone/Ethinyl Estradiol Vaginal Ring13 cycles (in 21 days, out 7)