A: LARC methods include IUDs, which are small, T-shaped plastic devices that are inserted into the uterus through the cervix; and the contraceptive implant, which is a small rod that is inserted under the skin of a woman’s upper arm and releases progestin into the body. Both types of devices are typically inserted by trained providers in an outpatient setting.
There are two forms of IUDs. One of these is the hormonal IUD, which releases progestin. Different brands are approved for use for up to 3 or 5 years. The other form of IUD is the copper IUD, which doesn’t contain hormones and is approved for use for up to 10 years. The contraceptive implant is designed to protect against pregnancy for 3 years. A woman may choose to discontinue any of these methods earlier if she desires pregnancy or prefers another method.
These are currently the most effective forms of reversible birth control available; the pregnancy rate with the implant is 0.05%, which is slightly lower than with the levonorgestrel IUD (0.2%) and the copper IUD (0.6%).
According to the American College of Obstetricians and Gynecologists, over the long term, LARC methods are 20 times more effective than birth control pills, the contraceptive patch, or the ring. Despite this effectiveness, the birth control pill continues to be the most popular form of contraception among women in the United States.
Q: Which patients can be considered for LARC?
A: All women are eligible for at least one form of LARC, if not all forms. For example, IUDs and the contraceptive implant are currently
approved for nulliparous women, parous women, adolescents, and breastfeeding mothers. Even women with medical conditions such as diabetes, hypertension, breast cancer, dysfunctional uterine bleeding, and many other conditions are eligible for LARC. For example, women with breast cancer or significant liver disease should avoid progestin-containing contraception, including a progestin IUD or implant, but they are eligible for a copper IUD, which lacks hormones. A handy reference tool available as a phone app was updated this year by the Centers for Disease Control and Prevention (CDC). It’s called “United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016” and it guides clinicians to determine which contraception women with many different medical conditions are eligible for.
IUDs and the contraceptive implant may be initiated after a woman has given birth (vaginally or via cesarean) and if she breastfeeds—as early as while she is still in the hospital after childbirth. These methods do not interfere with breastfeeding performance or cause problems to the newborn. Providers are encouraged to discuss LARC during prenatal care so that women have opportunities to consider these methods and possibly initiate them while still in the hospital.
Women who ended their pregnancies may also initiate LARC immediately after an abortion.
Healthcare providers should consider discussing contraception with their patients during a variety of encounters, including annual visits or problem-focused visits—not just in cases when a patient brings up contraception on her own.
Q: What safety concerns related to LARCs should physicians be aware of?
A: The most serious, but rare (1 in 1000), complication related to the IUD is uterine perforation, which may occur at the time of insertion. It may cause problems with abdominal organs and should be removed via laparoscopy. An ultrasound may facilitate a difficult insertion and decrease the chance of perforation. Another concern is expulsion, which occurs in 2%-10% of cases and is more likely to occur during the first year of use. It does not cause bodily harm but leaves a woman without protection against pregnancy.
While not a safety concern, a relatively common side effect of all LARCs is a change in a woman’s menstrual bleeding profile. Women should be prepared for these changes and know when to follow up for management of undesirable side effects or possible gynecologic problems. Spotting, light bleeding, as well as heavier or longer menstrual bleeding are common during the first 3-6 months of copper IUD use and usually decrease over time. Women using the hormonal IUD may also experience these changes initially. Amenorrhea and lighter, shorter menses are also common with the hormonal IUD, particularly after 6 months of use, which may be a desired side effect for some women but unacceptable for others. The contraceptive implant may also change bleeding patterns, but in contrast to both IUDs, the changes do not always go away after 6 months of use. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be administered to treat undesirable side effects. In all cases, women who have very heavy bleeding should be evaluated for underlying gynecologic problems.
Q: What sort of screening tests or exams should a woman undergo prior to LARC initiation?
A: A woman may initiate any contraceptive method, including LARC methods, at any time during her menstrual cycle, as long as the clinician can be reasonably certain that she is not pregnant, which is done by obtaining a pregnancy test and using a checklist such as the one provided by the CDC. For IUDs, women at risk for sexually transmitted infections (women under 25 years of age or older women with new or multiple sex partners) should be screened for chlamydia and gonorrhea at time of insertion. If clinical suspicion for an infection is low based on the woman’s history, and there is no evidence of cervicitis on pelvic exam, a woman may receive an IUD that same day. If results come back positive for chlamydia or gonorrhea, the IUD may stay in and the woman should be treated. However, IUD insertion should be delayed in women with pelvic inflammatory disease or purulent cervicitis until they complete treatment. There is no specific screening test or exam necessary before initiating a contraceptive implant.
Q: The ACA provides access to reproductive services without the requirement for a copay. What steps are necessary in order to provide a LARC and meet requirements under the ACA?
A: The ACA requires most private insurance plans to cover at least one type of all of the FDA-approved contraceptive methods for women. Some insurance companies, however, require women to receive preauthorization before receiving a LARC method with no out-of-pocket costs.[Office managers may set up protocols to obtain preauthorization for women who schedule appointments for initiating LARC methods before their visit so that they can receive an IUD or a contraceptive implant when they come in.
Similarly, women who qualified for Medicaid under the ACA’s expansion of the program are eligible to receive an IUD or the birth control implant at no cost. However, for women who were enrolled in a traditional Medicaid program prior to the introduction of the ACA, coverage is determined by their state.
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