Long-acting reversible contraception (LARC) methods are 20% more effective than traditional contraceptives and are recommended by the American Academy of Pediatrics and American College of Obstetrics and Gynecology as first-line contraception for adolescent girls. Large studies show that LARC use reduces unintended pregnancies, increases user satisfaction, and prolongs duration of use. This article prepares the primary care provider (PCP) with knowledge on safety, efficacy, eligibility, confidentiality, anticipatory guidance, how to find a LARC provider, and guidance on common side effects so the PCP can confidently counsel adolescent patients on LARC methods.
Key points
- •
Long-acting reversible contraception (LARC) methods are now recommended as the first line of contraception for nulliparous adolescents by the American Academy of Pediatrics and American College of Obstetrics and Gynecology.
- •
Hormonal LARC methods work by blocking ovulation, thickening cervical mucus, and changing the lining of the uterus. Nonhormonal methods work by altering the environment in the endometrium and inhibiting the motility of sperm.
- •
LARC methods are the most effective contraceptive methods after abstinence.
- •
Even if primary care providers are not trained to insert LARCs, they can advise and counsel their patients about LARC methods if they have knowledge about the methods.
Introduction
Long-acting reversible contraception (LARC) methods are 20% more effective than traditional combined hormonal contraceptives (CHCs) and are recommended by the American Academy of Pediatrics and American College of Obstetrics and Gynecology as the first-line contraceptive choice for adolescent girls. Large studies have shown that LARC use reduces unintended pregnancies, increases user satisfaction, and prolongs duration of use for contraception. Primary care providers (PCPs) are on the front line in providing access to contraception for adolescents; however, contraceptive options have changed dramatically in the past decade and PCPs may find contraceptive counseling challenging. This article prepares the PCP with knowledge on safety, efficacy, eligibility, confidentiality, anticipatory guidance, how to find a LARC provider, and troubleshooting common side effects. With this information, the PCP will find contraceptive counseling concerning LARC both satisfying and effective.
Introduction
Long-acting reversible contraception (LARC) methods are 20% more effective than traditional combined hormonal contraceptives (CHCs) and are recommended by the American Academy of Pediatrics and American College of Obstetrics and Gynecology as the first-line contraceptive choice for adolescent girls. Large studies have shown that LARC use reduces unintended pregnancies, increases user satisfaction, and prolongs duration of use for contraception. Primary care providers (PCPs) are on the front line in providing access to contraception for adolescents; however, contraceptive options have changed dramatically in the past decade and PCPs may find contraceptive counseling challenging. This article prepares the PCP with knowledge on safety, efficacy, eligibility, confidentiality, anticipatory guidance, how to find a LARC provider, and troubleshooting common side effects. With this information, the PCP will find contraceptive counseling concerning LARC both satisfying and effective.
Discussion
Why Contraception for Adolescents?
Teen birth rates in the United States have been declining steadily in the past 25 years and the teen birth rate for 2015 (22 births/1000 girls 15–19 years) is the lowest level recorded in recent history ; however, even the low rate for 2015 is much higher than the rates observed in other developed countries. The consequences of teen pregnancy are widespread, including health risks to the mother and child, socioeconomic impact, and public financial burden (see Heidi K. Leftwich and Marcus Vinicius Ortega Alves’ article, “ Adolescent Pregnancy ,” in this issue).
When a young woman has access to contraception, she can safely delay pregnancy so as to finish her education, pursue a career, and then become a mother when she is better prepared. Adolescents who do not use contraception at their first sexual encounter are twice as likely to become teenage mothers as those who did use a method of contraception. Effective contraceptive counseling with a focus on LARC, access to all contraceptive methods, and an understanding of the right to access confidential contraception are paramount to reducing the number of unintended pregnancies in the adolescent population. Table 1 briefly outlines available contraceptive methods.
The Contraceptive CHOICE project in St Louis provided more than 9000 women free education and access to all contraceptive options, including intrauterine devices (IUDs), subdermal implant, injection, pill, patch, and vaginal ring. When LARC methods were offered alongside traditional methods, 75% of women selected LARC. LARC use resulted in a significant reduction in unintended pregnancies, reduced abortion rates, increased user satisfaction with their contraceptive method, and longer duration of use over non-LARC methods. Despite these results, fewer than 5% of teens on birth control are using LARC methods. Adolescents are still significantly more likely to be using less-effective methods, such as condoms (21%) and the pill (47%) for contraception. To decrease unintended pregnancies, LARC methods should be offered first to sexually active adolescents if there is no contraindication.
Long-Acting Reversible Contraception Methods: How They Work
As seen in Table 2 , the primary subdermal implant available in the United States today is marketed by Merck as Nexplanon and has been available since 2011. Before 2011, the implant had been available as Implanon and Norplant. The current implant contains etonogestrel and provides contraception for 3 years. Nexplanon was updated from Implanon to include barium sulfate, making it detectable on radiographs and the applicator was improved for safer and easier insertion. Fig. 1 shows the Nexplanon implant.
| Brand Name | Duration | Efficacy | Expected Bleeding Pattern |
|---|---|---|---|
| Nexplanon | 3 y; can be removed and replaced at 3 y | 0.05% failure rate | Variable, ranges from none to light spotting. Some users experience prolonged bleeding. |
The contraceptive effect is achieved without the use of estrogen. The implant continually releases etonogestrel, a synthetic progestin, which prevents fertilization from occurring by blocking ovulation, thickening cervical mucus, and changing the lining of the uterus. The implant is immediately reversible on removal. Blood levels of etonogestrel were undetectable 7 days after removal and pregnancy has been reported as soon as 7 to 14 days from removal.
Mirena, Skyla, Liletta, Kyleena, and Paraguard are the IUDs currently on the market for contraception. They are briefly compared in Table 3 . The important difference to note among the 5 options is that the Paraguard copper IUD contains no hormones and contraception is achieved by copper changing the endometrium and inhibiting motility of sperm. Mirena, Skyla, Liletta, and Kyleena release levonorgestrel, which prevents pregnancy by preventing ovulation, thickening cervical mucus, promoting changes in the endometrium, and inhibiting motility of sperm.
| IUD Brand Name | Duration, y | Efficacy, % Failure Rate | Expected Bleeding Pattern |
|---|---|---|---|
| Mirena | 5 | 0.2 | None to light |
| Skyla | 3 | 0.9 | None to light |
| Liletta | 3 | 0.2 | None to light |
| Paraguard | 10 | 0.8 | Variable to heavy |
| Kyleena | 5 | <0.5 | None to light |
Mirena, Skyla, Liletta, and Kyleena lead to a reduction in menstrual flow over time. Mirena is also approved for treatment of dysmenorrhea. Menstrual bleeding is invariably heavier and longer in duration with Paraguard than with the levonorgestrel options; therefore, in most adolescent medicine settings, this is not a widely recommended option. However, Paraguard is the only IUD approved for emergency contraception and is 99.9% effective at preventing pregnancy if inserted within 5 days of unprotected intercourse. Kyleena was approved for clinical use by the Food and Drug Administration in October 2016; therefore, additional data concerning its use among adolescent patients are still being gathered.
Why Long-Acting Reversible Contraception
Long-acting reversible contraception methods are the most effective contraceptive methods besides abstinence
In 2009, Colorado implemented full and free access to LARC methods for young women in the state’s family planning clinics. Analysis of the outcomes of this program revealed that LARC use in young women aged 15 to 24 quadrupled, the fertility rate dropped 26% in 15-year-olds to 19-year-olds, the high-risk birth rate was greatly reduced, and abortions decreased by 34% in 15-year-olds to 19-year-olds. The success of this program highlights the real-world efficacy of LARC methods.
The implant and the IUD are not user dependent and do not require maintenance, such as refills, timing, replacing, or dosing, thus making them highly effective contraceptive methods that are ideal for adolescents. The implant has a failure rate of fewer than 1 pregnancy per 100 women in a year. IUDs are similarly effective to the implant with fewer than 1 pregnancy per 100 women in a year. Typical use of LARC is at least as effective as many female sterilization methods, yet it is immediately reversible. LARC methods are 20 times more effective than CHCs, which have a rate of 9% unintended pregnancies per year. See Fig. 2 for side-by-side comparison of unintended pregnancy rates by method.
Full access? Get Clinical Tree
