• Nathan Riley, MD

Obgyno Wino Podcast Episode 96 - Long-Acting Reversible Contraception: Implants & IUDs

"No reniego de mi naturaleza,

no reniego de mis elecciones,

de todos modos he sido una afortunada.

Muchas veces en el dolor se encuentran

los placeres más profundos,

las verdades más complejas,

la felicidad mas certera.

Tan absurdo y fugaz es nuestro

paso por el mundo,

que solo me deja tranquila

el saber que he sido auténtica,

que he logrado ser

lo mas parecido a mi misma

que he podido.”

- Frida Kahlo

2017 Chianti from Cecchi Winery

PB #186, Published November 2017 (Reaffirmed 2019)

Five Pearls

1. Increased LARC use has contributed in part to the decrease in unwanted pregnancies in the U.S. With less unintended pregnancy, there's less demand for abortion.

2. LARCs are safe, effective at preventing pregnancy, and patients love them.

3. The most common reason that LNG-IUD users have the device removed is intermenstrual bleeding, heavier and crampier periods for the copper IUD, and irregular, unpredictable bleeding for the subdermal implant.

4. Copper IUD can be used for emergency contraception but not the other LARCs.

5. LNG-IUD can be helpful for decreasing overall bleeding volume, and 20% of patients report amenorrhea within the first 12 months of use.

Long-acting reversible contraception (LARC) basics

- IUDs and implants under the skin (e.g. Nexplanon) are the two types

- IUDs are made of copper or plastic

- plastic IUDs and subdermal implants secrete progestin (synthetic progesterone) over varying periods of time depending on the brand

- LARCs have been all the rage over the past decade

- in 2012, 12% of women on contraception were using a LARC method (10:1 IUD-to-implant)

- increased LARC use has contributed in part to the decrease in unwanted pregnancies in the U.S.

- with less unintended pregnancy, there's less demand for abortion

- almost no contraindications to LARCs per the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC)

Findings from the CHOICE study

- >9000 women aged 14-45 yrs were offered their choice of any contraception free of charge (with counseling around pros/cons of each)

- 75% chose a LARC (46% chose a progestin-releasing IUD, 12% chose copper IUD, and 17% chose implant)

- continuation rates in Table 1 (much better overall for LARC methods)

- similar initiatives have corroborated the CHOICE findings (e.g. Colorado Family Planning Initiative)

- a cost-effectiveness analysis found that, from the public payer perspective, LARC use becomes cost neutral within 3 years of initiation

This lady has two copper IUDs. One is sufficient.

Copper IUD - Paragard T380A

- made of copper, FDA approved for 10 years (though there are data suggesting efficacy for at least 12 years)

- works by impairing fertilization through inhibition of sperm migration and viability

- similar failure rate to sterilization procedures (2 of 100 women during 10 years of use)

- most common "adverse" effect: heavier menstrual bleeding and cramping

- 06.-0.8% risk of unintended pregnancy over first year of use (compare this with 9% risk through typical use of COC)

- not approved as abortifactant (though it's still a powerful form of emergency contraception, w/ 0.23% pregnancy rate)

- can be placed within 5 days after unprotected intercourse to prevent undesired pregnancy

- women with obesity have higher failure rates with levonorgestrel or ulipristal emergency contraception, so a copper IUD may be a better option for them, as its highly effective regardless of patient's weight

Note: placing a copper IUD as emergency contraception is the gift that keeps on giving, as it stays in place and prevents pregnancy for 10+ years after placement!

Levonorgestrel-releasing IUDs

- work by increasing volume and viscosity of cervical mucous, making it impenetrable to sperm

- not approved as abortifactants

- adverse effects: headaches, nausea, breast tenderness, mood changes, and ovarian cyst formation (acne rare)

- no effect on bone mineral density or fracture risk

- insufficient systemic absorption of steroid to inhibit ovulation for most women

- decreased menstruation common due to progesterone's stabilizing effect on endometrium

- no difference in weight gain between LNG-IUD and copper IUD (per CHOICE)

- LNG-IUDs are not recommended for use as emergency contraception

Note: All IUDs have 2-10% expulsion rate during first year. LNG-IUD carries 0.14% risk of uterine perforation during placement. Copper IUD carries 0.11% risk of uterine perforation during placement.

LNG-20 (Mirena)

- contains 52 mg levonorgestrel, releases 20 mcg/day

- 0.2% risk of unintended pregnancy over first year of use (same for Liletta)

- FDA approved for 5 years, though studies have found that it's still effective for up to 7 years (pregnancy rate of 0.4-0.5 per 100 women-years) (link 1, link 2)

LNG-18.6 (Liletta)

- contains 52 mg levonorgestrel, releases 18.6 mcg/day

- DA approved for 4 years

- similarly to the LNG-20, extended use (up to 5 years) has not been found less efficacious in preventing pregnancy

LNG-19.5 (Kyleena)

- contains 19.5 mg levonorgestrel, releases 17.5 mcg/day

- approved for 5 years

- pregnancy rate 0.31 per 100 women-years of use

LNG-13.5 (Skyla)

- contains 13.5 mg levonorgestrel, releases 14 mcg/day

- approved for 3 years

- pregnancy rate 0.33 per 100 women-years of use

- slightly smaller than the other IUDs

The Subdermal Implant

- plastic coating around a 68 mg etonogestrel core

- device is 4 cm long, 2 mm thick, radio-opaque (visible on x-ray)

- placed subdermally under local anesthetic

- works by inhibiting ovulation, thickening cervical mucous, and altering endometrium

- most effective means of reversible contraception (0.05% risk of unintended pregnancy)

- equally effective in women with any BMI

- adverse effects include: irregular bleeding patterns, GI issues, headaches, breast pain, or vaginitis

- no difference in weight gain between the implant and copper IUD (per CHOICE)

- 10-15% report acne, but very few discontinue for this reason

- little to no effect on bone mineral density or fracture risk

- risks related to placement include pain, light bleeding, hematoma, or malpositioned placement (composite risk <2%)

- fertility returns rapidly after removal

- FDA approved for 3 years, but likely effective for up to 5 years

What's the best time to insert an IUD or implant?

- any time in the cycle works

- no backup contraception required after placement of copper IUD

- backup contraception (e.g. condoms) recommended for 7 days after placement of any LNG-IUD or implant UNLESS placed:

  • immediately after surgical abortion

  • within 21 days of childbirth

  • upon transition from another reliable contraceptive method

  • within 7 days of starting menstruation (5 days for implant)

Post-abortion IUD placement considerations

- IUD can be placed immediately after non-septic, 1st or 2nd abortion (medication or otherwise)

- if IUD placed immediately after 1st trimester abortion (medical or surgical), 4-5% risk of expulsion

- placement of IUD after 2nd trimester abortion carries slightly higher risk of expulsion than 1st trimester but no reported differences in pain

- best to place it immediately, as you don't require a second visit for "interval" IUD placement; insignificant difference in expulsion rates

- IUD placement is contraindicated immediately after septic abortion

Note: interval placement refers to having a LARC placed any time apart from immeidately post-abortion or postpartum

Post-abortion implant placement considerations

- totally cool to place it on the same day as surgical abortion or upon completion of medication abortion

- you could even place the implant on the first day of mifepristone administration! (recall that mifepristone is administered 24-48 hrs prior to misoprostol administration)

- placement on day of mifepristone administration carries insignificant risk of abortion failure and patients report high satisfaction w/ this method

Postpartum IUD/implant placement considerations

- ovulation can resume shortly after birth, and up to 60% of women don't wait until that routine 6-week postpartum visit to have intercourse

- ACOG is fully in support of placing LARCs before discharge from the hospital after birth as its hugely helpful in preventing unintended pregnancy and short inter-pregnancy interval

- IUDs can be placed immediately after placenta is expelled in vaginal or cesarean birth (cat 2 if placed up to 4 weeks postpartum, cat 1 if placed >4 weeks postpartum)

- IUD expulsions rates are slightly higher (10-30%) than interval or postabortion placement (risks versus benefits, amiright? what if they don't show up for their follow-up appointment for interval placement?)

- delaying placement also carries a higher relative risk of uterine perforation (still <1% absolute risk)

- IUD contraindicated immediately postpartum if: chorio/endometritis or ongoing/active postpartum hemorrhage (fuckin' duh)

- no real contraindications for the implant

Note on breastfeeding: US MEC considers LARCs cat 2 if placed within 30 days of giving birth if patient is breastfeeding. Progestin-only contraceptive methods don't seem to adversely effect milk production or let-down. So this cat 2 business is a little misguided, in my opinion...counseling should include this theoretical risk of disrupting breastfeeding.

Do I have to screen for sexually transmitted infections (STI) prior to IUD placement?

- ok to collect at time of placement

- don't delay placement!

- simply treat if results are positive for infection

- if you fail to recognize an active chlamydial and gonorrheal infection at time of placement and the STI goes untreated, then the presence of an IUD is associated with a higher risk of pelvic inflammatory disease (PID), though absolute risk remains <0.5%

- prophylactic antibiotics aren't required and don't reduce risk of PID

- if the patient has an active known STI or if mucopurulence is present on speculum exam, it is recommended that she be treated first prior to IUD placement (wait until infection is clear: treatment complete, no mucopus, no tenderness on bimanual exam)

- CDC recommends testing for cure 3 months after completing treatment

The most common complaints from LARC users revolve around abnormal vaginal bleeding

- copper IUD users most commonly discontinue use due to heavy menstrual bleeding and dysmenorrhea (9.7% discontinue for this reason, compared to 1.3% for LNG-IUD users)

- LNG-IUD users most commonly discontinue use due to amenorrhea and intermenstrual spotting (4.3% discontinue for this reason, compared to 0% for copper IUD users)

- LNG-IUDs release levonorgestrel, which concentrates in the endometrium, thinning and decidualizing it

- this makes it resistant to the effects of estrogen (this is how it protects against hyperplasia/malignancy)

- most women continue to ovulate while using LNG-IUD

- irregular spotting usually lasts 90 days after placement

- less likely to experience amenorrhea with lower dose IUDs but more intermenstrual bleeding

- the implant improves dysmenorrhea, but unpredictable bleeding patterns are the most common reason for discontinuation

What's the best way to manage the irregular bleeding that comes with LARCs?

- NSAIDs (e.g. Naproxen) work for bleeding and cramping associated with the copper IUD

- they also work for LNG-IUD-associated bleeding (and implants!)

- tranexamic acid doesn't work for LNG-IUD-associated bleeding

- transdermal estrogen makes the bleeding worse

Don't forget: many women choose LNG-IUDs to manage their heavy menstrual bleeding. With an LNG-IUD, she can expect 80-97% reduction in menstrual flow. This makes them way more effective than COCs for this indication. 20% of women using an LNG-IUD experience amenorrhea within first year of placement.

Do I have to remove on IUD for any procedures?

- any procedure inside the uterine cavity should be done after removal of the IUD (apart from endometrial sampling)

- colposcopy, cervical ablation and excisional procedures, and endocervical sampling can all be done with the IUD in place

What happens if IUD is in place and actinomyces is reported on PAP?

- generally an incidental finding

- no treatment needed and IUD can stay in place if patient is asymptomatic

- considering removing IUD and treating with oral antibiotics if patient is symptomatic

What if my patient gets pregnant with an IUD in place?

- first off, make sure the pregnancy is in the uterus (higher risk of ectopic pregnancy when an IUD is in place)

- if pregnancy is viable, risk of removal of IUD (miscarriage) must be weighed against the risk of adverse effects to the pregnancy by keeping it in place

- if kept in place, increased risk of SAB, septic abortion, chorio, and preterm delivery

- with copper IUD, there's also an increased risk for placental abruption, placenta previa, c-section, and fetal growth restriction

- removal of the IUD lowers the risks but not to baseline

- unclear if exposure to levonorgestrel from retained LNG-IUD poses any harm to fetus

IUDs and implants don't cause ectopic pregnancies

- as mentioned, if pregnancy happens with an IUD in the uterus, there's a higher chance of that pregnancy being ectopic

- implants and IUDs are cat 1 per US MEC even with history of ectopic

When can a menopausal women remove their IUD?

- since LNG-IUD is associated with amenorrhea for many women, best to wait until 50-55 years (average age of menopause in the U.S. is ~51)

- copper IUD can be removed after amenorrhea for at least 12 mos

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