LARC methods 04/12/17 Background Choice Which larc and why? Scenarios Common problems.

Why larcs? Marie Stopes data 48% pregnancies are unplanned. Average age first intercourse? 15 yrs Average age first pregnancy? 30 years 37% who attend TOP had one previously 40% who start cocp will have stopped in first 6 months

Abortions in 2015 Total number England and Wales in 2015 185,824; driven by over 30’s 91% carried out <13 weeks 51% medical abortions (17% 2003) 98% of these are funded by the NHS

LARC methods; all more cost effective than oral methods at 1 year Implant, injectables, IUD. LARC methods; all more cost effective than oral methods at 1 year MOST cost effective; implant, IUD.

Larc’s; all suitable for Nulliparous Breast feeding women Following abortion BMI>30 Diabetics Migraine Contraindication to oestrogens.

Which LARC? Tailor information to specific needs of the woman Offer choice all methods; written and verbal…..leaflets Includes; mode action, failure rate, side effects, risks, benefits. Dispel misconceptions ; show devices

Sayana Press, subcutaneous depo

Sayana Press 104 mg MPA for subcut injection. Bioequivalent to depo-provera. Injected every 13 weeks +/- 7d May be preferable for patients prone to haematoma ( eg bleeding disorders, anticoagulation) Licensed for self administration!!

Copper IUD’s

Implant; Nexplanon

Implant; what is it? 40mmx2mm subdermal rod releasing etonogestrel over 3 yrs. Unmatched failure rate Needs removal/replacement. Training required Nexplanon is radio-opaque

Etonogestrel serum levels.

Effects of weight on serum levels

How to facilitate choice? Some cases……

Case one 30 yrs, 6 week postnatal check, 2nd child. Breast feeding Not keen on hormones due to s/e on pill Tends to have heavy menses What other information do you and she need in order to make her choice? Discuss how and when you would do this.

Case one Plans for further children Sexually active since delivery? Using condom? Previous contraceptive methods Attitudes, preconceptions,preferences Discuss larc methods, consider leaflet, show devices If undecided arrange another appt.

Counselling; verbal and written Mode of action, duration Failure rate Risks, side effects Effects on bleeding Return of natural fertility Insertion procedure, timing in cycle …..documentation, consent

Counselling;how does it work? IUD: prevents fertilisation (primarily) and implantation. It is therefore not abortifacient. IUS: prevents implantation and possibly fertilisation. >75% continue to ovulate. Implant and depo; prevent ovulation

Counselling; Duration of use. IUD; mostly 10 yrs ( 380mm copper, banded arms) Gold standard T-Safe Cu380 IUS; 5 yrs ( or longer if fitted in 45+; unlicensed) Jaydess; 3 years DMPA; 12 weeks ( really 14 weeks) Implant; 3 yrs

Counselling; failure rate IUD; 14/1000 over 7 yrs IUS; 11/1000 over 7 yrs Depo <4/1000 over 2 yrs Implant; 0.5 per 1000 Comparable to sterilisation Filshie clip 2-3/1000 Vasectomy 0.5/1000(UK RCOG)

Side effects and risks; IUD/IUS IUD; heavy painful periods IUS and IUD;expulsion 1in 20 Perforation; 2 in 1000; 6 x higher if breast feeding (PID;<1% low risk women)Maximal in 20 days after fitting; screen at risk. COUNSEL AND DOCUMENT

IUD insertion Pain of the procedure Vasovagal reactions Adequate resuscitation policy/equipment Pain after the procedure Bleeding?

IUD should be offered first line to young nulliparous women alongside other methods. Leeds student medical practice 2013

PID risk? Neither IUD or IUS intrinsically increase PID risk. It is crucial to insert through a cervix which is established to be pathogen free. Test for chlamydia (and gonorrhoea where prevalent) before fitting SEXUAL HISTORY TAKING

Case two 25 yrs single mum New partner, needs contraception BMI 35, trying++ to lose weight Previous ectopic Which larc methods would be suitable for her and what information does she need in order to make a decision?

What about ectopic pregnancy? This is much less common than in a woman not using any contraception. If pregnancy does occur with IUD in situ it is important to exclude ectopic urgently with USS. A previous ectopic is not a contraindication to IUD use.

Side effects and risks; depo Altered bleeding patterns Weight gain Concerns about effects on bone density ( adolescents and over 45) Delay in return fertility; up to 12m

Depo; monitoring Age 45,been on depo 20 yrs Amenorrhoea No current partner Overweight smoker Is any special advice required in this situation or can she just continue to come and see the practice nurse for her 12 weekly injection?

Depo and bone density Use of depo contraception is associated with a small loss of BMD which is usually recovered after discontinuation of the method There is no evidence that is increases fracture risk

Depo and bone density, FSRH Women should be reviewed every 2 years to assess the benefits and potential risks of continuation of the method and supported in their choice of whether to continue. Use may continue up to age 50.

Implant; side effects;bleeding Bleeding; counsel with care, document. Commonest reason for removal 20% amenorrhoea 25% regular bleeds 25% prolonged/frequent bleeds 30% infrequent bleeds

Implant; side effects There is no evidence for effects on weight, libido, headaches or mood; but some women will complain of these. Some women report worsening acne but in others it may improve. Try to encourage continuation if possible

Counselling; timing of method IUD and IUS; usually in first week of cycle Implant; day 1-5 of cycle. Depo; day 1-5 of cycle

Exception; timing of method If a health professional is reasonably sure that a woman is not pregnant or at risk of pregnancy from recent unprotected sexual intercourse (UPSI), contraception can be started immediately unless the woman prefers to wait until her next period. Such practice may be outside the product licence/device instructions.

Follow up? Implant; none required IUD/IUS; follow up if any problems Depo; every 12 weeks.

Case three 35 yrs, smoker, epileptic on carbamazepine Taking high dose cocp Bled++ on cerazette What other options does she have and how would you help her make a decision?

Women on medication Drugs which induce liver enzymes can reduce the efficacy of the contraceptive implant but do not appear to reduce the efficacy of depo contraception or the LNG-IUS

Special considerations Management of bleeding problems Late depo (Women over 40)

Bleeding problems Erratic bleeding common in early weeks with all larc’s. Amenorrhoea at 12 months; 70% with depo 65% with Mirena 20% with implant

Case four age16, implant 6 months No bleeding 4 months; now bleeding all the time What do you need to ask her and how would you manage this problem?

Bleeding problems Always consider underlying cause if there has been an obvious change in bleeding pattern. Need to consider disease; eg chlamydia....gynae exam, swabs. Consider pregnancy, exclude other gynae pathology.

Red flags Development of a change in bleeding pattern following a consistent spell Cervical screening defaulter Pelvic pain, change in vaginal discharge Dyspareunia Failed trial of medical management

Bleeding problems; implant Common; counselling important; commonest cause discontinuation Consider trial 20-30 dose COC for 3 cycles; After; she may (or may not!) obtain acceptable pattern

Bleeding problems; depo Consider giving next injection early, at 10 weeks. May use NSAID, eg naproxen

Case five Age 18, gap year travelling in 6m time Focal migraine Bleeding++ on cerazette Any better options? What do you discuss with her and advise?

Late depo 24 yr old , 13w since last depo Had sex twice in last week. Is she at risk of pregnancy? Can she have her injection? What would you do in same scenario if it was 15 weeks since her last injection?

Late depo. Can be given up to 2 weeks late ( ie 14 weeks) without need for additional contraception or pregnancy testing. Outside product licence After 14 weeks management depends on whether UPSI has occured and how many days after.( suggest check faculty guidance)Need to assess need for emergency contraception if required.

IUS; other uses Licensed for treatment of menorrhagia. Licensed for progesterone component of HRT( licence for 4 yrs but FSRH guidance suggests adequate protection for 5 yrs)