A Clinician’s Guide to LARC Annie Skorupa, MSN, APRN-FNP Family Nurse Practitioner Community Health Connection- Tulsa

LARC: What is it? LARC = long-acting reversible contraception Contraception that works for an extended period of time without user action Can be removed at any time if the user desires pregnancy without delayed return to fertility

Intrauterine Devices (IUDs) Can be inserted at any time during the menstrual cycle Last between 3-10 years depending on the device Skyla- 3 years Liletta- 4 years (hopefully 7 soon) Mirena, Kyleena- 5 years Paragard- 10 years Skyla and Liletta have smaller insertion device, making it optimal for women who have never had a child (nulliparous) Immediate return to fertility after removal

Intrauterine Devices (IUDs)- How Do They Work? Paragard is hormone-free, works by using copper Prevents fertilization of the egg by the sperm Creates a “hostile environment” for sperm, making it more difficult to survive All others contain a low-dose of progesterone-derivatives (estrogen- free) Thickens cervical mucus, making it more difficult for sperm to travel to the egg Thins the uterine lining, making it more difficult for fertilized egg to implant Ovulation is not affected

Intrauterine Devices (IUDs)- Who Can Have Them? Basically, everyone! With a few exceptions: Chronic pelvic infections History of ectopic pregnancy Active breast cancer (hormonal IUDs) Distorted or small uterine cavity Can be placed immediately post-partum (within 10 minutes of delivery of placenta) Can be placed in nulliparous women (women who have never been pregnant or had a baby before) CDC Medical Eligibility Criteria (MEC)

Intrauterine Devices (IUDs)

Intrauterine Devices (IUDs)- How Are They Inserted? Woman placed in lithotomy position Cervix cleansed Tenaculum placed Depth of uterine cavity measured with a device called a “sound” IUD placed using placement device (different for each one) Insertion device removed, IUD stays behind Strings cut (can be trimmed at follow up appointment) Home care reviewed- pelvic rest x7 days Return in 1 month for string check

Intrauterine Devices (IUDs)- What Can Go Wrong? Risks of insertion: Pain Infection Uterine perforation Potential side effects: Paragard- heavier bleeding, increased cramping Skyla, Kyleena, Liletta, Mirena- changes to bleeding patterns What can we do? Add BC pills for 2-3 months, ibuprofen (or other NSAID) for 1-2 weeks, tamoxifen

Chance of amennorhea (periods stopping) Bleeding Profile Mirena (52mg) -5 years Liletta (52mg) -4 years Kyleena (19.5mg) -5 years Skyla (13.5mg) -3 years Chance of amennorhea (periods stopping) -periods most likely to stop with Mirena/Liletta. Least likely to stop with Skyla

The Implant (Nexplanon) Another LARC method Small, flexible rod that is inserted into the upper arm Lasts for 3 years

The Implant (Nexplanon)

The Implant (Nexplanon)- How Does It Work? Progestin-derivative. Does not contain estrogen. Stops ovulation- egg is not released Thickens cervical mucus Thins the lining of the uterus

The Implant (Nexplanon)- Who Can Have It? Basically, everyone! With a few exceptions: Known pregnancy Can be placed immediately post-partum Can be placed in nulliparous women CDC Medical Eligibility Criteria (MEC) No pelvic exam needed prior to placement

The Implant (Nexplanon)- How Is It Placed? Area anesthetized with lidocaine Cleanse with iodine. Device used to place device under the surface of the skin Implant deployed, device (needle) removed Dressing applied Home care reviewed: Back up method of contraception for the first 7 days Keep outer dressing on and clean/dry for 24 hours Do not soak until insertion site completely closed Call if any signs of infection

The Implant (Nexplanon)- What Can Go Wrong? Risks of insertion: Pain Infection Bleeding Nerve or blood vessel injury Improper placement Side effects: Changes to bleeding patterns Weight gain, headaches, depression What can we do? Estrogen add-back with oral contraceptives Early removal

What Other Options Do We Have? Depo-Provera injection Progestin only Prevents ovulation, thickens cervical mucus Pills Progestin-estrogen, progestin-only More contraindications Patch Progestin-estrogen Works by preventing ovulation, thickening cervical mucus Ring Non-hormonal methods

“The best birth control is the one the patient will use.”

Is She Pregnant? Does it matter for LARC? CDC Criteria to rule out pregnancy: Currently menstruation No intercourse since the beginning of her last period Has been consistently and reliably using contraception Is <7 days from spontaneous or induced abortion Is exclusively breastfeeding Same-day quick start at Community Health Connection All methods can be started the same day, with exception of IUDs

Which Birth Control?

Medical Eligibility Criteria

Why LARC? Highly effective Easy to use Nexplanon the most effective form of birth control on the market- more effective than tubal ligation Easy to use Does not depend on the user Relatively easy to access in Tulsa Desirable side effects for some (amenorrhea, etc)

Emergency Contraception (EC) Can be used up to 5 days after unprotected intercourse Ineffective after implantation- not likely to prevent implantation Mechanism of action depends on many factors Plan B Most effective in women less than 160 pounds Available over-the-counter Ella Can be used in women over 160 pounds Need to wait 5 days to start contraception after using Paragard Also provides contraception for 10 years after

Teen Clinic @ Community Health Connection Tuesday afternoons 1:30-6:00pm at 21st & Mingo Thursday afternoons 1:30-6:00pm at 3rd & Lewis Title X and other discounts available Confidential Offers pregnancy testing, STD testing, contraception counseling Appointments available throughout the week also