Are you up with the LARCs? Dr Christine Roke National Medical Advisor, Family Planning March 2011

Long Acting Reversible Contraception - LARC Action less often than monthly All less than 1% failure rate

Long Acting Reversible Contraception - LARC Depo Provera injection Intrauterine contraception Implants

Longacting contraception Why? Methods that require something with every act of sexual intercourse or need to be taken every day have higher user failure rates Combined pill has about 3% failure rate per year in every day use and 8% in first year of use Women have first baby in NZ at about 30 So average woman has more than 10 years contraceptive use before first baby About 1 in 3 may therefore have an unintended conception in that time

Average woman has less than 2 children So many years of contraception required when family complete with possible contraceptive failure

Depo Provera Problem with women returning on time for subsequent injections Now internationally recommended that “late” injection is more than 14 weeks since last injection Still schedule next appointment for 12 weeks

Possible side effects Most don’t put on weight Most don’t have mood changes

Depo Provera and bone density Depo Provera may reduce bone density by 5 – 7% over the first 2 years of use – it then plateaus Caused by suppression of oestrogen When Depo Provera discontinued, regain this loss of bone density over next few years

Bone density Maximum increase in bone mass age , some sites reach peak bone mass by 18, others later Reduced in anorexia nervosa, exercise- induced amenorrhoea etc Increased in Maori and Pacific nation people

Depo Provera use Can be used by adolescents if other methods unsuitable, especially if 18 or older All ages - review at 2 years – risks and benefits –UK Faculty of Family Planning and Reproductive Health care, WHO

Intrauterine contraception Now clear that STIs cause infection not IUDs beyond the initial insertion phase Ideal to exclude STIs before insertion If asymptomatic chlamydia found, can treat and insert IUD if reinfection not likely If STI or PID diagnosed while IUD in situ, treat and only remove if not settling IUDs can be used by nulliparous women (although they do have higher expulsion rate)

Intrauterine contraception Fertility declines in 40s Copper IUDs – if inserted when 40 or older, can stay until postmenopausal if no problems Mirena - if inserted when 45 or older for contraception, can stay until postmenopausal if no problems

Implant

Jadelle Progestogen-releasing rods 2 rods of levonogestrel - lasts 5 years inserted subdermally into upper arm under local anaesthetic by trained clinician Subsidised from 1 st August 2010 Available on individual prescription (obtain trochar from Bayer NZ)

Action Slow release of progestogen which works by Inhibiting ovulation for first year or so Thickening cervical mucus Oestrogen levels remain above threshold for loss of bone density

Jadelle efficacy Annual pregnancy rate Women 60kg or more Year Year Year Year 40.0 Year

Side effects Main side effect is change in bleeding pattern Can have other hormonal side effects but lower hormonal levels than POP – headache, weight gain, acne Scar for insertion and removal - occasionally local wound problem

Jadelle bleeding pattern Irregular bleeding and amenorrhoea common Settles to long term pattern over first months Bleeding less likely to settle with time than Depo Provera or Mirena Bleeding problems are commonest reason for discontinuation Spotting and irregular bleeding common – 14% (1 in 7) discontinue for this reason: –5% for prolonged episodes of vaginal bleeding and spotting –4% for irregular bleeding –3% for heavy bleeding

Bleeding Discussion of possible bleeding problems essential before insertion Bleeding pattern possibly related to weight – lighter women more likely to have amenorrhoea, heavier women more likely to have more numerous bleeding days Management of irregular bleeding –COC as long as oestrogen not contraindicated –NSAIDs days

Advantages Rapid return of fertility when removed Lower PID rates Less dysmenorrhoea Low ectopic pregnancy rate

Insertion By day 7 or reliable contraception Contraceptively effective immediately if inserted by day 5, otherwise 7 days Contraindicated if breast cancer within last 5 years Should not be used by those on enzyme inducing medication Otherwise suitable for all ages provided able to manage possible bleeding problems Superficial placement essential

Continuation and removal Jadelle continuation rate at 2 years >80% At 5 years 40% Do not attempt removal if implants impalpable Refer to interventional radiologist

New ways of taking COC Tricycling = taking 3 packets of pills in a row without a break Continuous = no breaks Less risk of contraceptive failure Less breakthrough bleeding with time but some women will find this spotting a problem – take 7 day break No known medical concerns