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

3. 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

4. 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

5. 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

6. 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)

7. Intrauterine Devices (IUDs)

8. 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

9. 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

10. 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

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

12. The Implant (Nexplanon)

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. Which Birth Control?

21. Medical Eligibility Criteria

22. 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)

24. 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

25. 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