1. LARC: What Is It and Why Is It Important for Teens?
Jan Shepherd, MD, FACOG

2. Learning Objectives
Define LARC and discuss why it can be important in preventing unintended pregnancy
Discuss the increasing role of intrauterine contraception in family planning for all age groups
Describe the contraceptive implant and discuss potential benefits and side effects of the method
Describe the concept of a Reproductive Life Plan and how it can be used in counseling teens

3. Disclosure I am on the Speakers Bureau for Bayer (IUCs)
Merck (Implant)
Teva (IUD)

4. U.S. Pregnancies: Unintended vs. Intended
51%
Unintended
49%
Unintended births
29%
Elective abortions
20%
Guttmacher Institute; January 2012.

5. Teenage pregnancy is more common in the USA than in most other industrialized countries
Source Presentation: Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics

6. Our Teen Birth Rate is Declining
Colorado
United States
Change from
-50%
-49%
Change from
-13%
-8%
And Colorado went from #23 to #29 in latest statistics
CDC

7. But We Still Have Work To Do
Total Teen Births 2011
Total
Colorado
United States
Under 15 67
3,974
15-17
1,383
95,538
18-19
3,351
234,234
Race/Ethnicity
Colorado
United States
Non-Hispanic White
37%
39%
Non-Hispanic Black 7%
24%
Native American 2%
Asian or Pacific Islander 1%
Hispanic
53%
33%

8. Colorado Statistics
41% of high school students (36% of females) have had sexual intercourse
4% (2% of females) had first intercourse before age 13
13% (11% of females) have had intercourse with 4 or more partners
7% (8% of females) did not use any contraception with last intercourse
CDC

9. Contraceptive Use and Unintended Pregnancy
52% of unintended pregnancies attributable to sexually active women using no method
48% of unintended pregnancies — women using some form of birth control
Mosher WD, Jones J. Vital and Health Statistics 2010.

10. First Year Contraceptive Failure: Perfect Use vs Typical Use30 25 20 15 10 5
OCs
DMPA
Implants
Condom
Vasectomy
Copper IUD
Diaphragm
Withdrawal
Spermicides
Progestin IUD
Tubal Ligation
Hatcher RA. Contraceptive Technology.

11. Typical Use * All especially common in teens
Women forget to take pills
Injectable users miss a shot
Couples don’t use a condom every time they have sex
Methods are used incorrectly
Women do not expect to have sex
Users’ supplies run out
* All especially common in teens

12. Current Trends in Contraception
Emphasizing greater success
 Duration of action   Ease of adherence   Efficacy in typical use
LARC: Long Acting Reversible Contraception
Intrauterine contraception
Subcutaneous implant
Improved Counseling
Reproductive Life Plan

13. Long- Acting Reversible Contraception
= “Forgettable Contraception”

14. WHO Method Comparison

15. Intrauterine Contraception (IUC)
Levonorgestrel Intrauterine Systems
Copper T 380A

16. Debunking Myths About Intrauterine Contraception
IUCs are abortifacients
IUCs cause pelvic inflammatory disease (PID)
IUCs cause infertility
IUCs cannot be used in nulliparous women

17. IUC: Mechanism of Action
Mechanism of Action - Spermicidal
Foreign body reaction
Copper T 380A
Heavy metal toxic to sperm
Levonorgestrel IUC
Progestin thickens cervical mucous
Prevents egg & sperm getting together
Not an abortifacient

18. History of IUC Dalkon Shield
Contraceptive Use in the US
History of IUC Dalkon Shield
Dalkon Shield
Increased rate of PID, septic abortion, infertility
Infections related to woven thread
Off the market for over 30 years
Modern IUCs are not your grandmother’s IUD .

19. IUCs Do Not Cause PID 5-Year Cumulative Rates of Discontinuation for PID
A. Randomized trial comparing Mirena to CuT 380A
B. Randomized trial comparing Mirena to Nova T
P < .05
*Nova T is not available in the US.
Sivin I et al. Contraception 1990;42:
Andersson K et al. Contraception 1994;49:56-72.

20. IUCs Do Not Cause PID Therefore do not cause infertility
Tubal infertility not linked to IUC use1
PID risk with cervicitis same with & without IUC2
Therefore can be used by women who have not had children, including adolescents
1. Hubacher D. NEJM 2001;345: Grimes D. Lancet 2000;356:

21. Fertility After Discontinuation of Contraceptive
PID/Ectopic Pregnancy/Future Fertility
Fertility After Discontinuation of Contraceptive
100 80
IUD OC
Diaphragm
Other methods 60
Pregnancies (%) 40 20 12 18 24 30 36 42
Months After Discontinuation
Vessey MP, et al. Br Med J. 1983;286:106.

22. Copper T 380A (Paragard®) On US market since 1988
High efficacy (failure rate .5-.8% per year)
Approved for 10 years use
Changes in menstrual bleeding
Can increase flow and cramping
Controlled by NSAIDS

23. Cu T 380A September 2005 Labeling Changes
Contraindications
Removed “depressed immune conditions, including HIV”
Recommended patient profile
Removed multiparity
Removed mutual monogamy

24. CuT380A and Menstrual Problems
Counsel that first few periods likely to be heavier and may have increased cramping
NSAIDS (e.g. ibuprofen) around the clock on the first day and continued for 3-5 days
Decreases bleeding by up to 50%1
Symptoms usually improve after first few cycles2
1. Contraception 2013;87: Contraception 2009;79:

25. Levonorgestrel IUS (Mirena®)
32 mm
High efficacy (failure rate .2% per year)
Approved for 5 years use
Low systemic levels of hormone
Changes in menstrual bleeding
Irregular bleeding at first, then decreased flow or no periods (20%)
Steroid reservoir
32 mm
levonorgestrel g/day

26. LNG IUS - Noncontraceptive Benefits
FDA-approved for treatment of heavy menstrual bleeding
Better than medical therapy*
Decreases menstrual cramps (off-label)
Even in medical conditions
* N Engl J Med 2013;368:

27. New Levonorgestrel IUS (Skyla®)
High efficacy (failure rate .4%/year)
Effective for 3 years
Smaller, thin inserter, lower hormone dose
Approved for nullips
Changes in menstrual bleeding
Irregular bleeding at first, then short, light periods
Levonorgestrel
14-5 μg/day

28. Risks of Intrauterine Contraception
Expulsion %
Perforation - 1,000-2,000
Infection/PID - related to insertion
If pregnancy occurs, ectopic possible
1 of 2 with Mirena and Skyla
1 of 16 with Paragard
Discussion for patients

29. *Committee Opinion #539 October 2012.
ACOG Statements
On IUDs: “IUDs offer safe, effective, long-term contraception and should be considered for all women…”
On Adolescents: “Providers should strongly encourage young women who are appropriate candidates to use this method.”
“IUDs are safe to use among adolescents.”
“IUDs do not increase an adolescent’s risk of infertility.” *
*Committee Opinion #539 October 2012.

30. Which IUC? LNG IUS Cu T 380A Low-dose LNG IUS
Woman with heavy flow or cramps
Anyone who desires  bleeding/amenorrhea
Cu T 380A
Woman who prefers regular predictable cycles
Wants/Needs to avoid hormones
Prefers longer duration (10 years)
Low-dose LNG IUS
Lighter, less painful periods
Lower systemic hormone exposure

31. The Subdermal Implant (Implanon®  Nexplanon®)

32. Norplant®
Implanon®

33. Single-Rod Implant 2 mm 40 mm Rate-controlling membrane (0.06 mm) Core
Core: 40% Ethylene vinyl acetate (EVA)
60% Etonogestrel (68 mg)
Membrane: 100% EVA
Core 6

34. Nexplanon®

35. Advantages 3 years of most effective contraception
Pelvic exam not required
Progestin-only method, can use
When estrogen contraindicated
If estrogenic side effects with another method
Improves acne and menstrual cramps
Insertion and removal easier than previous implants

36. Estradiol Levels During Treatment
1500
Implant n = 44
1250
Copper IUD n = 29
1000
Mean estradiol (pmol/L)
750
500
250
Baseline
Month 12
Month 24
Last measurement
 Does not affect bone density like Depo Provera does
Beerthuizen R, et al. Hum Reprod. 2000;15:

37. Discontinuation Rates due to Adverse Events
Bleeding irregularities % (104/942)
Weight gain % (22/942)
Emotional lability % (22/942)
Headache % (15/942)
Acne % (12/942)
Depression % (9/942)
1.7% of Women Experienced Problems at Removal
IMPLANON™ [package insert]. Roseland, NJ: Organon USA Inc; 2006.

38. Bleeding Patterns Bleeding is usually irregular
Can be light or heavy, short or prolonged
Skipped periods most common
Pattern can vary throughout the duration of use
Total amount of bleeding/spotting days usually similar to or slightly less than a normal menstruating woman
Key difference is the irregularity and unpredictability of the bleeding

39. Managing BTB with Nexplanon
COUNSELING
*Oral contraceptives,
if not contraindicated
Provera or Aygestin for 21 days x 3 mos
Progestin-only pills x 3 months
Estrogen x 10 days
NSAIDs (e.g. ibuprofen) x 5-10 days
Contraception 2008;78: Contraception 2011;83:

40. Managing Hormonal Side Effects with Implant (or LNG- IUS)
Acknowledge client’s concerns
Agree to remove it if she desires
Point out very low incidence of these side effects, then: “Is there anything else in your life that could be causing this headache, moodiness, etc.”
Remind client that if related to the method, side effects usually decrease over time

41. Role of LARC: CHOICE Project
Method Chosen
LNG IUS – 45%
Copper IUD - 10%
Implant – 13%
Depo Provera – 8%
OCPs – 23%
Obstet Gynecol 2011;117:

42. Continuation: CHOICE Project
1 year1
2 year2
LNG IUS – 88%
Copper IUD – 85%
Implant - 83%
Depo Provera – 57%
OCPs – 55%
LARC – 87%
Non-LARC – 57%
LNG IUS – 79%
Copper IUD – 77%
Implant - 68%
Depo Provera – 38%
OCPs – 43%
LARC – 77%
Non-LARC – 41%
1. Obstet Gynecol 2011;117: Obstet Gynecol 2013;122:

43. Efficacy of LARC: CHOICE Project
22X more effective than pill, patch or ring (0.27 vs pregnancies per 100 women)
Double this effect in teens
Rate of teenage birth in the CHOICE cohort 6.3/1000 vs. 34.3/1000 nationally
Rate of abortion less than half the regional and national average
1. N Engl J Med 2012;366; Obstet Gynecol 2012;120:

44. Depo Provera
The almost-LARC

45. Depo Provera (DMPA) Amenorrhea Highly Effective (.22 pregnancy rate)
Positives
Negatives
Highly Effective (.22 pregnancy rate)
Easy to use
Anonymous
Can use when estrogen contraindicated
No drug interactions
Amenorrhea
Prolonged pituitary suppression
Median time to pregnancy is 9–10 months
Up to 18 months is WNL
Weight gain
Vaginal dryness
Adverse effect on lipids
↓ Bone density

46. Recovery of Bone Density in Adolescents
J Adolesc Health 2006;39:

47. Committee Opinion #415 September 2008.
ACOG Statement
“Concerns regarding the effect of DMPA on bone mineral density should neither prevent practitioners from prescribing DMPA nor limit its use to 2 consecutive years.”
Committee Opinion #415 September 2008.

48. Improved Contraceptive Counseling  Reproductive Life Plan
Being intentional about preparing for and starting pregnancies
Making conscious decisions about
When to have children
How many to have
Ensuring the healthiest pregnancies and families
CDC

49. Reproductive Life Plan = True “Family Planning”
Encouraging clients to think about contraception
In terms of
Planning for when they do want children
Protecting themselves until that time
Not just for this year or this relationship

50. Reproductive Life Plan
Clinicians help clients make a Reproductive Life Plan by asking:
Do you hope to have children? More children?
How many?
When?
Every woman, every year

51. Reproductive Life Plan
Avoiding unintended pregnancy
More effective use of contraception
First-line option for many
LARC: Long Acting Reversible Contraception
Fertility-preserving behavior
Planning for desired pregnancies
Preconception care

52. Case
A 16-year-old, newly sexually active, presents to the clinic for her first appointment, requesting contraception.
Do you plan to have children? Yes
How many? Two or three
When? Not until I finish high school and college

53. Reproductive Life Plan
Avoiding unintended pregnancy
Effective use of contraception
First-line option
LARC: Long Acting Reversible Contraception
Intrauterine contraception
Subcutaneous implant
Protection against STIs!

54. More Ways to Encourage Use of LARC
You are >22 times more likely to become pregnant with OCPs, patch, or ring than with a LARC method!
Ask about feasibility of daily pill taking  “How often do you want to have to think about your birth control?”
Get It and Forget it
Anticipate and dispel misconceptions

55. Counseling About Safety
LARC methods are very safe
All avoid the blood clot risks of estrogen-containing methods
All reduce the risk of ectopic pregnancy and certain cancers
IUC is the #1 method of birth control in the world and its use is on the rise in the US

56. LARC *Always need condoms to prevent STIs
Methods requiring attention > q 3 years
Independent from
Intercourse
User motivation and adherence
Do not require frequent visits for resupply
Highest effectiveness, continuation rates, and user satisfaction proven in teens
Excellent safety record
*Always need condoms to prevent STIs