1. Long Acting Reversible Contraceptive Options for College Women
A new era of contraception
Beth Kutler FNP
Gannett Health Services
Cornell University

2. The purpose of this activity is to enable the learner to counsel effectively about long acting contraceptive methods (Intrauterine devices and implantable rods) as well as learn new insights for effective placement and management of potential side effects
The presenter has no financial conflicts to disclose

3. 2013 ACHA National College Health Assessment :
49.2% of females had vaginal sex in the 30 days prior to the survey
1.9 % of college students who had vaginal intercourse within the last 12 months reported experiencing an unintentional pregnancy in that time frame
18.8 % reported using EC within the last 12 months

4. 7.9%
61.6%
61.7%
31%
7.9 % ( up from 5.2 % in 2008) of these women were using a highly effective contraceptive method the last time they had vaginal intercourse
2013 ACHA survey

5. Percentage of Women Experiencing Unintended Pregnancy in First Year
Talking points
Graph shows the percentage of women experiencing an unintended pregnancy within the first year of use
In the United States, 76% of all women using reversible methods use either the pill or male condom—which, as this slide shows, are not the most effective methods. [Kost, Lepkowski]
“Typical use” is how effective each method is during actual use, including inconsistent and incorrect use.
“Perfect use” is how effective the method can be if directions for use are followed at every act of intercourse.
According to these data: [Trussell]
For typical use, the most effective methods generally don’t require adherence.
Methods that require adherence generally show a big difference between perfect-use and typical-use failure rates.
Even the least effective methods are much more effective than no method at all.
The most effective methods don’t protect against STIs.
The most effective methods may be the hardest to access, especially for teens.
References
Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology. 19th edition. New York, NY: Ardent Media, Inc.; 2007.
Trussell J. Reducing unintended pregnancy in the United States. Editorial. Contraception. 2008;77:1-5.
Kost K, Singh S, Vaughan B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception. 2008;77:10-21.
Lepkowski JM, Mosher WD, Davis KE, et al. National Survey of Family Growth, Cycle 6: sample design, weighting, imputation, and variance estimation. National Center for Health Statistics. Vital Health Stat. 2006;2(142).
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Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Breaking the Contraceptive Barrier program in April Original funding received from Duramed Research, Inc., a subsidiary of Barr Pharmaceuticals, through an educational grant. This slide is available at
* Standard Days Method: 5%, Two Day Method: 4%
Hatcher RA. Contraceptive Tech. 19th ed

6. Increased use of LARC* has the potential to lower unintended pregnancy rates among adolescents
Because LARC methods have the highest effectiveness and continuation rates among teens and the potential to reduce unintended pregnancy rates, the College recommends that they be offered as first-line contraceptive methods and encouraged as options for most adolescents
Encouraging the use of LARC methods for appropriate candidates may help lower unintended pregnancy rates because gaps in use and discontinuation of shorter acting methods are associated with unintended pregnancy rates in high-risk women, including adolescents
References:
Trussell J. Contraceptive failure in the United States. Contraception 2011;83(5);397–404. Epub 2011 Mar 12.
Raine TR, Foster-Rosales A, Upadhyay UD, Boyer CB,Brown BA, Sokoloff A, et al. One-year contraceptive continuation and pregnancy in adolescent girls and women initiating hormonal contraceptives. Obstet Gynecol 2011;117:363–71.
*LARC = Long-Acting Reversible Contraception

7. Get It
And Forget It !

8. LARC methods should be first-line recommendations for all women and adolescents

9. Contraceptive Cohort Study
Recruited 10,000 participants over 4 years
60 % age 14-25
47% nulliparous
No cost contraception for 3 yrs
Counseled in all methods, starting
with top tier methods
Participant choice

10. LARC Acceptance LNG-IUS 46.0% CuT380A 11.9% Implant 16.9% DMPA 6.9%
Percentage
LNG-IUS
46.0%
CuT380A
11.9%
Implant
16.9%
DMPA
6.9%
Pills
9.4%
Ring
7.0%
Patch
1.8%
Other
<1.0%
75%

11. Method Choice ages 14-20
More then 2/3 of women aged chose LARC methods
% of all contraceptive users 2010
% of 4,167 Choice sample

13. Intrauterine Contraception in Nulliparous Women
a Prospective Observational Study
Study Objectives:
Assess nulliparous women’s satisfaction with the IUD as a method of contraception
Identify any medical history that may predict satisfaction or dissatisfaction with this method
Quantify the rates of discontinuation and/or complications for IUD use among nulliparous women
117 women currently enrolled in ongoing study. Receive surveys at 1 ,6, 12 and 18 months following placement

14. What, if any, symptoms did you feel related to the IUD placement ?#
Question
None
Mild
Moderate
Severe
Response
Average Value 1
Nausea from the pre-medication 80 6 3 92
1.23 2
Cramping from the pre-medication 69 14 91
1.35
Pain and cramping during the IUD insertion procedure 23 32 37 93
3.13 4
Light-headedness, nausea, and/or sweating during procedure 49 18 22
1.80 5
Pain and cramping in the first hour after insertion 25 35 31
3.02
Pain and cramping in the first 24 hours after insertion 33 19
2.76 7
Pain and cramping hours after insertion 40 12
2.20 8
Pain and cramping after one week had passed 57
1.62

15. How well informed did you feel prior to your IUD placement ?#
Answer
Bar
Response % 1
Very well informed 80
86.02% 2
Fairly well informed 12
12.90% 3
Neutral
0.00% 4
Not well informed
1.08% 5
Very poorly informed
Total 93
100.00%

16. How likely are you, at this point (6mo) are you to
How likely are you, at this point (6mo) are you to recommend the IUD to a friend ? #
Answer
Bar
Response % 1
Very Likely 68
79.07% 2
Likely 11
12.79% 3
Neutral 6
6.98% 4
Unlikely
0.00% 5
Very Unlikely
1.16%
Total 86
100.00%

17. But what about…? Multiple sexual partners Nulliparity Future fertility
Placement trouble

18. IUDs Do Not Cause Infertility
Infertility is not more likely after IUD discontinuation compared to other reversible methods
No evidence that IUD use is associated with subsequent infertility
Chlamydia, not previous IUD use, is associated with infertility
There are no studies demonstrating an increased risk of pelvic inflammatory disease in nulliparous IUD users, and no evidence that IUD use is associated with subsequent infertility
In a study of nearly 2,000 women with primary tubal infertility using several control groups to minimize bias, previous copper IUD use was not associated with an increased risk of tubal occlusion in nulliparous women
Those with tubal infertility were more likely to have antibodies to chlamydia, indicating that the presence of a sexually transmitted infection was the likely explanation of infertility
Encourage condom use
Reference:
Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F,Guzman-Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561–7.
---
Modified from: Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception. Safety: IUC Does Not Cause Infertility [PowerPoint slide]. Washington, DC: Association of Reproductive Health Professionals (ARHP) March. Available at Accessed August 1, 2012.

19. Safety: IUD Does Not Cause Infertility
[Insert Lecture Name Here]
Safety: IUD Does Not Cause Infertility
IUD is not related to infertility
Chlamydia is related to infertility
Tubal infertility by previous copper T IUD use and presence of chlamydia antibodies, nulligravid women
Talking Points
Background: Previous studies of IUDs, many no longer in use, suggested that copper IUDs might cause tubal infertility, decreasing the use of this method in nulligravid women.
Hubacher et al. enrolled 1,895 women in a case-control study: 358 women with primary infertility with tubal occlusion documented by hysterosalpingogram, 953 women who were infertile without tubal occlusion (infertile controls), and 584 primigravid women (pregnant controls).
Information was obtained about the women’s past use of contraceptives including copper IUDs, previous sexual relationships, and history of STIs. Each subject had antibody testing for Chlamydia trachomatis. Stratified analysis and logistic regression analyses were employed.
Results: Odds ratio for tubal occlusion associated with previous use of a copper IUD was 1.0 (95% CI, 0.6–1.7) using infertile controls. When the primigravid women served as controls, the odds ratio was 0.9 (95% CI, 0.5–1.6). Odds ratio for tubal occlusion associated with chlamydia was 2.4 (95% CI, 1.7–3.2).
Conclusions: Previous use of a copper IUD is not associated with increased risk of tubal occlusion among nulligravid women; rather, chlamydial infection is.
These results have been confirmed by others:
Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subsequent fertility: Follow-up after participation in a randomized clinical trial. Contraception. 2007;75:88-92.
Skjeldestad F, Bratt H. Fertility after complicated and non-complicated use of IUDs. A controlled prospective study. Adv Contracept. 1988;4:
Wilson JC. A prospective New Zealand study of fertility after removal of copper intrauterine contraceptive devices for conception and because of complications: A four-year study. Am J Obstet Gynecol. 1989;160:391-6.
Reference
Hubacher D, Lara-Ricalde R, Taylor D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. NEJM. 2001;345:561-7.
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Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.
Hubacher D, et al. NEJM

20. Fertility Rates in Parous Women After Discontinuation of Contraceptive
[Insert Lecture Name Here]
Fertility Rates in Parous Women After Discontinuation of Contraceptive
Pregnancies (%)
Months After Discontinuation 20 40
6060 80
100 12 18 24 30 36 42
IUC OC
Diaphragm
Other methods
Talking Point
Research indicates that return of fertility after IUD removal is rapid, similar to that after discontinuation of barrier methods.
References
Vessey MP, Lawless M, McPherson K, Yeates D. Fertility after stopping use of intrauterine contraceptive device. Br Med J (Clin Res Ed). 1983;286(6359):106.
Andersson K, Batar I, Rybo G. Return to fertility after removal of a levonorgestrel releasing intrauterine device and Nova-T. Contraception. 1992;46:575.
Belhadj H, Sivin I, Diaz S, et al. Recovery of fertility after use of the levonorgestrel 20 mcg/d or copper T 380 Ag intrauterine device. Contraception. 1986;34(3):261.
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Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.
Vessey MP, et al. Br Med J
Andersson K, et al. Contraception
Belhadj H, et al. Contraception

21. Ectopic Pregnancy
IUDs may be offered to women with a history of ectopic pregnancy (MEC cat. 1)
IUD use does not appear to increase absolute risk
Ectopic rate with IUD= 0.5/1,000 women-years
Ectopic rate with no contraception= /1,000 women- years
However, if pregnancy does occur with an IUD in place, the pregnancy is more likely to be ectopic
The U.S. MEC classifies use of both the copper and LNG IUDs in women with a history of ectopic pregnancy as Category 1 (no restriction)
Use of an IUD does not appear to increase the absolute risk of ectopic pregnancy
Cohort data demonstrate an ectopic pregnancy rate of 0.5 per 1,000 women-years among women using either the copper IUD or the LNG IUD, compared with a rate of per 1,000 women-years among women who do not use contraception
A meta-analysis of 16 case-control studies concluded that IUDs do not increase the risk of ectopic pregnancy because they prevent pregnancy so effectively
However, if pregnancy does occur with an IUD in place, the pregnancy is more likely to be ectopic
The absolute risk remains low
References:
Sivin I, Stern J. Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. International Committee for Contraception Research (ICCR). Fertil Steril 1994;61:70–7.
Xiong X, Buekens P, Wollast E. IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies. Contraception 1995;52:23–34.
Furlong LA. Ectopic pregnancy risk when contraception fails. A review. J Reprod Med 2002;47:881–5.
U. S. Medical Eligibility Criteria for Contraceptive Use, Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86.
Sivin I. Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception. Obstet Gynecol 1991;78:291–8.

22. [Insert Lecture Name Here]
Ectopic Pregnancy
Levonorgestrel IUS
0.20*
Copper IUD
0.34*
No method *
The risk of ectopic pregnancy is actually lower in women with an intrauterine device than in those using no contraception, indicating a protective effect.
Sources:
Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49(1):56.
Sivin I. IUDs and ectopic pregnancy. Stud Fam Plann 1983 Feb;14(2):57.
*Ectopic pregnancies per 1,000 woman-years
Andersson et al. Contraception 1994;49:56.
Sivin. Stud Fam Plann 1983;14:57-63.

23. Safety: IUDs Do Not Cause PID
[Insert Lecture Name Here]
Safety: IUDs Do Not Cause PID
PID incidence for IUD users is similar to that of the general population
Risk is increased only during the first month after insertion
Preexisting STI at time of insertion, not the IUD itself, increases risk
Talking Point
The presence of a preexisting sexually transmitted infection (STI) at time of insertion, not the IUD itself, increases the risk of PID.
References
Svensson L, Westrom L, Mardh PA. Contraceptives and acute salpingitis. JAMA. 1984;251(19):
Sivin I, Stern J, Coutinho E, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991;44(5):
Farley T, Rowe P, Meirik O, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339:1904.
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Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.
Svensson L, et al. JAMA
Sivin I, et al. Contraception
Farley T, et al. Lancet

24. Rate of PID by Duration of IUD Use
[Insert Lecture Name Here]
Rate of PID by Duration of IUD Use
Rate per 1,000 woman years
N = 20,000 women
1.6
9.25
<21 days of use
21 days - 8 years of use
Talking Points
Longer duration of IUD use is associated with a lower rate of pelvic inflammatory disease.
Among approximately 20,000 women using the device for 21 days to 8 years, incidence of the disease was approximately 1 per 1000 woman-years, as opposed to a rate of nearly 10 in 1000 woman-years among women using the IUC for 20 days or less.
Reference
Farley T, Rowe P, Meirik O, Rosenber MJ, Chen J-H. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339:1904.
Adapted from Farley T, et al. Lancet

25. Screening: Poor Candidates for Intrauterine Contraception
[Insert Lecture Name Here]
Screening: Poor Candidates for Intrauterine Contraception
Known or suspected pregnancy
Puerperal sepsis
Immediate post septic abortion
Unexplained vaginal bleeding
Cervical or endometrial cancer
Uterine fibroids that interfere with placement
Current purulent cervicitis, chlamydia, or gonorrhea
Talking Points
Note that these screening guidelines differ from the manufacturer’s package insert.
Few absolute contraindications to intrauterine contraception use exist. The listed conditions are rated Category 4, according to the WHO Medical Eligibility Criteria for Contraceptive Use.
Conditions assigned to Category 4 are those that represent an unacceptable health risk if the contraceptive method is used.
For complete information about relative contraindications, see the WHO criteria, available at:
Reference
World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva: WHO; Available at Accessed February 1, 2007.
- - -
Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.
WHO. Medical Eligibility Criteria for Contraceptive Use.

27. Safe for women with estrogen contraindications
2/3 for increased risk pf STI’s
CDC; “ If a woman has a very high individual likelihood of exposure to GC or CT infection, the condition is cat. 3”
These woman represent a 6% greater risk of IUD related complication

29. Copper IUD ParaGard polyethylene wrapped with copper wire
Approved for use up to 10 years (probably more)
Mechanisms of action:
Inhibition of sperm migration and viability
Change in ovum transport speed
Damage to or destruction of ovum
Damage to or destruction of fertilized ovum
All effects occur before implantation
Highly effective
Reported typical use failure rate at one year of 0.8 per 100 women
Ten-year failure rate comparable to female sterilization (1.9 per 100 women)
References:
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F,Kowal D, editors. Contraceptive technology. 19th rev. ed. New York (NY): Ardent Media; 2007.
Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol 1999;181:1263–9.
Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects. Am J Obstet Gynecol 2002;187:1699–708.

30. LNG IUS Mirena LNG IUS releases 20 mcg levonorgestrel/day
Approved for use up to 5 years (probably more)
Mechanisms of action:
Similar effects as copper IUD
Also causes endometrial suppression and changes in cervical mucus
All effects occur before implantation
Highly effective
One-year failure rate of 0.2 per 100 women
May be effective up to 7 years
References:
Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart F, Kowal D, editors. Contraceptive technology. 19th rev. ed. New York (NY): Ardent Media; 2007.
Sivin I, Stern J, Coutinho E, Mattos CE, el Mahgoub S, Diaz S, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNG 20) and the Copper T380 Ag IUDS. Contraception 1991;44:473–80.

31. New LNG IUS Skyla LNG IUS releases 14 mcg levonorgestrel/day
3.3 cm sq
Insertion tube
o.5 cm
2.8 x 3 cm
Insertion tube
0.4cm
Skyla LNG IUS releases 14 mcg levonorgestrel/day
Approved for use up to 3 years
Highly effective
FDA approved in 2013
Three-year cumulative pregnancy rate of 0.9%
Reference:
Bayer Healthcare Pharmaceuticals Inc. Skyla Prescribing Information. February Available at Accessed April 4th, 2013.

32. IUD Placement

34. Screening for STI chlamydia and gonorrhea
57,728 IUD insertions:
47% unscreened
19% screened on day IUD was inserted
Overall PID risk within 90 days= 0.54%
No difference in PID regardless of screening
Suffrin et al OB. Gyn :
Treat mucopurulent cervicitis prior to placement
Routine antibiotic prophylaxis is not recommended before insertion
Do not remove IUD for PID tx unless tx failure
Screen at risk women through most convenient process

36. ± Pre placement counseling essential
800 mg Ibuprofen 1 hour prior to placement
Anxiolytics
50 mg Tramadol
Topical and/or instilled lidocaine
Cervical blocks
Misoprostol
Menses

37. Post-Abortion Insertion
Insertion of an IUD immediately after abortion or miscarriage is safe and effective
Significantly reduces the risk of repeat abortion
Increases rates of use
Adolescents should be counseled regarding risk of expulsion
Immediate insertion of the copper IUD or LNG IUD after a first-trimester abortion is classified as Category 1 (no restriction) in the U.S. MEC and Category 2 (advantages outweigh the risks) for second-trimester postabortion insertion (because of a higher risk of expulsion compared with insertion after a first-trimester abortion)
Women who have an abortion are at high risk of repeat unintended pregnancy
Ovulation may resume within 10 days of abortion
References:
Grimes DA, Lopez LM, Schulz KF, Stanwood NL. Immediate postabortal insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD DOI: / CD pub3.
Fox MC, Oat-Judge J, Severson K, Jamshidi RM, Singh RH, McDonald-Mosley R, et al. Immediate placement of intrauterine devices after first and second trimester pregnancy termination. Contraception 2011;83:34–40.
Goodman S, Hendlish SK, Reeves MF, Foster-Rosales A.Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion. Contraception 2008;78:143–8.
Gillett PG, Lee NH, Yuzpe AA, Cerskus I. A comparison of the efficacy and acceptability of the Copper-7 intrauterine device following immediate or delayed insertion after first-trimester therapeutic abortion. Fertil Steril 1980;34:121–4.
U. S. Medical Eligibility Criteria for Contraceptive Use, Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86.
Lahteenmaki P, Luukkainen T. Return of ovarian function after abortion. Clin Endocrinol 1978;8:123–32.

38. Copper IUD as EC Most effective method of emergency contraception
Can be inserted up to 5 days after unprotected intercourse to prevent pregnancy
In a study of 1,963 women who underwent insertion of a copper IUD for postcoital contraception, including 95 nulliparous women, the pregnancy rate was 0.23%
Women who use the copper IUD for postcoital contraception may benefit from retention of the device for long-term contraception, the same study found that only 5.7% of participants discontinued copper IUD use before the 12-month follow-up period
References:
Cheng L, Gulmezoglu AM, Piaggio GG, Ezcurra EE, Van Look PP. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD DOI: / CD pub3.
Wu S, Godfrey EM, Wojdyla D, Dong J, Cong J, Wang C,et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG 2010;117:1205–10.

39. Efficacy of Emergency contraception
In UK 11/2013 labeling of levonorgestrel EC stated was ineffective in wgts >80 kg (176 #) and Ella ineffective
Glasier A, et. all. Contraception. 2011;84:363‐7.

40. Bleeding Concerns Overall Menstrual blood loss reduction of 79-97%.
FDA approval for treatment of menorrhagia
Varma, R. Eur J Obstet Gynecol Reprod Biol 2006

41. Fertility and Sterility
Volume 97, Issue 3, March 2012, Pages 616–622.e3

42. Copper T related bleeding can decrease over time
Side effects from the copper IUD: do they decrease over time? David Hubacher⁎, Pai-Lien Chen, Sola Park. Contraception 79 (2009) 356–362

43. Managing Bleeding Concerns
Anticipatory guidance and reassurance
Treat with NSAIDs
Cycle with oral contraceptives
70% experience oligomenorrhea or amenorrhea within 2 years of insertion of Mirena
These numbers likely to be lower with Skyla

44. 3 most common reasons for requesting removal before 6 months of use
Obstet Gynecol 2013;122:1214–21)

45. Long acting reversible method. Discrete. Effective for 3 years
Nexplanon
Convenient
Long acting reversible method. Discrete. Effective for 3 years
Effective
0.5 to 1 pregnancy /1,000 users
Reversible
After implant is removed, most women (94%) ovulate by 3 months; the majority ovulate within 3 weeks. Drug level is undetectable one week after removal. Funk S, Contraception May;71(5):
Safe
Progesterone only. MEC 1 or 2 where estrogen is contraindicated. Inhibits ovulation
No evidence of long-term effects such as deep vein thrombosis or anemia. Studies regarding bone mineral density have been conflicting. BeerthuizenR, Hum Reprod. 2000;15:

46. Easy Placement Insertion in <1 min Removal 3-5 min
1% complications related to insertion
1.7% related to removal
Can be placed anytime pregnancy reasonably excluded
Back up method for 7 days unless :
inserted within 5 days of menses
immediately post-abortion
Immediately upon switching from another hormonal method

47. Bleeding patterns with etonogestrel implant
Favorable bleeding patterns in the 1st 3 months are likely to continue
Unfavorable patterns have a 50% chance of improving
Women with low body weight have fewer bleeding and spotting days
Contraception
Volume 71, Issue 5, May 2005, Pages 319–326

48. Bleeding Patterns with Implant
First 2 Years
Percentage of 90– day intervals
After implant insertion, changes in menstrual bleeding patterns are common and include amenorrhea or infrequent, frequent, or prolonged bleeding
A change in bleeding pattern is the most common reason for implant discontinuation
Anticipatory guidance regarding bleeding patterns may improve satisfaction and continuation (11.3%)
Definitions:
Amenorrhea: no bleeding or spotting
Infrequent: Less than three bleeding/spotting episodes per reference period (excluding amenorrhea)
Prolonged: Any bleeding/spotting episode that lasts for more than 14 days in a row
Frequent: Greater than five bleeding/spotting episodes per reference period
Based on 3,315 ninety–day reference periods (N=780), Reference Periods 2 through 6
Reference:
Darney P, Patel A, Rosen K, Shapiro LS, Kaunitz AM. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril 2009;91:1646–53.
Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008;13(suppl 1):13–28.

49. Managing Bleeding Concerns
Common strategies include short courses of combined OCs or NSAIDs
No published placebo controlled trials to support use of these treatments
Limited data suggest decreases in bleeding episode length with:
Mefenamic acid
Mifepristone in combination with ethinyl estradiol or doxycycline
Doxycycline alone
More research is needed to determine whether these or other interventions affect long-term continuation or acceptability of the implant
References:
Mansour D, Bahamondes L, Critchley H, Darney P, Fraser IS. The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users. Contraception 2011;83:202–10.
Phaliwong P, Taneepanichskul S. The effect of mefenamic acid on controlling irregular uterine bleeding second to Implanon use. J Med Assoc Thai 2004;87(suppl 3):S64–8.
Weisberg E, Hickey M, Palmer D, O’Connor V, Salamonsen LA, Findlay JK, et al. A pilot study to assess the effect of three short-term treatments on frequent and/or prolonged bleeding compared to placebo in women using Implanon. Hum Reprod 2006;21:295–302.
Weisberg E, Hickey M, Palmer D, O’Connor V, Salamonsen LA, Findlay JK, et al. A randomized controlled trial of treatment options for troublesome uterine bleeding in Implanon users. Hum Reprod 2009;24:1852–61.

50. Weight Changes with LARC Methods
Nexplanon % of users report weight gain
Only 2.3% discontinue due to weight gain
Contraception 88 (2013) 503–508

51. Thank You !
Questions ?
Beth Kutler

52. LARC Online Resources www.acog.org/goto/larc www.jahonline.org
Selected practice recommendations for contraceptive use, (SPRC, 2013)
Medical Eligibility Guidelines for Contraception (MEC, 2010)