Long-acting Reversible Contraception-Highly Efficacious, Safe, and Underutilized.

The Centers for Disease Control and Prevention provides evidence-based resources that summarize patient eligibility for different contraceptive methods based on selected patient characteristics and medical conditions. 6 LARC is well suited for patients with medical problems that pose contraindications to estrogen use, including poorly controlled diabetes or hypertension, current or past venous thromboembolism, migraines with aura, and cigarette smokers (aged Š35 years). All LARC devices can be placed right after birth or abortion, providing immediate contraception. The copper IUD will not interfere with lactogenesis. Multiple randomized clinical trials and observational studies have failed to demonstrate any negative effects of progestin-containing contraceptives (shot, implant, progestin only pills) on the quality of maternal lactation or first-year infant growth. 7

There are 6 FDA-approved LARC devices: 5 IUDs (1 copper, 4 levonorgestrel-containing) and 1 subdermal progestin implant. LARC has excellent efficacy (>99%), high continuation rates, and multiple noncontraceptive benefits, yet is underutilized in the United States. Use of an IUD alone does not increase the long-term risk of pelvic infection or infertility. LARC use decreases the absolute risk of ectopic pregnancy. Adolescents and nulliparous women can safely use IUDs. Noncontraceptive benefits of the levonorgestrel-containing IUD include decreased blood loss and protection from endometrial proliferation. LARC provides excellent options for patients with medical conditions that preclude the use of estrogen. Counseling about LARC should be noncoercive via shared decision-making and within the context of patient preferences and medical history.

There are currently 1 copper and 4 levonorgestrel-containing IUDs and 1 progestin implant approved for contraceptive use by the US Food and Drug Administration (FDA) ( Table ). The progestin implant is placed subdermally with local anesthesia in the upper arm. LARC devices can be inserted and removed by trained professionals (including primary care clinicians) in the office setting without sedation. Evidence supports extended use of some LARC devices beyond the FDA-approved duration of use. The copper IUD is the most effective method of emergency contraception available (if placed within5d of unprotected intercourse; duration, 10–12 y); it inhibits fertilization through spermicidal effect. LARC provides greater efficacy compared with short-acting hormonal methods that require user involvement (eg, oral contraceptive pill, progestin shot, vaginal ring, contraceptive patch). Because LARC requires no user involvement, its effectiveness with typical use (eg, patient adherence) matches its theoretical efficacy with perfect use (>99%). In contrast, the effectiveness of oral contraceptives with typical use is substantially lower (91%) than theoretical efficacy with perfect use (>99%). Although the contraceptive mandate of the Affordable Care Act requires insurers to cover FDA-approved contraceptives without patient cost sharing, contraceptive coverage varies widely based on state of residence, insurance plan, and employer. Thus, one potential shared disadvantage of LARC is expensive out-of-pocket costs ($500-$1000 for the device plus costs for the office visit and procedure) for patients who lack full contraceptive coverage.

Misunderstanding about LARC safety contribute to its underutilization. Concerns that women who are nulliparous, unmarried, or adolescents areathigherriskforpelvicinflammatorydiseaseandinfertilityfromusing FDA-approved IUDs are not supported by current literature. 3 Any risk of pelvic infection associated with IUD insertion is very low (0.5%) and limited to several weeks post insertion. IUD users have a lower absolute risk of ectopic pregnancy than non-IUD users, but in the rare event that IUD users become pregnant, the relative risk of ectopic pregnancy is elevated. Patients concerned about devices getting lost should be informed that uterine perforation from IUDs is rare (1/1000 insertions) and distant migration of properly placed subdermal implants is rare (case reports). Upon removal of LARC, baseline fertility rapidly returns. Requirements that LARC only be inserted during menses unnecessarily delay access; LARC can be inserted anytime pregnancy has been reasonably ruled out, based on history and urine pregnancy testing.

Noncontraceptive benefits of LARC can improve health outcomes. Levonorgestrel-containing IUDs can treat menstrual-related disorders. By decreasing menses, levonorgestrel-containing IUDs can improve anemia and prevent surgical interventions to treat fibroids and endometriosis. Progestin-containing LARCs can alleviate symptoms related to other menstrual-related conditions, such as dysmenorrhea and migraine headaches. Because progestins suppress endometrial proliferation, the levonorgestrel-containing IUD has been used to treat atypical endometrial hyperplasia.

Selecting a contraceptive is a highly preference-sensitive decision, such thatmorethan1treatmentoptionisacceptable. Shareddecision-making is a patient-centered counseling method that has been associated with decreased decisional conflict and better contraceptive outcomes. 8 During this process, clinicians and patients work together to decide what method reflects patients’ values and preferences. Clinicians should respect patient preferences and decisions in a noncoercive manner, which may include prioritizing patient-desired method attributes over duration of action or contraceptive effectiveness and not choosing a clinician-recommended method (eg, declining a copper IUD because of concerns about worsening menses) or not choosing a method at all.