2. LARC methods 04/12/17 Background Choice Which larc and why? Scenarios
Common problems.

3. Why larcs? Marie Stopes data
48% pregnancies are unplanned.
Average age first intercourse?
15 yrs
Average age first pregnancy?
30 years
37% who attend TOP had one previously
40% who start cocp will have stopped in first 6 months

7. Abortions in 2015
Total number England and Wales in ,824; driven by over 30’s
91% carried out <13 weeks
51% medical abortions (17% 2003)
98% of these are funded by the NHS

8. LARC methods; all more cost effective than oral methods at 1 year
Implant, injectables, IUD.
LARC methods; all more cost effective than oral methods at 1 year
MOST cost effective; implant, IUD.

11. Larc’s; all suitable for
Nulliparous
Breast feeding women
Following abortion
BMI>30
Diabetics
Migraine
Contraindication to oestrogens.

12. Which LARC? Tailor information to specific needs of the woman
Offer choice all methods; written and verbal…..leaflets
Includes; mode action, failure rate, side effects, risks, benefits.
Dispel misconceptions ; show devices

13. Sayana Press, subcutaneous depo

14. Sayana Press 104 mg MPA for subcut injection.
Bioequivalent to depo-provera.
Injected every 13 weeks +/- 7d
May be preferable for patients prone to haematoma ( eg bleeding disorders, anticoagulation)
Licensed for self administration!!

16. Copper IUD’s

17. Implant; Nexplanon

18. Implant; what is it?
40mmx2mm subdermal rod releasing etonogestrel over 3 yrs.
Unmatched failure rate
Needs removal/replacement.
Training required
Nexplanon is radio-opaque

19. Etonogestrel serum levels.

20. Effects of weight on serum levels

21. How to facilitate choice?
Some cases……

22. Case one 30 yrs, 6 week postnatal check, 2nd child. Breast feeding
Not keen on hormones due to s/e on pill
Tends to have heavy menses
What other information do you and she need in order to make her choice? Discuss how and when you would do this.

23. Case one Plans for further children Sexually active since delivery?
Using condom?
Previous contraceptive methods
Attitudes, preconceptions,preferences
Discuss larc methods, consider leaflet, show devices
If undecided arrange another appt.

24. Counselling; verbal and written
Mode of action, duration
Failure rate
Risks, side effects
Effects on bleeding
Return of natural fertility
Insertion procedure, timing in cycle
…..documentation, consent

25. Counselling;how does it work?
IUD: prevents fertilisation (primarily) and implantation. It is therefore not abortifacient.
IUS: prevents implantation and possibly fertilisation. >75% continue to ovulate.
Implant and depo; prevent ovulation

26. Counselling; Duration of use.
IUD; mostly 10 yrs ( 380mm copper, banded arms) Gold standard T-Safe Cu380
IUS; 5 yrs ( or longer if fitted in 45+; unlicensed)
Jaydess; 3 years
DMPA; 12 weeks ( really 14 weeks)
Implant; 3 yrs

27. Counselling; failure rate
IUD; 14/1000 over 7 yrs
IUS; 11/1000 over 7 yrs
Depo <4/1000 over 2 yrs
Implant; 0.5 per 1000
Comparable to sterilisation
Filshie clip 2-3/1000
Vasectomy 0.5/1000(UK RCOG)

28. Side effects and risks; IUD/IUS
IUD; heavy painful periods
IUS and IUD;expulsion 1in 20
Perforation; 2 in 1000; 6 x higher if breast feeding
(PID;<1% low risk women)Maximal in 20 days after fitting; screen at risk.
COUNSEL AND DOCUMENT

29. IUD insertion Pain of the procedure Vasovagal reactions
Adequate resuscitation policy/equipment
Pain after the procedure
Bleeding?

30. IUD should be offered first line to young nulliparous women alongside other methods.
Leeds student medical practice 2013

31. PID risk?
Neither IUD or IUS intrinsically increase PID risk. It is crucial to insert through a cervix which is established to be pathogen free.
Test for chlamydia (and gonorrhoea where prevalent) before fitting
SEXUAL HISTORY TAKING

32. Case two 25 yrs single mum New partner, needs contraception
BMI 35, trying++ to lose weight
Previous ectopic
Which larc methods would be suitable for her and what information does she need in order to make a decision?

33. What about ectopic pregnancy?
This is much less common than in a woman not using any contraception.
If pregnancy does occur with IUD in situ it is important to exclude ectopic urgently with USS.
A previous ectopic is not a contraindication to IUD use.

34. Side effects and risks; depo
Altered bleeding patterns
Weight gain
Concerns about effects on bone density ( adolescents and over 45)
Delay in return fertility; up to 12m

35. Depo; monitoring Age 45,been on depo 20 yrs Amenorrhoea
No current partner
Overweight smoker
Is any special advice required in this situation or can she just continue to come and see the practice nurse for her 12 weekly injection?

36. Depo and bone density
Use of depo contraception is associated with a small loss of BMD which is usually recovered after discontinuation of the method
There is no evidence that is increases fracture risk

37. Depo and bone density, FSRH
Women should be reviewed every 2 years to assess the benefits and potential risks of continuation of the method and supported in their choice of whether to continue. Use may continue up to age 50.

38. Implant; side effects;bleeding
Bleeding; counsel with care, document. Commonest reason for removal
20% amenorrhoea
25% regular bleeds
25% prolonged/frequent bleeds
30% infrequent bleeds

39. Implant; side effects
There is no evidence for effects on weight, libido, headaches or mood; but some women will complain of these.
Some women report worsening acne but in others it may improve.
Try to encourage continuation if possible

40. Counselling; timing of method
IUD and IUS; usually in first week of cycle
Implant; day 1-5 of cycle.
Depo; day 1-5 of cycle

41. Exception; timing of method
If a health professional is reasonably sure that a woman is not pregnant or at risk of
pregnancy from recent unprotected sexual intercourse (UPSI), contraception can be
started immediately unless the woman prefers to wait until her next period. Such
practice may be outside the product licence/device instructions.

42. Follow up? Implant; none required IUD/IUS; follow up if any problems
Depo; every 12 weeks.

43. Case three 35 yrs, smoker, epileptic on carbamazepine
Taking high dose cocp
Bled++ on cerazette
What other options does she have and how would you help her make a decision?

44. Women on medication
Drugs which induce liver enzymes can reduce the efficacy of the contraceptive implant but do not appear to reduce the efficacy of depo contraception or the LNG-IUS

45. Special considerations
Management of bleeding problems
Late depo
(Women over 40)

46. Bleeding problems
Erratic bleeding common in early weeks with all larc’s.
Amenorrhoea at 12 months;
70% with depo
65% with Mirena
20% with implant

47. Case four age16, implant 6 months
No bleeding 4 months; now bleeding all the time
What do you need to ask her and how would you manage this problem?

48. Bleeding problems
Always consider underlying cause if there has been an obvious change in bleeding pattern.
Need to consider disease; eg chlamydia....gynae exam, swabs.
Consider pregnancy, exclude other gynae pathology.

49. Red flags
Development of a change in bleeding pattern following a consistent spell
Cervical screening defaulter
Pelvic pain, change in vaginal discharge
Dyspareunia
Failed trial of medical management

51. Bleeding problems; implant
Common; counselling important; commonest cause discontinuation
Consider trial dose COC for 3 cycles;
After; she may (or may not!) obtain acceptable pattern

52. Bleeding problems; depo
Consider giving next injection early, at 10 weeks.
May use NSAID, eg naproxen

53. Case five Age 18, gap year travelling in 6m time Focal migraine
Bleeding++ on cerazette
Any better options?
What do you discuss with her and advise?

54. Late depo 24 yr old , 13w since last depo Had sex twice in last week.
Is she at risk of pregnancy?
Can she have her injection?
What would you do in same scenario if it was 15 weeks since her last injection?

55. Late depo.
Can be given up to 2 weeks late ( ie 14 weeks) without need for additional contraception or pregnancy testing. Outside product licence After 14 weeks management depends on whether UPSI has occured and how many days after.( suggest check faculty guidance)Need to assess need for emergency contraception if required.

56. IUS; other uses Licensed for treatment of menorrhagia.
Licensed for progesterone component of HRT( licence for 4 yrs but FSRH guidance suggests adequate protection for 5 yrs)