Long-Acting Reversible Contraceptive Methods (LARC)

A patient presents to your office to be counseled regarding long-acting reversible contraception. In discussing the etonogestrel subdermal implant, you explain that the adverse effect most likely to lead to discontinuation of this contraceptive method is

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• Irregular uterine bleeding is the most common reason people discontinue using the etonogestrel implant. Studies suggest that more than 50% of patients request removal in the first 6 months because of irregular or frequent bleeding. The bleeding pattern experienced by patients following the first 3 months after insertion may be predictive of their bleeding pattern over the first 2 years. Only 50% of patients with unfavorable bleeding patterns in the first 3 months experience improvement. Options to treat unscheduled bleeding including addition of cOCPs, NSAIDs, mifepristone plus estradiol or doxycycline, or doxycycline alone, although improvement is generally minimal.

• Acne is commonly reported in users of progestin-only contraceptives. In implant users, 10-14% report worsening acne, although this symptom only accounts for 1-4% of all discontinuations. Amenorrhea occurs in approximately 20% of all implant users and accounts for approximately 1% of discontinuations.

• Etonogestrel does not have a significant effect on bone mineral density, unlike medroxyprogesterone acetate. Depo has a black box warning indicating a significant risk of bone mineral density loss that increases with duration of use longer than 2 years (although this is reversible). Weight gain is reported by up to 12% of implant users and accounts for only 2-4% of discontinuations.

A 22 year old nulliparous woman present for gynecologic care. She had a levonorgestrel IUD placed approximately 1 year ago. She reports monthly menses and no pelvic pain. On physical examination, the IUD strings are not visualized and cannot be visualized after sweeping the cervical canal. Urine pregnancy test result is negative. Pelvic ultrasonography fails to identify the IUD in the endometrial cavity. In addition to recommending back-up contraception, the best next step is

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• The most common cause for nonvisualized IUD strings is string retraction into the cervical canal. The first step in management is to use an endocervical cytobrush to sweep the strings from the canal. If strings are still not visualized, then evaluation of IUD location must be undertaken. A back-up method of contraception is recommended until the IUD can be confirmed to be in the appropriate location.

• Pelvic ultrasonography is the appropriate initial imaging study to confirm the IUD’s location in the endometrial cavity. If it is in the appropriate location, the IUD should be left in place and can be relied on for contraception.

• If ultrasonography cannot confirm the IUD’s location in the endometrial cavity, X-ray is the most appropriate next imaging step, imaging from the costal margin to the pubic symphysis. If the IUD is not seen, expulsion is diagnosed. The rate of expulsion for IUDs is approximately 2-3% and higher when the IUD is placed immediately postpartum. If x-ray confirms the IUD is located outside of the uterus, the diagnosis is perforation and the next best step is laparoscopy to remove the IUD as a foreign body in the peritoneal cavity can be associated with inflammatory changes and pelvic viscera injury. The rate of perforation is 1 per 1000 IUD insertions.

• CT and MRI are more expensive and time-consuming than plain film X-ray. Diagnositc hysteroscopy is not necessary given the ability of ultrasound to identify an IUD in the uterus. Evaluation for possible expulsion should be completed prior to surgical intervention with laparoscopy.

A 38-year-old woman, G3P3, presents 3 months after placement of a copper IUD. She currently experiences bleeding every 30 days, with 7 days of heavy bleeding. She is a smoker and has only moderately controlled hypertension because she forgets to take her medication regularly. She is currently sexually active with one partner. In addition to reassurance, the best next step to manage her heavy menses is to

add combined oral contraceptive pills

add NSAIDs

switch to combined oral contraceptive pills

switch to progestin-only pills

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· Copper IUDs can cause increased menstrual bleeding and cramping, which accounts for a discontinuation rate of 5-15% within 1 year of placement. The hypothesized mechanism is an excess of prostaglandins in the endometrial cavity.

· It is reasonable to offer reassurance when patients present with heavy bleeding, especially in the first 3-6 months. NSAIDs can be effective in reducing blood loss and pain associated with copper IUDs, as they are prostaglandin synthetase inhibitors.

· There is limited evidence to recommend adding a combined oral contraceptive to the IUD for 1-3 months in order to decrease bleeding and pain. In this patient, who is >35 years old and a smoker with hypertension, estrogen-containing methods are contraindicated, either in combination with the IUD or alone. Progesterone-only pills are an option, but they must be taken at the same time every day and are not the best option for this patient, who has told you she has difficulty taking her blood pressure medications.

· Tranexamic acid has been shown to improve heavy menstrual bleeding, but there is limited evidence for its use in women experiencing this as an adverse effect form an IUD. It is contraindicated in patients with a history of thromboembolic events and should be used with caution in patients with intrinsic thrombotic risk factors.