Long-acting reversible contraception continued

Cost effectiveness

• LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use

• IUDs, the IUS and the implant are more cost effective than injectable contraceptives

• Increasing the use of LARC will reduce unwanted pregnancies

The Care Pathway

Informed consent for special groups

• Information should take into account the woman’s needs

• If needed, offer support with decision making such as:
  • an interpreter for women who do not speak English
  • an advocate for women with sensory impairments or learning disabilities
• Be aware of the law on providing contraceptives for young people and people with learning disabilities

• Follow the Fraser guidelines when providing contraception for women younger than 16 years

• Look at contraceptive choices in terms of the needs of the woman, rather than relieving anxieties of carers or relatives

• If a woman is unable to understand and take responsibility for decisions about contraception, carers and others should meet to agree a care plan

Consent for unlicensed use

• When using a LARC method outside its UK Marketing Authorisation, always discuss this, obtain informed consent, and document this in the notes

Long-acting reversible contraception continued

Training and referral

• All healthcare professionals providing LARC methods need training in the relevant skills

• Staff should fit IUDs and the IUS only if they are trained, and if they fit at least one IUD or IUS a month

• Practices and services that do not offer LARC methods should have an agreed mechanism for referring women

• If a woman being treated for a current venous thromboembolism needs hormonal contraception, refer her to a specialist in contraceptive care

Choice of method for different groups of women

• All LARC methods are suitable for:
  • nulliparous women
  • women who are breastfeeding
  • women who have had an abortion (at time of abortion or later)
  • women with BMI >30
  • women with HIV
  • encourage safer sex
  • women with diabetes
  • women with migraine with or without aura – all progestogen-only methods may be used
  • women with contraindication to oestrogen
• Choices for adolescents:
  • IUD, IUS, implants: no specific restrictions to use
  • DMPA: care needed; use only if other methods unacceptable or not suitable
• Choices for women more than 40 years old:
  • IUD, IUS, implants: no specific restrictions to use
  • DMPA: care needed, but generally benefits outweigh risks
• Choices for women post-partum, including breastfeeding:
  • IUD, IUS: can be inserted from 4 weeks after childbirth (see page 4)
  • DMPA, implants: any time after childbirth
• Choices for women taking other medication:
  • IUS, DMPA: no evidence that effectiveness of other medication reduced
  • implants: not recommended for women taking enzyme-inducing drugs
• Choices for women with epilepsy:
  • IUD, IUS, DMPA: no specific contraindications; DMPA use may be associated with reduced seizure frequency
  • implants: not recommended for women taking enzyme-inducing drugs
• Choices for women at risk of sexually transmitted infection (STI):
  • IUD, IUS: tests may be needed before insertion
  • DMPA, implants: no specific contraindications
  • provide advice on safer sex

Long-acting reversible contraception continued

Copper intrauterine devices and the intrauterine system

Use in women over 40

• IUDs: Women aged 40 years or older when their IUD is inserted can keep it until they no longer need contraception, even if this is beyond the duration of the UK Marketing Authorisation

• IUS: Women who are aged 45 years or older when their IUS is inserted and are amenorrhoeic may keep it until they no longer need contraception, even if this is beyond the duration of UK Marketing Authorisation

Assessing and managing STIs and other infections

• Before inserting an IUD or IUS, test for:
  • Chlamydia trachomatis in women at risk of STIs
    • Neisseria gonorrhoeae in women at risk of STIs in areas where it is prevalent
    • any STIs in women who request it
• For women at increased risk of STIs, give prophylactic antibiotics before inserting an IUD or IUS if testing has not been completed

• For women with identified risks associated with uterine or systemic infection, arrange investigations, and give appropriate prophylaxis or treatment before inserting an IUD or IUS

When fitting

• The risk of uterine perforation is related to the skill of the healthcare professional inserting the IUD or IUS

• IUDs only: When choosing an IUD, consider the licensed duration of use, and the fact that the most effective IUDs contain at least 380 mm² of copper and have banded copper on the arms

• Provided it is reasonably certain that the woman is not pregnant, an IUD or IUS may be inserted:
  • at any time during the menstrual cycle (but, for the IUS, if the woman is amenorrhoeic or it is more than 5 days since her period started, she should use barrier contraception for the first 7 days after insertion)
  • immediately after first or second trimester abortion (or at any time afterwards)
  • from 4 weeks post-partum, irrespective of the mode of delivery
• If the woman has epilepsy, have emergency drugs including anti-epileptic medication available because seizure risk may be increased at the time of fitting an IUD or IUS

• Women with a history of venous thromboembolism may use the IUS

• Give the woman information about follow-up and when to seek help about problems (see table on pages 6–7)

Follow-up and managing problems

• At first follow-up visit (after the first menses, or 3–6 weeks after insertion), exclude infection, perforation or expulsion

• IUD only: For heavier and/or prolonged bleeding associated with use of an IUD:
  • treat with non-steroidal anti-inflammatory drugs and tranexamic acid
  • or suggest changing to the IUS if the woman finds bleeding unacceptable
• If Actinomyces-like organisms are seen on a cervical smear, assess for pelvic infection, and remove the IUD or IUS if there are signs of infection

• If a woman becomes pregnant with an intrauterine pregnancy, advise removal of the IUD or IUS before 12 weeks’ gestation, whether or not she intends to continue the pregnancy

Long-acting reversible contraception continued

Injectable contraceptives

When administering

• Give by deep intramuscular injection into the gluteal or deltoid muscle or the lateral thigh

• Provided it is reasonably certain that the woman is not pregnant, use may be started:
  • up to and including the fifth day of the menstrual cycle without the need for additional contraceptives
  • at any other time in the cycle, but barrier contraception should be used for the first 7 days after injection
  • immediately after first or second trimester abortion, or at any time afterwards
  • at any time post-partum

Follow-up and managing problems

• Repeat injections of DMPA may be given up to 2 weeks late without the need for additional contraceptives

• Treat persistent bleeding associated with DMPA use with mefenamic acid or ethinylestradiol

• When considering DMPA use beyond 2 years, review the woman’s clinical situation, discuss the balance of benefits and risks, and support her choice

• There is no evidence of congenital malformation to the foetus if pregnancy occurs during DMPA use

Implants

When fitting

• Provided it is reasonably certain that the woman is not pregnant, etonogestrel implant may be inserted:
  • at any time (but use barrier methods for first 7 days if the woman is amenorrhoeic or it is more than 5 days since menstrual bleeding started)
  • immediately after abortion in any trimester
  • at any time post-partum
• Give the woman information about what to expect, and when to seek help about problems (see table on pages 6–7)

Follow-up and managing problems

• No routine follow-up is needed but the woman should be strongly encouraged to return to discuss problems, if she wants to change her method of contraception, or if it is time to have the implant removed

• Treat irregular bleeding with mefenamic acid, ethinylestradiol or mifepristone

• Remove the implant if a woman becomes pregnant and continues with the pregnancy, although there is no evidence of a teratogenic effect

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG30

National Institute for Health and Clinical Excellence. Long-acting reversible contraception Quick Reference Guide. October 2005