Long-Acting Reversible Contraception: Comparing Methods

Charles P. Vega, MD; Anna L. Altshuler, MD, MPH


January 22, 2016

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Charles P. Vega, MD: Hello. I'm Charles Vega, and welcome to Critical Issues in Medicine. Today we're focusing on women's health. I am a clinical professor of family medicine at the University of California at Irvine. I'm delighted today to be joined by Dr Anna Altshuler, who is an obstetrician/gynecologist at California Pacific Medical Center in San Francisco, California. Anna, welcome.

Anna L. Altshuler, MD, MPH: Thank you, Chuck. It's nice to be here.

Nexplanon vs the Others

Dr Vega: We talked about contraception broadly last time, but with a real focus on long-acting reversible contraception (LARC), and we spent some time discussing intrauterine devices (IUDs)—specifically, that they are generally highly effective, well tolerated, offer some advantages in particular populations, and are underused.

Today I wanted to talk about another type of LARC, Nexplanon® (etonogestrel implant), and compare and contrast this method with others. Nexplanon is a very thin rod, 2 mm wide and about 4 cm long, that is inserted in the upper arm, provides a fairly steady dose of hormones, and is effective for up to 3 years. Therefore, it can be a good option as a sure method for contraception. It was also designed with the idea of being easier to both implant and remove compared with previous implanted devices.

We talked about some of the advantages and potential disadvantages of IUDs, but this implanted system is another long-term option. Anna, which patients might be better for one vs the other?

Dr Altshuler: I first want to mention that the Nexplanon is just as effective as IUDs, if not more so, with a similar efficacy of greater than 99%. The way I counsel patients in deciding which device is right for them is just describing what it is like. For some patients, having something in their uterus is something that they're not interested in, and the implant offers a nice alternative because it's in the arm. They are able to palpate the device, so it tells them that it's there. The challenge with an IUD is that it's hard to reach the strings, and people lose awareness that it's there. Some women may become paranoid that it may have fallen out or it's not working anymore. This is rarely the case, but still, there is this paranoia that may be added based on the location.

The procedure for insertion of Nexplanon is simpler than it is for the IUD. It's done in the office, it takes about 5 minutes, and it requires less training and less knowledge of anatomy to be able to insert the Nexplanon compared with the IUD. The risks associated with insertion are also much lower. We hadn't talked about this before, but for the IUD, there's a small risk for uterine perforation, whereas with the Nexplanon, there is very little, if any, risk for injury to any organs. Also the discomfort of insertion is greater with an IUD. It can cause pretty strong menstrual-like cramps at the time of insertion. I frequently tell patients that it's brief but intense, so when they're uncomfortable, it's shortly going to end. With the Nexplanon, we numb the skin in the area where the device is going to go in, so there's very little pain, if any.

Dr Vega: Is backup contraception necessary after insertion of Nexplanon?

Dr Altshuler: Yes. We recommend using a backup method for 1 week for women initiating the method and not switching from another hormonal method to the Nexplanon.

Dr Vega: That's relatively short compared with initiation of oral contraceptive pills, correct?

Dr Altshuler: That's right. The copper IUD, however, is immediately effective, so there is no backup method necessary for that one in particular. Another point is that women may make a decision about which device is best for them based on systemic vs local hormonal effects of the device. For example, the copper IUD has no hormones, so that may be an option for women who don't want to have any exogenous hormones as their method of contraception. When we're discussing Nexplanon compared with the levonorgestrel IUD, the Nexplanon releases a systemic hormone, etonogestrel, whereas the levonorgestrel IUD really works locally in the uterus by releasing the hormone there, making the uterine lining thin, and thickening the cervical mucus as the way to prevent pregnancy. Some women prefer having something that's more locally active rather than systemic.

The most important point that I discuss with patients is the bleeding pattern. The biggest downside to the implant is that the bleeding pattern may be unpredictable. It's more unpredictable than it is with levonorgestrel and copper IUDs, so anticipatory guidance is extremely important. There are three possible changes that women might experience once they have the implant, and it's hard to predict who's going to experience what. The most common bleeding pattern is infrequent bleeding, which happens about a third of the time. Amenorrhea is possible as well, as it is with a levonorgestrel IUD. A minority of women (about 15%) will experience prolonged bleeding or more frequent bleeding. Those profiles are problematic, so it's important to give women the right information about what to expect. Tell women that you are not sure what their experience will be and outline the possibilities. It's always important to communicate that if a bleeding profile is unacceptable to the woman, she can always return, and we can try another form of contraception.

Dr Vega: That's why they're reversible, right? How do you compare the Nexplanon implant with depot medroxyprogesterone acetate (DMPA; Depo-Provera®) injections? Hormone levels, particularly serum progestin levels, and side effects could be different in the implant vs DMPA injections administered every 3 months.

Dr Altshuler: That's right. Most women don't make the decision based on the amount of hormone that's in the implant vs the injection. They're typically deciding based on the duration of coverage. With the DMPA injection, a woman has to come back every 3 months, whereas the Nexplanon implant is in place for up to 3 years, so that's usually the deciding factor rather than the quantity of hormone.

Depo-Provera has the highest amount of progestin compared with any other contraception available in the US market. It's much more likely to achieve amenorrhea compared with the implant, which may be acceptable or desirable for some women. The other thing to note is that with the injection, there may be delayed return to fertility. For some women, that's up to a year, whereas with the implant, woman may be ovulatory the next cycle after it is removed.

Considerations in Adolescents

Dr Vega: I want to spend a minute just discussing the use of these LARC methods among adolescents. We know that approximately 30% of young women will become pregnant prior to the age of 20 years, even though rates of teen pregnancy are declining.[1] It was really interesting to me to see a recent study conducted in the St Louis region involving over 1400 adolescent females who were provided comprehensive contraceptive services and allowed to choose an LARC.[2] Teens who chose an IUD were given the option to have it placed that very day, which, as we discussed in our earlier conversation, is a streamlined approach that offers patients a better level of care. In this study, over 70% of these young women chose an LARC method; and, compared with national rates, the rates of pregnancy were reduced by 41% and the rates of elective abortion were reduced by one third. This is really what we're aiming for here.

Can you comment on the use of LARCs among adolescent females and what you see as some of the barriers and potential advantages of the LARC?

Dr Altshuler: Definitely. For a long time, there was this belief that adolescents or nulliparous women were not candidates for IUDs. The situation is different with the implants because they are a newer method and not inserted into the uterus. Based on the best evidence that we have available to us, adolescents are eligible for all methods of contraception including IUDs, which is sort of a new concept. A lot of clinicians, and the women themselves, may not be aware of that. There's this common misconception that you start using the pill when you're maybe in high school or college, and if that fails or becomes difficult to use because a woman forgets to take a pill every day, for example, then she may transition to the IUD. But this is an old approach.

The most recent approach, one that the CHOICE project in St Louis used, is tier-based counseling.[2] When we're talking to patients, we need to discuss all methods that are available. We try to counsel based on effectiveness. We start with the most effective forms of contraception first, which include the IUDs and the implants, and if those are unacceptable for whatever reason, we go down to the second-tier methods, which include pills, injections, the etonogestrel/ethinyl estradiol vaginal ring, and hormonal patches. As is true for all other areas of medicine, we start with what's most effective, and then we adjust based on people's preferences.

Dr Vega: That makes a lot of sense, particularly as you are keeping patients' beliefs and desires in mind. It's a very common-sense approach to counseling in particular for higher-risk groups who we know have a higher rate of unintended pregnancy.

Dr Altshuler: That's right. People still tend to choose the method that their friends use and the one with which they are most familiar. That's why pills still tend to be the most common method. The other important issue is access. Pills are easy. It's easy to receive a prescription and to fill it at the pharmacy. Also, pills have other indications, such as treating acne or heavy uterine bleeding. Those other uses provide cover, if you will, and may make it easier to conceal that the teen is using it to protect herself from pregnancy because having sex as a young person may be taboo in her community. That's why pills have been around the longest and also are the go-to method for a lot of young people. As we had talked about, the LARC methods offer many advantages because they're the forgettable methods. Someone can get it and have protection for a number of years without having to remember to take something daily, weekly, or monthly, with no need to get refills or return to the doctor for check-ups related to the contraceptive method.

Confidentiality is also really important for adolescents. That's one aspect that's unique to adolescents. Their health insurance is through their parents, and so their parents may find out that they're receiving one of these devices. It's important to have referrals in place so a patient can go to a place where LARCs are publicly funded, and they can receive the device for free. As the CHOICE project showed, improving access by providing contraception at no cost really increased uptake of these methods.

Dr Vega: As a clinician, I'm certainly mindful that an adolescent is on their parents' insurance, and I try to keep their family planning options confidential. That is difficult over time when there is a frequent need for a refill on a prescription. It's hard for both the clinician and the adolescent to maintain that level of confidentiality. Eventually there could be an issue that can lead to real consequences in the home, none of which are probably as significant as becoming pregnant. In the end, it usually seems to work out, but it takes the right level of communication. Particularly if the teen feels like they are struggling, it's definitely worth having a family conference as soon as possible to allow all sides to take ownership of the issue and have a frank and open discussion. I find that these meetings are highly effective and can make the relationship between the adolescent and the caregivers better as well. It can be difficult, but I think it is absolutely something for which we should take responsibility and be leaders. It can lead to a lot of good things.

Dr Altshuler: The last thing I want to mention is an older, historic concern that young women who get IUDs might become infertile as a result of the IUD. That's a common myth among young people who are obviously looking into the future and don't want to interfere with their ability to get pregnant sometime down the road. The reality is that IUDs don't cause infertility, and it's a common misconception that has not been proven to be true.

Dr Vega: There are a lot of great advances that can be implemented in a very patient-centered way, including with adolescents. The outcomes of reductions in unintended pregnancy and elective abortions are really important ones and are what we're trying to achieve with family planning and patient care overall.

Dr Altshuler: Even though LARCs are the most effective strategy in family planning, which, at its core, is the ability to determine if and when to have children, some people will still become pregnant while using contraception. In an effort to provide comprehensive reproductive care, we should counsel patients in advance about their options if they end up in this situation. As we know, options include parenting, adoption, or abortion. The decision to not have a child is common in the United States. About 1 in 3 women has an abortion,[3] so we all know women who've had abortions—many of our patients and many of our family members.

Despite it being so common, physicians rarely discuss abortion with their patients. Women hear about abortion in the media where it's heavily politicized and sensationalized. As a consequence, many women lack correct medical information that abortion is very safe and legal. It's important for us as clinicians to have open conversations with our patients to reinforce that if a pregnancy occurs, we will help her attain whatever she decides.

Dr Vega: Anna, I'd like to say thanks very much for your time and insight. To our listeners, please return and join us for our last segment on critical issues in women's health.

Dr Altshuler: Thank you.


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