Are you up with the LARCs?

1. Are you up with the LARCs? Dr Christine Roke National Medical Advisor, Family Planning March 2011

2. Long Acting Reversible Contraception - LARC • Action less often than monthly • All less than 1% failure rate

3. Long Acting Reversible Contraception - LARC • Depo Provera injection • Intrauterine contraception • Implants

4. Longacting contraceptionWhy? • Methods that require something with every act of sexual intercourse or need to be taken every day have higher user failure rates • Combined pill has about 3% failure rate per year in every day use and 8% in first year of use • Women have first baby in NZ at about 30 • So average woman has more than 10 years contraceptive use before first baby • About 1 in 3 may therefore have an unintended conception in that time

5. Average woman has less than 2 children • So many years of contraception required when family complete with possible contraceptive failure

6. Depo Provera • Problem with women returning on time for subsequent injections • Now internationally recommended that “late” injection is more than 14 weeks since last injection • Still schedule next appointment for 12 weeks

7. Possible side effects • Most don’t put on weight • Most don’t have mood changes

8. Depo Provera and bone density • Depo Provera may reduce bone density by 5 – 7% over the first 2 years of use – it then plateaus • Caused by suppression of oestrogen • When Depo Provera discontinued, regain this loss of bone density over next few years

9. Bone density • Maximum increase in bone mass age 11-14, some sites reach peak bone mass by 18, others later • Reduced in anorexia nervosa, exercise-induced amenorrhoea etc • Increased in Maori and Pacific nation people

10. Depo Provera use • Can be used by adolescents if other methods unsuitable, especially if 18 or older • All ages - review at 2 years – risks and benefits • UK Faculty of Family Planning and Reproductive Health care, WHO

11. Intrauterine contraception • Now clear that STIs cause infection not IUDs beyond the initial insertion phase • Ideal to exclude STIs before insertion • If asymptomatic chlamydia found, can treat and insert IUD if reinfection not likely • If STI or PID diagnosed while IUD in situ, treat and only remove if not settling • IUDs can be used by nulliparous women (although they do have higher expulsion rate)

12. Intrauterine contraception • Fertility declines in 40s • Copper IUDs – if inserted when 40 or older, can stay until postmenopausal if no problems • Mirena - if inserted when 45 or older for contraception, can stay until postmenopausal if no problems

13. Implant

14. Jadelle • Progestogen-releasing rods • 2 rods of levonogestrel - lasts 5 years • inserted subdermally into upper arm under local anaesthetic by trained clinician • Subsidised from 1st August 2010 • Available on individual prescription (obtain trochar from Bayer NZ)

15. Action Slow release of progestogen which works by • Inhibiting ovulation for first year or so • Thickening cervical mucus • Oestrogen levels remain above threshold for loss of bone density

16. Jadelle efficacy

17. Side effects • Main side effect is change in bleeding pattern • Can have other hormonal side effects but lower hormonal levels than POP – headache, weight gain, acne • Scar for insertion and removal -occasionally local wound problem

18. Jadelle bleeding pattern • Irregular bleeding and amenorrhoea common • Settles to long term pattern over first 3 - 6 months • Bleeding less likely to settle with time than Depo Provera or Mirena • Bleeding problems are commonest reason for discontinuation • Spotting and irregular bleeding common – 14% (1 in 7) discontinue for this reason: • 5% for prolonged episodes of vaginal bleeding and spotting • 4% for irregular bleeding • 3% for heavy bleeding

19. Bleeding • Discussion of possible bleeding problems essential before insertion • Bleeding pattern possibly related to weight – lighter women more likely to have amenorrhoea, heavier women more likely to have more numerous bleeding days • Management of irregular bleeding • COC as long as oestrogen not contraindicated • NSAIDs 5 -10 days

20. Advantages • Rapid return of fertility when removed • Lower PID rates • Less dysmenorrhoea • Low ectopic pregnancy rate

21. Insertion • By day 7 or reliable contraception • Contraceptively effective immediately if inserted by day 5, otherwise 7 days • Contraindicated if breast cancer within last 5 years • Should not be used by those on enzyme inducing medication • Otherwise suitable for all ages provided able to manage possible bleeding problems • Superficial placement essential

22. Continuation and removal • Jadelle continuation rate at 2 years >80% • At 5 years 40% • Do not attempt removal if implants impalpable • Refer to interventional radiologist

23. New ways of taking COC • Tricycling = taking 3 packets of pills in a row without a break • Continuous = no breaks • Less risk of contraceptive failure • Less breakthrough bleeding with time but some women will find this spotting a problem – take 7 day break • No known medical concerns