Long acting reversible contraceptive’s

1. Long acting reversible contraceptive’s Aims; to give you basic knowledge to be able to give women good advice and manage some of the common scenarios which occur.

2. Why LARC’s? Cost effectiveness(nice 2005) Reliable Safe Reversible

3. Larc’s Includes implants, injectables,IUD and LNG-releasing IUS(Mirena) All methods more cost effective than cocp at one year. Implant , IUD and IUS more cost effective than depo.

5. Teenage Pregnancy Strategy 1999 To reduce the under 18 conception rate by 50% by 2010! “Increasing use of larcs will reduce unwanted pregnancies” ….NICE

7. Abortions in 2012 • Total number England and Wales in 2012 185,122, 2.5% less than in 2011. • 91% carried out <13 weeks • 48% medical abortions • 97% of these are funded by the NHS

8. 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

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

10. Mirena IUD

11. Copper IUD’s

12. Implant; Nexplanon

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

14. 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.

15. Case one • Plans for further children • Sexually active since delivery? • Using condom? • Previous contraceptive methods • Discuss larc methods, consider leaflet, show devices • Counselling regarding methods. • If undecided arrange another appt.

16. 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

17. How does it work? IUD: prevents fertilisation (primarily) and implantation. It is therefore not abortifacient. IUS: prevents implantation and possibly fertilisation. Implant and depo; prevent ovulation

18. 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) DMPA; 12 weeks Implant; 3 yrs

19. 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)

20. Side effects and risks; IUD/IUS IUD; heavy painful periods IUS and IUD;expulsion 1in 100 Perforation; 1 in 1000 (PID;<1% low risk women)Maximal in 20 days after fitting; screen at risk. COUNSEL AND DOCUMENT

21. 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

22. 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?

23. 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

24. Depo; monitoring • Age 40,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?

25. 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

26. Depo and bone density 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.

27. Side effects and risks; implant Bleeding; counsel with care, document. Commonest reason for removal NO evidence effects on weight, mood, libido, BMD, headaches

28. Timing of method IUD and IUS; usually in first week of cycle Implant; day 1-5 of cycle. Depo; day 1-5 of cycle

29. 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.

30. Follow up Implant; none required IUD/IUS; check at 6 weeks then only if problems Depo; every 12 weeks.

31. 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?

32. 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

33. Special considerations Management of bleeding problems Late depo Women over 40

34. 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

35. 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?

36. 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.

37. Bleeding problems; implant Common; counselling important; commonest cause discontinuation Consider trial 20-30 dose COC for 3 cycles; After; she may (or may not!) obtain acceptable pattern

38. Bleeding problems; depo Consider giving next injection early, at 10 weeks. May use mefenamic acid.

39. 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?

40. 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?

41. Late depo. Can be given up to 2 weeks late ( ie 14 weeks) without need for additional contraception or pregnancy testing. 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.

43. Case six A 51 year old lady comes to discuss her Mirena IUS. She has now had this for 5 years. She is wondering if she needs to have it replaced. She is not having any bleeds. What do you advise her?

44. Women over 40; IUD and IUS If over 40 when IUD fitted can leave until contraception no longer required (amenorrhoea for 12 months if over 50 or 2 yrs if under 50) Women who have the LNG-IUS inserted at the age of 45 or over for contraception can retain the device until the menopause is confirmed of contraception no longer required.

45. Menopause? Faculty guidance • To help determine when contraception no longer needed with progesterone only methods. • Measure FSH level. If>30 on 2 occasions, 6 weeks apart; may stop method 1 year later.

46. IUS; other uses Licensed for treatment of menorrhagia. Licensed for progesterone component of HRT( 4 yrs)

47. Abortions 2012 England and Wales • Under 18 abortion rate was DOWN 12.8 per 1000 women (15 per 1000 in 2011) • Total rate ( age 15 to 44) was 16.5 per 1000, 5.4% lower than in 2011.