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LARCs Part 1
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According to the 2017 Youth Risk Behavior Survey, nearly 40% of US teens reported ever having sex; however, only 54% reported using a condom at last intercourse, 37% reported using a hormonal method, and 14% reported not using anything to prevent pregnancy. On the flip side, we know that long-acting reversible contraceptives are recommended as first-line for adolescents for contraception. So why aren’t teens using them? Long-acting reversible contraception (LARCs) include the copper intrauterine device (IUD), the hormonal (progesterone-only) IUD, and the progesterone-only subdermal implantable rod. When used correctly, the failure rate for these is <1%. The benefits are that each of these methods is effective for up to 3-10 years, but can be removed at any time with rapid return to baseline.
- The CHOICE project showed that LARCs are acceptable and preferred by adolescents if given appropriate counseling and access.
- ACOG and the AAP agree LARCs should be presented as the first line option for teens.
- The CDC medical eligibility criteria chart is a nice resource to assess the contraindications of each contraceptive option.
- LARCs include:
- Intrauterine Devices (IUDs)
- These are progesterone only and therefore are beneficial for women who should not or do not tolerate an estrogen component.
- Abnormal uterine bleeding (AUB) should be worked up prior to placement of an IUD.
- There are 3,5 and 6 year hormonal IUDs on the market. A daily amount of hormone is released from the plastic IUD with a progesterone reservoir.
- The 5 year hormonal IUD: levonorgestrel-releasing intrauterine system (trade name Mirena) is also indicated for dysmenorrhea.
- 60-80% of women who use the Mirena will become amenorrheic.
- The 6 year hormonal IUD levonorgestrel-releasing intrauterine system (trade name Liletta)
- 50% of women who use the Liletta will become amenorrheic after 2 years.
- The copper IUD (trade name Paragard) is the longest acting IUD (use for 10 years) uses copper ions as spermicide to inhibit implantation.
- It can also be used for emergency contraception.
- Some contraindications for IUDs include: known uterine anomaly and/or large fibroids.
- The “type” of period an adolescent is having won’t change with the copper IUD; that is, if a teen has a very heavy period prior to use of Paragard, this will not change.
- Subdermal Implant: etonogestrel implant (trade name: Nexplanon)
- This is a 3-5 year plastic progesterone only rod that goes under the skin of the arm.
- The main mechanism is to thicken the cervical mucus; inhibiting transport and thinking the uterine lining to make it less habitable.
- There is also, however, some effect on ovulation and therefore, once removed there might be some lag time prior to becoming pregnant.
- About 20% of women with Nexplanon will become amenorrheic because there is less of a local effect.
- The effect on monthly periods is variable. About half of women may not notice much of a difference, about a third of women may have daily spotting and others it might be more random.
- Long acting injectable hormone shot: Depo-Provera
- Second line contraception options for adolescents include: birth control pills (daily), patches (weekly) and rings (monthly) which all require some frequency of use and therefore have the risk of inherent human error.
- Third line contraception includes condoms.