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LARCs Part 1

Megen Vo, MD and Lisa Patel, MD
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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. 
  • LARCs include:
    • Intrauterine Devices (IUDs)
      • Hormonal 
        • 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.
      • Non-hormonal
        • 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 shotDepo-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.

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September 2020 Peds RAP Written Summary 290 KB - PDF

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