Long-acting reversible contraceptive use has doubled in past decade

Evelyn Lewin

26/10/2020 4:25:51 PM

What do GPs and patients need to know about these devices that have ‘much lower failure rates’ than condoms or the pill?

Doctor holding an intrauterine device
Usage rate increases for IUDs were highest among the 35–39 and 40–44 age groups.

‘It’s a good result. It’s a wonderful form of contraception.’
That is Dr Alex Polyakov, a senior lecturer in the Department of Obstetrics and Gynaecology at the University of Melbourne and a consultant obstetrician, gynaecologist and fertility specialist at the Reproductive Biology Unit at the Royal Women’s Hospital in Melbourne.
He is talking to newsGP about new research published in ANZJOG that found the use of long‐acting reversible contraceptives (LARCs) has roughly doubled in the past decade.
The retrospective population-based observational study used Pharmaceutical Benefits Scheme (PBS) dispensing claims of etonorgestrel implant and levonorgestrel intrauterine devices (IUDs) in a 10% random sample of females aged 15–44 from 2006–18.
The study found that annual PBS claims for LARCs increased approximately two-fold, from 21.7 to 41.5 per 1000 women throughout the study period.
Rate increases for the implant were highest among the 15–19 and 20–24 age groups, while rate increases for the IUDs were highest among the 35–39 and 40–44 age groups.
Dr Polyakov is pleased to see the increased uptake. He says one of the main benefits of LARCs is that they are not user-dependent.
‘And so they have much lower failure rates,’ he said.
Dr Polyakov says user-dependent, short-acting forms of contraception such as the pill and condoms have much higher failure rates compared to LARCs’ failure rate of less than 1% with typical use.
They also have other benefits.
‘Most of them, like Mirena and Implanon, contain progesterone, so they decrease the probability of endometrial cancer,’ Dr Polyakov said.
Reduction in vaginal blood loss is another positive. 
‘The amount of blood loss is usually less [with both forms of LARCs], so they’re perfectly suitable for people who have heavy periods,’ he said.
‘Also, it’s worth noting that over the years they’re probably the cheapest forms of contraception because they’re both on PBS and the cost is really insignificant, considering that Implanon works for three years and Mirena works for five years.’
That is not to say that LARCs are without risks or side effects.
‘The risks of Implanon are damage to the nerves and blood vessels in the arm,’ Dr Polyakov said.
‘I think it’s a very low risk if it is inserted correctly by someone who is properly trained to do it.’
Dr Polyakov says other risks of Implanon include bruising and infection, both of which are uncommon.
Meanwhile, he says there is a ‘very low’ risk of uterine perforation upon inserting an IUD. Even if that occurs, Dr Polyakov says it is ‘very rare to actually cause damage’ even if a perforation occurs.
He says the main problem with both forms of LARCs is that vaginal bleeding patterns can become unpredictable after their insertion.
‘There is a certain proportion of women, whether you’re looking at Implanon or Mirena, who would have either continuous spotting or very irregular bleeding,’ he said.
‘And sometimes it’s quite heavy and, probably in about 10–15 % of patients, the device – either Implanon or Mirena – would have to be removed for that reason.
‘There is also the risk of emotional side effects because these devices are progesterone-based, and so people who are prone to emotional disturbance or depression may find that [these issues are] worse with these devices.’
While LARCs have potential risks, these should not necessarily deter health practitioners from prescribing them.
‘The good news is that both implants and IUDs are relatively easy to remove and so they are certainly worth a try,’ Dr Polyakov said.
‘And if side effects arise then they can be removed and some other form of contraception can be used.’
Dr Polyakov was glad to see the research also address a common misunderstanding regarding intrauterine devices such as Mirena.
‘There is this misconception that was raised in the [research] that women who haven’t had children should not use intrauterine contraceptives like Mirena,’ he said.
‘That is clearly wrong.
‘These contraceptives are suitable [for nulliparous women], it’s just technically a little bit more difficult to insert.’
Dr Polyakov would like to see more women offered LARCs as contraceptive options. He says this topic is routinely broached at the six-week postnatal check-up.
‘I also think if someone comes in for contraceptive counselling or for a renewal of a contraceptive pill the topic should be raised,’ he said.
He says practitioners should also be aware that both LARC options are suitable for teenagers, as well as older women.
‘Implanon is a great option for teenagers because they always forget to take the pill,’ he said.
‘Mirena is also an option, but it’s a little bit trickier to insert [if they are nulliparous].’
While the study found that use of LARCs has roughly doubled in the past decade, it noted a slowing in the rate of increase of LARC dispensing since 2016.
‘This was most pronounced for the use of the implant among those aged 15–24 years,’ the authors wrote.
‘Given that the slowing rate increase was observed among groups with the highest baseline rates, it is possible the observed plateau in the rate of LARC dispensing represents a ceiling effect of LARC uptake.
‘It is also possible that the plateau relates to a switch toward other forms of contraceptives, including non-hormonal LARCs.’
Dr Polyakov hopes to encourage further use of LARCs in women seeking contraception.
‘I think more GPs should be trained how to use these devices and counsel patients about how to use them and when to use them, etcetera,’ he said.
‘[LARCs] are a wonderful form of contraception which are much more effective than user-dependent options and, I can’t stress this enough, the failure rate is really very, very low.
‘There are certainly side effects and possible complications with both, but both side effects and complications can be managed.
‘Its use absolutely should be more encouraged by the medical profession because there are substantial benefits compared to other [contraceptive] options.’
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Dr Megan Elizabeth Elliott-Rudder   27/10/2020 11:41:17 AM

Younger women are better suited to Kyleena, released March 2020, particularly if they are nulliparous, low BMI, likely to have a smaller uterus.

Dr Melissa Ann Brown   27/10/2020 8:51:24 PM

I have been inserting IUDs in nulliparous women as young as 17 for years in my GP surgery, and I do not find it more technically difficult or taking any longer than inserting them for women who have had children. The discomfort of insertion is also variable and not necessarily worse in nulliparous women in my experience.