Evidence-Based Strategies for Common Clinical Questions

The Most Effective Birth Control: Long-Acting Reversible Contraceptives

Author: Laura Kantor, MD | Pediatrics Resident

Column Editor: Kathleen Berg, MD | Co-Director, Office of Evidence-Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine 

Long-acting reversible contraceptives (LARCs) have been well established as safe and effective for teens, with rapid return to fertility following removal. However, LARC use among sexually active adolescents is only 2-3%.¹ Contraceptive implants and intrauterine devices (IUDs) are LARCs with the lowest rates of unintended pregnancy during the first year at less than 1%, compared to oral contraceptives (OCPs) at 9% and the male condom at 18%.² Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) have released policy statements encouraging LARCs as the primary method of contraception.^2,3 Pediatricians are pivotal to increasing access to LARCs for adolescents and therefore should be familiar with the indications, mechanisms of action, and limitations of currently available options.

The contraceptive implant is a radiopaque progestin-only device inserted subcutaneously into the upper arm to suppress ovulation.² Typical failure rate is <1% in the first year, and the implant may remain in place for up to three years. Placement and removal require a free, in-person training session sponsored by the product manufacturer.^1,2 Once the implant is placed, a backup method of contraception should be used for the first week. Additionally, condom use to prevent sexually transmitted infections is still strongly recommended. Implants are safe and effective immediately post-partum.^2-4 Contraceptive implants may cause irregular bleeding,^1,5 but may also improve dysmenorrhea or menorrhagia.⁵

IUDs are T-shaped devices placed through the cervix into the uterus during a speculum exam.⁵ Five approved IUDs in the United States include the copper IUD (Cu-IUD) and four progestin-only levonorgestrel IUDs (LNG-IUDs).³ The Cu-IUD is polyethylene wrapped with copper wire to prevent fertilization through inhibition of sperm migration and viability.³ It can be used when hormonal contraception is contraindicated or not desired, typically when an adolescent desires cyclical menses.⁵ The Cu-IUD is approved for use for 10 years and can be used as emergency contraception within five days of unprotected intercourse.⁵ Adverse effects commonly include heavier menstrual bleeding or cramping.³ The LNG-IUDs release levonorgestrel to prevent fertilization by increasing viscous cervical mucus impenetrable to sperm and thinning the uterine lining.³ LNG-IUDs are approved for use for three to seven years depending on the type.⁶ LNG-IUDs can be used to treat dysmenorrhea or menorrhagia and have a protective effect against endometrial cancer and no effect on risk of breast cancer.⁵ Irregular bleeding is expected for the first three to six months. However, menstrual periods may eventually stop, which may be desirable for teens.¹ Failure rate is <1% for IUDs with typical use, and there are no significant drug interactions.⁴ IUDs do not increase rates of sexually transmitted infections beyond 21 days post-insertion.^2,4 Rates of adverse events are low and can include expulsion (2-10% in the first year), perforation (<0.0014%), ectopic pregnancy (0.001%) and symptomatic ovarian cysts (3.5%).^1,7

Insertion and removal of IUDs do not require completion of a specific training program, but training may be sought through ACOG regardless of specialty or professional society affiliation.¹ Patient discomfort may be expected during placement. However, routine use of analgesic prophylaxis is not recommended.² Placement is contraindicated for patients with distorted uterine cavities, untreated cervical or endometrial cancer, unexplained vaginal bleeding, malignant gestational trophoblastic neoplasia, active genital tract infection, purulent cervicitis, or pelvic tuberculosis.^1,4 If asymptomatic, patients can be screened for sexually transmitted infections during placement and treated afterward if found positive.^2,5 IUD placement should be delayed only if the patient has active purulent cervicitis or if pregnancy cannot be reasonably excluded.¹

LARCs are the first-line contraceptive method for teens and highly effective at preventing unintended pregnancies.⁵ Additionally, LARCs often have desirable secondary effects for teens, including reducing menstrual flow, which can be beneficial in those with secondary anemia or dysmenorrhea.¹ There are few contraindications to LARC use. However, in a survey of 561 pediatricians, most (88%) reported counseling about contraception, including LARCs (64%), but only 4% reported inserting them.⁷ Another interview-based study identified challenges to placement of LARCs, including lack of training for pediatricians and lack of necessary tools for on-site IUD insertion in pediatric offices.⁸ These barriers could be removed to offer more valuable contraception therapy for adolescents. The following resources provide LARC placement training opportunities as well as state-based consent resources to help pediatricians provide this evidence-based contraceptive care.

References:

1. Menon S; COMMITTEE ON ADOLESCENCE. Long-acting reversible contraception: specific issues for adolescents. Pediatrics. 2020;146(2):e2020007252. doi:10.1542/peds.2020-007252
2. Committee on Adolescence. Contraception for adolescents. American Academy of Pediatrics Policy Statement. Pediatrics. 2014;134(4). doi:10.1542/peds.2014-2299 (Reaffirmed March 2021).
3. The American College of Obstetricians and Gynecologists. Practice Bulletin No. 186: Long-acting reversible contraception: implants and intrauterine devices. 2017. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices Published 2017. Accessed September 22, 2021.
4. Curtis KM, Tepper NK, Jatlaoui TC, et al. US medical eligibility criteria for contraceptive use 2016. MMWR Recomm Rep. 2016;65(3):1-103. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html Accessed September 22, 2021.
5. Francis JKR, Gold MA. Long-acting reversible contraception for adolescents: a review. JAMA Pediatr. 2017;171(7):694-701. doi:10.1001/jamapediatrics.2017.0598
6. Mirena [package insert]. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2021. 
7. Fridy RL, Maslyanskaya S, Lim S, Coupey SM. Pediatricians' knowledge and practices related to long-acting reversible contraceptives for adolescent Girls. J Pediatr Adolesc Gynecol. 2018;31(4):394-399. doi:10.1016/j.jpag.2018.01.004
8. Norris AH, Pritt NM, Berlan ED. Can pediatricians provide long-acting reversible contraception? J Pediatr Adolesc Gynecol. 2019;32(1):39-43. doi:10.1016/j.jpag.2018.09.008