The Generalist: Long-Acting Reversible Contraception (LARCs)

The Generalist: Long-Acting Reversible Contraception (LARCs)

Ben Shepherd, MD; Penny Wilson, MD; and Vanessa Cardy, MD

In this two-part segment, Aussies Ben Shepherd and Penny Wilson bring us up to speed on topics that are near global in their appeal and use: emergency contraception and long-acting reversible contraception (LARC)

• The American College of Obstetricians and Gynecologists (ACOG) recommends LARCs as “the most effective reversible contraceptive methods … including for adolescents”
• Perfect use and real-world use are almost the same with LARCs:
• Rates of unexpected pregnancy are well below 1%.
• For oral contraceptive pills (OCPs), pregnancy rates = 9%.
• Two main forms of LARCs
• IUD
• Copper
• Works by inhibiting fertilization (copper is “toxic to sperm”)
• Levonorgestrel IUD (Mirena, Skyla, Kyleena, Jaydess)
• Thickens the cervical mucus to inhibit sperm motility
• Causes atrophy of the endometrial lining
• Can sometimes (not always) inhibit ovulation
• Etonogestrel subdermal implant (Nexplanon or Implanon)
• Similar to levonorgestrel IUD, but more effective inhibition of ovulation 
• Barriers to LARC use
• Cultural expectations and patient preferences
• Cost and access to skilled inserters 
• Health provider knowledge and attitudes 
• History of IUDs:
• Early IUDs in the 1970s caused PID and tubal infertility. 
• Modern IUDs do not.
• Side effects
• LARCs are generally well tolerated. 
• Changes in bleeding pattern and cramping can occur:
• Heavy or painful bleeding; highest risk with copper IUD
• Levonorgestrel IUD is very unlikely to cause increased bleeding, usually significantly decreased or absent bleeding 
• Can settle in first few months
• Impact of implant varies
• Hormonal options can cause progestin side effects: 
• More likely with implant than with IUD
• Headaches, acne, change in libido, appetite or weight change
• Contraindications
• IUDs
• Uterine and cervical infections 
• Active cervical cancer
• Concerning uterine bleeding
• Uterine anatomic anomalies
• Levonorgestrel IUD/etonogestrel implant
• Current or recent breast cancer
• Severe liver disease
• Refer to the CDC for the full list of risks and benefits: 
• https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixk.html.

PEARL: LARCs are well tolerated by most women; they are significantly more effective and have fewer contraindications than other hormone-based forms of contraception.