In India, about half of the pregnancies are unplanned, according to a study published in the Lancet Global Health. These women are candidates for contraceptive services and counseling. The unplanned pregnancies are associated with increased risks of child and maternal morbidity and add to socioeconomic and mortality burden of the society. Thereby, increasing access to long-acting reversible contraception (LARC) is a critical strategy for decreasing the rate of unplanned pregnancy.
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LARC includes the subdermal implant and intrauterine devices (IUDs). It is highly efficacious and associated with high rates of continued contraception. Despite a majority of patients being medically eligible for LARC use, it is underutilized (14.3% of all contraceptive use) vs sterilization (28.2%) and hormonal contraception requiring user involvement (31.8%).
FDA Approved LARC
The US Food and Drug Administration (FDA) approved contraceptive use includes 1 copper and 4 levonorgestrel-containing IUDs and 1 progestin implant. The progestin implant is placed subdermally with local anesthesia in the upper arm. LARC devices can be inserted and removed by trained professionals (including primary care clinicians) in the office setting without sedation.
The copper IUD is the most effective method of emergency contraception available (if placed within 5 d of unprotected intercourse; duration, 10-12 y); it inhibits fertilization through spermicidal effect.
LARC provides greater efficacy compared with short-acting hormonal methods that require user involvement. Because LARC requires no user involvement, its effectiveness with typical use (eg, patient adherence) matches its theoretical efficacy with perfect use (>99%). In contrast, the effectiveness of oral contraceptives with typical use is substantially lower (91%) than theoretical efficacy with perfect use (>99%).
One potential shared disadvantage of LARC is expensive out-of-pocket costs ($500-$1000 for the device plus costs for the office visit and procedure) for patients who lack full contraceptive coverage.
Debunking Myths about LARC Safety
Underutilization of LARC is largely contributed to misunderstandings about its safety. Concerns that women who are nulliparous, unmarried, or adolescents are at higher risk for pelvic inflammatory disease and infertility from using FDA-approved IUDs are not supported by current literature. Any risk of pelvic infection associated with IUD insertion is very low (0.5%) and limited to several weeks postinsertion. IUD users have a lower absolute risk of ectopic pregnancy than non-IUD users, but in the rare event that IUD users become pregnant, the relative risk of ectopic pregnancy is elevated. Patients concerned about devices getting lost should be informed that uterine perforation from IUDs is rare (1/1000 insertions) and distant migration of properly placed subdermal implants is rare (case reports). Upon removal of LARC, baseline fertility rapidly returns. Requirements that LARC only be inserted during menses unnecessarily delay access; LARC can be inserted anytime pregnancy has been reasonably ruled out, based on history and urine pregnancy testing.
Noncontraceptive benefits of LARC can improve health outcomes. Levonorgestrel-containing IUDs can treat menstrual-related disorders. By decreasing menses, levonorgestrel-containing IUDs can improve anemia and prevent surgical interventions to treat fibroids and endometriosis. Progestin-containing LARCs can alleviate symptoms related to other menstrual-related conditions, such as dysmenorrhea and migraine headaches. Because progestins suppress endometrial proliferation, the levonorgestrel-containing IUD has been used to treat atypical endometrial hyperplasia.
The Centers for Disease Control and Prevention provides evidence-based resources that summarize patient eligibility for different contraceptive methods based on selected patient characteristics and medical conditions. LARC is well suited for patients with medical problems that pose contraindications to estrogen use, including poorly controlled diabetes or hypertension, current or past venous thromboembolism, migraines with aura, and cigarette smokers (aged ≥35 years). All LARC devices can be placed right after birth or abortion, providing immediate contraception. The copper IUD will not interfere with lactogenesis. Multiple randomized clinical trials and observational studies have failed to demonstrate any negative effects of progestin-containing contraceptives (shot, implant, progestin only pills) on the quality of maternal lactation or first-year infant growth.
For further information follow the link: 10.1001/jama.2018.8877
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