5.6: Long-Acting Reversible Contraception

Learning Objectives

By the end of this section, you will be able to:

• Compare and contrast the different types of intrauterine contraception devices
• Compare and contrast the different types of contraceptive implant devices
• Discuss the benefits and complications of LARC devices

A long-acting reversible contraception (LARC) option is the most effective form of contraception available (ACOG, 2024); LARCs include intrauterine contraception devices and contraceptive implants. The efficacy of these devices is the same as or better than that of female sterilization. However, LARCs are easily placed in the office, and no activity restrictions or downtime is necessary after insertion. Additionally, when the person desires to discontinue this method, the return to fertility is immediate. LARCs are cost-effective and can be used for extended periods of time, some for up to 10 years. They do not provide protection against STIs.

Long-Acting Reversible Contraception: Benefits and Complications

The major benefit to LARCs is their high degree of protection against unintended pregnancy, a pregnancy that is unwanted or mistimed (Kopp Kallner, 2018). Research has consistently shown that LARCs are the most effective choices for people in their childbearing years. Interestingly, LARC use is still very low among adolescents, a group at high risk of unintended pregnancy and low adherence to contraception. Nurses in contraceptive clinics can advocate for this high-risk group to choose LARC methods, highly effective contraception that is not dependent on teens remembering to use it.

Benefits

The risks associated with LARC methods are very low and without the risks of blood clots, strokes, and myocardial infarction that are present with estrogen-containing methods. This benefit allows higher-risk persons the option of safe, reliable contraception. In addition, when using a LARC method, the occurrence of amenorrhea is high. The absence of menstruation in a person with ovaries and a uterus, who is of reproductive age is considered amenorrhea. Persons with anemia due to menorrhagia, very heavy or prolonged menstrual bleeding, will have minimal monthly bleeding, offering protection from anemia. Use of LARCs also greatly reduces the incidence of dysmenorrhea, especially related to endometriosis. The levonorgestrel-releasing intrauterine contraception (LNG-IUC) reduces the risk for endometrial cancer by preventing thickening of the endometrium. Choosing to use LARCs offers persons privacy with their birth control choices. When using an intrauterine device or a contraceptive implant, the person has no packages of contraceptive pills and no tasks to do before acts of intercourse, and the device cannot be seen by others. The patient is in full control of their contraceptive choice, and that can feel very empowering. Another benefit to choosing a LARC is the immediate return to fertility once the implant or intrauterine device is removed. The nurse emphasizes this immediate return of fertility, as it can be a benefit for people wanting to conceive; it can be a drawback for others who are not seeking pregnancy.

Complications

Although they are not common, complications for a person choosing LARCs can arise. These complications will be discussed to ensure the person is a good candidate for this method. It is also important when considering use of a LARC that all persons be provided the information they need to give informed consent for it (ACOG, 2024).

Pregnancy

One complication that could occur with a LARC in place is pregnancy, and it must be managed as soon as it is confirmed. LARCs containing progesterone, which causes the cilia in the fallopian tubes to slow, increase the risk for ectopic pregnancy (Hatcher, 2018). The nurse educates the patient to monitor for symptoms of pregnancy, to check for IUC strings monthly, and to notify their provider immediately if they become pregnant (ACOG, 2024). Pregnancy means that the current LARC must be removed and a decision about the future of the pregnancy must be made.

Expulsion or Misplacement of the IUC

A complication that can occur with an IUC is expulsion or misplacement of the device. If the person finds the IUC in their cervix, internal os, or outside their body, they must contact their provider to have the device removed completely and replaced if they desire (ACOG, 2024). Expelled or misplaced IUCs have a very high rate of unintended pregnancies and must be managed immediately. Placement after delivery of the placenta has the highest expulsion rate.

Contraceptive implants must be palpated monthly by the patient to ensure correct placement. If the person cannot feel the implant in the correct place, they must contact their provider to ensure correct placement and rule out unintended pregnancy. These patients should also be advised to use a backup method of contraception until placement can be confirmed and pregnancy can be ruled out (ACOG, 2024).

Perforation

Uterine perforation and extrusion of the IUC into the peritoneal cavity are very rare complications; however, they can occur with placement of the device (ACOG, 2024). The symptoms of perforation likely occur at time of placement, but the nurse educates the person to be aware of heavy vaginal bleeding, severe cramping, abdominal pain, and fever after IUC placement.

Pelvic Inflammatory Disease

The risk for pelvic inflammatory disease (PID), an infection of the female reproductive organs, when a person has intrauterine contraception is not necessarily increased overall, but it does increase in the first 3 weeks after placement (CDC, 2021). It most often occurs when sexually transmitted bacteria spread from the vagina to the uterus, fallopian tubes, or ovaries. Should the patient be diagnosed with PID while the IUC is in place, they should receive treatment according to the most recent CDC guidelines and have close clinic follow-up (CDC, 2021). The IUC can remain in place; however, if no clinical improvement is seen in 48 to 72 hours of initiating treatment, the clinician should remove the IUC. An unfortunate side effect of PID is the risk for infertility due to scarring of the fallopian tubes. The nurse can provide emotional support, education about other contraceptive choices, and information regarding the treatment and prevention of pelvic inflammatory disease.

Table 5.13 summarizes the pros, cons, and efficacy of the different LARCs.

Method	Pros	Cons	Perfect Use Efficacy (per 100 couples per year)
LNG-IUC	Effective for 3 to 8 years, reversible, decrease menstrual cramps and heavy bleeding, can cause person to become amenorrheic, excellent for persons who cannot remember to take a pill, immediate return to fertility	Irregular bleeding, headache, ovarian cysts, vulvovaginitis	99.8%
Copper T380A	Effective for 10 years, very few contraindications, excellent for persons who cannot remember to take a pill, immediate return to fertility	Heavier and more painful menses	99.8%
Contraceptive implant	Effective for 3 years, excellent for persons who cannot remember to take a pill, immediate return to fertility	Irregular bleeding, possible pain at insertion site, headache, gastrointestinal (GI) difficulties, insertion site infection	99%

Table 5.13 Comparing and Contrasting Long-Acting Reversible Contraception Methods (Hatcher, 2018)

Intrauterine Contraception Devices

An intrauterine contraception (IUC) device (IUD) is a small, plastic T-shaped contraceptive device that is placed inside the uterus to prevent pregnancy. Use of the copper-containing IUC (Paragard) and the IUCs containing levonorgestrel (LNG-IUC) has increased tremendously in the past 20 years, from 2.4 percent in 2002 to 14 percent in 2017 (Daniels & Abma, 2020; KFF, 2020). The population with the highest use of IUCs are those aged 25 to 34 years, 60 percent higher than younger persons aged 20 to 24 years (KFF, 2020). Since LARC products came onto the market, the number of unintended pregnancies and induced abortions has decreased (Espey & Hofler, 2017). One research study in Colorado noted that as LARC use increased by 5 percent to 19 percent in low-income teenagers and young persons, birth rates decreased by 29 percent, and abortion rates decreased by 34 percent (Espey & Hofler, 2017). Nurses can educate persons at high risk for unintended pregnancies (adolescents and low-income persons) and persons with little access to contraceptives (those who are homeless, of low socioeconomic status, or rural) about the long-term value of LARCs. The cost-benefit ratio leans toward LARCs as opposed to unintended pregnancies and abortions.

LNG-Intrauterine Contraception

LNG-IUCs are T-shaped intrauterine devices made of polydimethylsiloxane and containing levonorgestrel on the stem of the device (Dickey & Seymour, 2021) (Figure 5.14). The mechanism of action for LNG-IUCs is slightly different than for other progesterone-only methods, as the devices suppress ovulation in only 25 percent to 55 percent of cycles (Dickey & Seymour, 2021). The LNG-IUC alters the environment of the endometrium and prevents fertilization of the ovum by changing the viscosity of cervical mucus, making an uninhabitable environment for sperm and decreasing the motility and mobility of sperm (Dickey & Seymour, 2021). LNG-IUCs do not disrupt already fertilized ova (Bayer Pharmaceuticals, 2023; Espey & Hofler, 2017). Side effects include irregular bleeding, ovarian cysts, headache, and vulvovaginitis. Contraindications include pregnancy, uterine anomalies, pelvic infection, or reproductive tract or breast cancers (Dickey & Seymour, 2021).

Figure 5.14 Intrauterine Device: Mirena The LNG-IUC Mirena sits in the center of the uterus with the wings near the fundus and the strings hanging just outside the cervical os. The strings are long enough for the patient to feel them monthly to ensure placement of the IUC and for the clinician to remove the IUC when it is time. (CC BY 4.0; Rice University & OpenStax)

The LNG-IUC has many advantages. Perfect and typical effectiveness are the same, 99.8 percent (Hatcher, 2018). It prevents proliferation of the endometrium, reduces menstrual pain, provides immediate return to fertility, and causes amenorrhea in 6 percent to 20 percent of users, depending on the amount of progesterone in the device (Dickey & Seymour, 2021). In persons who suffer from very heavy periods, many times a clinician will offer to place an LNG-IUC to thin the uterine lining and decrease menstrual bleeding (Hatcher, 2018). Levonorgestrel (Mirena and Liletta) can protect against pregnancy for up to 7 and 6 years, respectively, and can be used to treat menorrhagia for up to 5 years (Bayer Pharmaceuticals, 2023). Kyleena can stay in place and remain effective for pregnancy prevention for 5 years (Bayer Pharmaceuticals, 2023). Skyla, which is approved for up to 3 years of use, and Kyleena are excellent options for adolescents because the IUC frame is smaller than those of Mirena and Liletta (Bayer Pharmaceuticals, 2023).

Life-Stage Context

Using LNG-IUC during Perimenopause

During perimenopause, many persons experience abnormal bleeding that can be light or very heavy and can be unexpected. Some perimenopausal persons carry extra clothes or pants with them because of unexpected very heavy bleeding. These persons can benefit from the LNG-IUC. The LNG-IUC causes a thin uterine lining, preventing heavy bleeding. The device is not contraindicated for use during perimenopause.

Paragard Intrauterine Device

Paragard, the copper T380A IUC, is a T-shaped device made of polyethylene with copper wire wrapped around the stem and arms of the device (Figure 5.15). Paragard has Food and Drug Administration (FDA) approval for 10 continuous years of use with an effectiveness rate of 99.4 percent to 99.9 percent (Hatcher, 2018). The mechanism of action is two-fold: the plastic and metal frame acts as a foreign body and causes inflammation in the uterus, and the inflammation causes a toxic environment that decreases sperm mobility and survival (Hatcher, 2018). Because of this inflammation, however, menstrual bleeding is heavier than prior to insertion of the IUC. This bleeding and cramping are the most common complaints from patients who use this method. Abnormal bleeding after placement can last 2 to 6 weeks while the uterus adjusts to the device. The patient should never fill more than one pad an hour, and if bleeding continues past 6 weeks, the person should call the clinic.

Figure 5.15 Intrauterine Device: Paragard The Paragard IUC is a 10-year contraceptive option that prevents pregnancy nearly 100 percent of the time. (CC BY 4.0; Rice University & OpenStax)

Because this IUC is hormone-free, very few contraindications exist, but those that do include pregnancy, current genital tract infection, uterine abnormalities, and copper allergy or Wilson’s disease (Hatcher, 2018). The nurse recommends Paragard to persons desiring a very effective, long-term contraceptive that is nonhormonal, such as those who are breast-feeding, who have religious reasons for not desiring hormones, smokers, and those with risk for thromboembolic disorders.

Patient Education for IUCs

After placement of the IUC, the nurse educates the person to check the IUC strings at the cervix monthly. If the strings are not felt, the patient should call the clinic and be seen to verify placement. Rare complications associated with IUC use include expulsion, method failure, and uterine perforation (Hatcher, 2018). Because of these complications, the nurse educates the patient using the PAINS acronym and explains that if any of those symptoms occur, the patient will need to get to an emergency department immediately for IUC placement check.

PAINS

The nurse educates the person to call the office with the following concerns:

P: Period late or missing; spotting after having stopped bleeding

A: Abdominal pain that is sharp and severe

I: Infection (vaginal discharge or smell)

N: Not feeling well (fever, tired, achy, chills)

S: Strings not being felt

If the patient experiences any of these symptoms, the nurse advises them to call the office immediately or go to the closest emergency department for evaluation.

Pharmacology Connections

Intrauterine Contraception: Mirena IUC

Nurses are often the gatekeepers in clinics, managing messages between clinicians and patients, especially after visits. Having a good understanding of how the intrauterine device works, what side effects are expected versus unexpected, and how long each device might last can help alleviate a lot of stress for both the nurse and the patient. Intrauterine contraceptive devices are gaining in popularity because this method of contraception can last as long as 10 years with an effective rate as high as 99.9 percent (CDC, 2023d).

• Generic Name: levonorgestrel
• Trade Name: Mirena (Skyla, Liletta, or Kyleena)
• Class/Action: hormonal contraceptive, progestin
• Route/Dosage: intrauterine
  • Kyleena: single dose 19.5 mg progesterone system intrauterine contraceptive
  • Liletta: single dose 52 mg progesterone system intrauterine contraceptive
  • Mirena: single dose 52 mg progesterone system intrauterine contraceptive
  • Skyla: single dose 13.5 mg progesterone system intrauterine contraceptive
• High Alert/ Black Box Warning: None
• Indications: FDA approved for contraception, menorrhagia, emergency contraception.
  • Non-FDA uses: endometrial hyperplasia (a condition in which the endometrium of the uterus becomes very thick, causing unusual bleeding), endometriosis and perimenopausal symptoms.
• Mechanism of Action: Levonorgestrel is a synthetic progesterone that sometimes inhibits ovulation and inhibits sperm from reaching the egg because of thickening of cervical mucus.
• Contraindications: acute liver disease, acute history of pelvic inflammatory disease, known or suspected breast carcinoma, conditions associated with increased susceptibility to infections (e.g., leukemia, AIDS, IV drug abuse) including pelvic infections, congenital or acquired pelvic anomaly that distorts the uterine cavity, genital bleeding with unknown cause, infected abortion in the past 3 months, thrombophlebitis or thromboembolic disorders, untreated vaginitis or cervicitis, known or suspected progestin-sensitive cancer, known or suspected hormone-sensitive cancer and known or suspected uterine or cervical neoplasia, or unresolved, abnormal Pap smear.
• Adverse Reactions/Side Effects: The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified:
  • Cardiovascular: Myocardial infarction
  • Neurologic: Dizziness, headache, migraine
  • Dermatologic: Acne
  • Gastrointestinal: Abdominal pain, nausea
  • Reproductive: Abnormal vaginal bleeding, amenorrhea, breast tenderness, dysmenorrhea, vaginitis, vulvovaginitis
• Nursing Implications: Witness consent. Review patient education with the family. Remain in the room to assist while procedure is being completed. Document in the patient’s chart.
• Parent/Family Education: The nurse educates the patient that they should periodically place a clean finger into the vagina and check for IUC strings near the cervix. Some cramping and bleeding intermittently for 2 to 6 weeks is normal after placement of an intrauterine contraception device (IUC), and irregular bleeding can be expected for 3 months. The patient may experience their normal menses or may not. The nurse provides education to the patient before they leave the office about calling to report heavy bleeding; pain with intercourse; abdominal pain; signs of infection including fever, chills, and malaise; and missing strings. If the person becomes pregnant while the IUC is in place, the nurse educates them to come back to the clinic immediately for an appointment.

Contraceptive Implant: Nexplanon

The contraceptive implant Nexplanon is a contraceptive device 4 cm in length and 2 mm in diameter, made of an ethylene vinyl acetate copolymer core containing etonogestrel surrounded by an ethylene vinyl copolymer skin (Dickey & Seymour, 2021) (Figure 5.16). The copolymer skin allows release of the etonogestrel over a 3-year period (Dickey & Seymour, 2021). The implant is very effective, with a perfect and typical effectiveness rate of 99 percent (Hatcher, 2021). It is inserted either in the hospital during the postpartum period or in the office; it is removed in the office by a trained clinician. The device lies subdermally on the underside of the arm above the medial epicondyle. The skin is injected with lidocaine for anesthesia, a small incision is made, and the device is placed by a disposable introducer. The arm is then wrapped to prevent bleeding. No sutures are necessary. The implant’s mechanism of action is to suppress ovulation, thicken cervical mucus, and alter the endometrial lining (Dickey & Seymour, 2021).

Figure 5.16 Contraceptive Implant: Nexplanon Nexplanon is a small device that is surgically implanted under the skin in the inner upper arm. The device provides 99.9 percent effective protection against pregnancy for 3 years. (CC BY 4.0; Rice University & OpenStax)

Side Effects of Nexplanon

Side effects include abnormal bleeding, changes in menstrual cycle, including amenorrhea, gastrointestinal difficulties, headaches, vaginitis, and ovarian cysts (Dickey & Seymour, 2021). Some people experience increased acne and weight gain. Complications related to the insertion of the device include pain at the insertion site, hematoma formation, and incorrect insertion (Dickey & Seymour).

Patient Education

The nurse demonstrates how to palpate for the device and instructs the person to palpate it occasionally to ensure correct placement. The person should be instructed to call the office if vaginal bleeding exceeds one pad an hour, or, if they experience any of the PAINS symptoms listed earlier. The nurse also stresses the importance of having the device removed after 3 years.