LARC’s

1. Long-Acting Reversible Contraception ( LARC ) ACOG Guidelines IUD / IUS Implant Presented B y: Barbara L. Scanlon, MSN Nurse-Family Partnership Supervisor PMCHNNJ

2. What are long-acting reversible contraception (LARC) methods? Long-acting reversible contraception (LARC) methods include the   intrauterine device (IUD)  the   birth control implant Both methods are highly effective in preventing pregnancy, last for several years, and are easy to use. Both are reversible—if you want to become pregnant or if you want to stop using them, you can have them removed at any time .

3. How effective are LARC methods? The IUD and the implant are the most effective forms of reversible birth control available. During the first year of typical use – fewer than 1 in 100 women using an IUD or an implant will become pregnant. This rate is in the same range as that for sterilization.

4. How do LARC methods compare with other methods of contraception? Over the long term, LARC methods are 20 times more effective than birth control pills the patch the vaginal ring

5. What is the intrauterine device (IUD)? The IUD is a small, T-shaped, plastic device W hich is inserted into and left inside the  uterus

6. There are two types of IUDs: 1 . The hormonal IUD releases  progestin . One hormonal IUD is approved for use for up to 5 years. Another is approved for use for up to 3 years . 2. The copper IUD does not contain hormones. It is approved for use for up to 10 years.

7. What are the benefits of the IUD? The IUD has the following benefits: Once it is in place, you do not have to do anything else to prevent pregnancy. No one can tell that you are using birth control. It does not interfere with sex or daily activities. It can be inserted immediately after an abortion, a miscarriage, or childbirth and while breastfeeding. Almost all women are able to use an IUD. If you wish to become pregnant or if you want to stop using it, you can simply have the IUD removed. The hormonal IUD helps decrease menstrual pain and heavy menstrual bleeding. The copper IUD also is the most effective form of  emergency contraception .

8. How does the IUD work? Both types of IUDs work mainly by preventing  fertilization  of the  egg  by the  sperm . The hormonal IUD also thickens cervical mucus, which makes it harder for sperm to enter the uterus and fertilize the egg, and keeps the lining of the uterus thin, which makes it less likely that a fertilized egg will attach to it .

9. How is the IUD inserted? A health care provider must insert and remove the IUD. He or she will review your medical history and will perform a  pelvic exam.   To insert the IUD, the health care provider puts the IUD in a slender plastic tube. The health care provider places the tube into the vagina  and guides it through the  cervix  into the uterus. The tube is withdrawn, leaving the IUD in place .

10. Will I feel anything when the IUD is inserted? Insertion of the IUD may cause some discomfort. Taking over-the-counter pain relief medication before the procedure may help. The IUD has a string made of thin plastic threads. After insertion, the strings are trimmed so that 1–2 inches extend past the cervix into the vagina. The strings should not be bother some or noticeable.

11. What are possible side effects of use of the IUD ? With the copper IUD, menstrual pain and bleeding may increase. Bleeding between periods may occur. Both effects are common in the first few months of use. Pain and heavy bleeding usually decrease within 1 year of use. Both hormonal IUDs may cause spotting and irregular bleeding in the first 3–6 months of use. The amount of menstrual bleeding and the length of the menstrual period usually decrease over time. Menstrual pain also usually decreases. A few women also may have side effects related to the hormones in these IUDs. These side effects may include headaches, nausea, depression, and breast tenderness .

12. What are possible risks of use of the IUD? Serious complications from use of an IUD are rare. However , some women do have problems. These problems usually happen during or soon after insertion: The IUD may come out of the uterus. This happens in about 5% of users in the first year of using the IUD. The IUD can perforate (or pierce) the wall of the uterus during insertion . It is rare and occurs in only about 1 out of every 1,000 insertions .

13. Pelvic inflammatory disease (PID)   PID is an infection of the uterus and fallopian tubes. PID may cause scarring in the reproductive organs, which may make it harder to become pregnant later. The risk of PID is only slightly increased in the first 20 days after insertion of an IUD, but the overall risk still is low (fewer than 1 in 100 women). Rarely, pregnancy may occur while a woman is using an IUD. In the rare case that a pregnancy occurs with the IUD in place, there is a higher chance that it will be an  ectopic pregnancy .

14. What is the birth control implant? The birth control implant is a single flexible rod about the size of a matchstick that is inserted under the skin in the upper arm. It releases progestin into the body. It protects against pregnancy F or up to 3 years.

15. How does the birth control implant work? The progestin in the implant prevents pregnancy mainly by stopping  ovulation . In addition, the progestin in the implant thickens cervical mucus, W hich makes it harder for sperm to enter the uterus and fertilize the egg. Progestin also keeps the lining of the uterus thin, making it less likely that a fertilized egg will attach to it .

16. What are the benefits of the birth control implant? The implant has the following benefits: Once it is in place, you do not have to do anything else to prevent pregnancy. No one can tell that you are using birth control. It can be inserted immediately after an abortion, a miscarriage, or childbirth and while breastfeeding. It does not interfere with sex or daily activities. Almost all women are able to use the implant. If you wish to become pregnant or if you want to stop using it, you can simply have the implant removed.

17. How is the birth control implant inserted? The implant is inserted into your arm by a health care provider. A small area on your upper arm is numbed with a local anesthetic. No incision is made. Your health care provider places the implant under the skin with a special inserter. The procedure takes only a few minutes.

18. How is the birth control implant removed? To remove the implant The health care provider again numbs the area. One small incision is made. The implant then is removed.

19. What are possible side effects of use of the birth control implant? The most common side effect of the implant is unpredictable bleeding. For some women, these bleeding patterns improve over time. Some women have less menstrual pain while using the implant. In some women, bleeding stops completely. Other common side effects include mood changes, headaches, acne, and depression. Some women have reported weight gain while using the implant, but it is not clear whether it is related to the implant.

20. What are possible risks of use of the birth control implant? Possible risks include problems with insertion or removal of the implant. These problems occur in less than 2% of women. Although rare, if a woman becomes pregnant while the implant is inserted there is a slightly increased risk that it will be an ectopic pregnancy.

21. Glossary Birth Control Implant:  A small, single rod that is inserted under the skin in the upper arm by a health care provider. It releases a hormone and protects against pregnancy for up to 3 years. Cervix:  The lower, narrow end of the uterus at the top of the vagina. Ectopic Pregnancy:  A pregnancy in which the fertilized egg begins to grow in a place other than inside the uterus, usually in one of the fallopian tubes. Egg:  The female reproductive cell produced in and released from the ovaries; also called the ovum. Emergency Contraception:  Methods that are used to prevent pregnancy after a woman has had sex without birth control, Fertilization:  Joining of the egg and sperm. Intrauterine Device (IUD):  A small device that is inserted and left inside the uterus to prevent pregnancy. Ovulation:  The release of an egg from one of the ovaries. Pelvic Exam:  A physical examination of a woman’s reproductive organs. Pelvic Inflammatory Disease (PID):  An infection of the uterus, fallopian tubes, and nearby pelvic structures. Progestin:  A synthetic form of progesterone that is similar to the hormone produced naturally by the body. Sperm:  A cell produced in the male testes that can fertilize a female egg. Sterilization:  A permanent method of birth control. Uterus:  A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy. Vagina:  A tube-like structure surrounded by muscles leading from the uterus to the outside of the body. If you have further questions, contact your obstetrician–gynecologist .

22. Copyright July 2014 by the American College of Obstetricians and Gynecologists http ://www.acog.org/Patients/FAQs/Long-Acting-Reversible-Contraception-LARC-IUD-and-Implant

23. Recommendations Although lowering unintended pregnancy rates requires multiple approaches , individual obstetrician–gynecologists may contribute by increasing access to LARC methods for their patients.   http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Increasing-Use-of-Contraceptive-Implants-and-Intrauterine-Devices-To-Reduce-Unintended-Pregnancy

24. LARC’s The IUD (Intrauterine Device) Is a small T-shaped device (no larger than 32 mm x 36 mm) It is inserted into the uterus by a healthcare provider to prevent pregnancy .   IUDs are categorized as long-acting reversible contraceptive methods (LARCs ). There are three different types of IUDs available in the U.S.

25. Based of the most recent estimate (2006), nearly half of all pregnancies in the U.S. are unintended (49%), and 43% of these pregnancies end in abortion.  In the U.S. each year, there are an estimated 1.5 million births resulting from unintended pregnancies. 

26. IUDs are HIGHLY EFFECTIVE in preventing pregnancy IUDs are 99% effective in preventing pregnancy. They are one of the most effective forms of birth control. IUDs do not require daily compliance or attention like oral contraceptives (the pill).

27. WOMEN WANT IUDS and LIKE IUDs once they have them Two-thirds of women of child-bearing age in the U.S. currently use birth control, and the use of IUDs is on the rise within this group: from 2% in 2002 to 7.7% in 2009. In a recent study 10,000+ women received contraceptive counseling and were provided any contraceptive method free of charge, 67% of women chose LARC methods (56% IUDs, 11% implants). The same study found that at 24 months after choosing their birth control method - women continued using IUDs longer than any other birth control method: 77% and 79% for Paragard and Mirena respectively , compared to 43% for the pill.

28.   IUDs are SAFE and RECOMMENDED for use by most women The American College of Obstetricians & Gynecologists (ACOG) recommends that LARCs be offered as first-line contraceptive methods and encouraged as options for most women, including adolescents. Skyla and Paragard are FDA-approved for use among women who have never had children (referred to clinically as nulliparous women).   Mirena is FDA-recommended for women who have had at least one child and women seeking a birth control method that helps treat heavy menstrual bleeding. IUDs can be safely inserted directly postpartum and postabortion . Inserting an IUD or implant immediately after an abortion significantly reduces the risk of subsequent abortions. Infertility is  not  more likely after discontinuation of an IUD than after discontinuation of other reversible methods of contraception.

29. Selected Practice Recommendations for Contraceptive Use In 2013, the CDC developed the  United States Selected Practice Recommendations for Contraceptive Use , which provides guidance on how contraceptive methods can be used and how to remove unnecessary barriers for patients in accessing and successfully using contraceptive methods.   The report offers guidance on when to initiate IUDs and clinical guidance on special considerations, advisable testing, routine follow-up and IUD management. In 2010 the Centers for Disease Control and Prevention (CDC) developed the  United States Medical Eligibility Criteria for Contraceptive Use This provides guidance on the safety of contraceptive methods , including IUDs , for women with specific characteristics and medical conditions.

30. IUDs can be LONG-LASTING but are easily removed at any time IUDs can last from 3 to 10 years, depending on IUD type They can be easily removed at any time by a healthcare provider. Rates of continuation and removal of IUDs are similar for adults and adolescents.

31. IUDs can be AFFORDABLE Under the Affordable Care Act, all contraceptive methods (including IUDs) and associated services (insertion, removal, and maintenance) must be covered by a health plan without cost-sharing. The National Women’s Law Center and Bayer HealthCare Pharmaceuticals (manufacturer of Mirena and Skyla)   have developed materials to help women and providers navigate obtaining health insurance coverage of IUDs without cost-sharing . IUD manufacturers ( Teva Women’s Health and Bayer HealthCare Pharmaceuticals) provide IUDs at reduced cost to medical facilities that qualify for the 340B federal drug pricing program.  IUD manufacturers also have patient assistance programs that offer IUDs free of charge for those who qualify and are uninsured.

32. Currently available IUDs work by preventing sperm from fertilizing ova although some aspects of the precise mechanism of action are not known. IUDs are not abortifacients; they do not interrupt an implanted pregnancy. Pregnancy is prevented by a combination of the ‘foreign body effect’ of the plastic frame and the specific action of the medication ( copper or Levonorgestrel ) that is released This impairs sperm function and implantation and prevents fertilization.

33. American College of Obstetricians and Gynecologists ACOG Recommendations regarding Long-Acting Reversible Contraceptives (LARCs) "Although lowering unintended pregnancy rates requires multiple approaches, individual obstetrician–gynecologists may contribute by increasing access to LARC methods for their patients. The following strategies can reduce barriers and increase use of implants and IUDs :

34. Provide counseling on all contraceptive options, including implants and IUDs even if the patient initially states a preference for a specific contraceptive method. Encourage implants and IUDs for all appropriate candidates, including nulliparous women and adolescents. Adopt same-day insertion protocols. Screening for chlamydia, gonorrhea, and cervical cancer should not be required before implant or IUD insertion but may be obtained on the day of insertion, if indicated. Avoid unnecessary delays, such as waiting to initiate a method until after a post-abortion or miscarriage follow-up visit or to time insertion with menses .

35. Support efforts to lower the up-front costs of LARC methods. Advocate for coverage of all contraceptive methods by all insurance plans, both private and public. Become familiar with and support local, state, federal (including Medicaid), and private programs that improve affordability of all contraceptive methods, including implants and IUDs." Source:  ( etonogestrel implant) http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Increasing_Use_of_Contraceptive_Implants_and_Intrauterine_Devices_To_Reduce_Unintended

36. What is NEXPLANON? NEXPLANON is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years. The implant is a flexible plastic rod about the size of a matchstick that contains a progestin hormone called etonogestrel . It contains a small amount of barium sulfate so that the implant can be seen by X-ray, and may also contain magnesium stearate. Your healthcare provider will insert the implant just under the skin of the inner side of your upper arm. You can use a single NEXPLANON implant for up to 3 years. NEXPLANON does not contain estrogen.

37. Important Safety Information About NEXPLANON You should not use NEXPLANON if you are pregnant or think you may be pregnant have or have had blood clots; have liver disease or a liver tumor; have unexplained vaginal bleeding; have breast cancer or any other cancer that is sensitive to progestin (a female hormone), now or in the past are allergic to anything in NEXPLANON. Talk to your health care provider about using NEXPLANON if you have diabetes, high cholesterol or triglycerides, headaches, gallbladder or kidney problems, history of depressed mood, high blood pressure, allergy to numbing medicines (anesthetics) or medicines used to clean your skin (antiseptics). As local anesthetic medicines t hat be used when the implant is placed into or removed from your arm . http:// iudtaskforce.org/IUDBasics

38. Immediately after the NEXPLANON implant has been placed Y ou and your health care provider should check that the implant is in your arm by feeling for it. If you and your health care provider cannot feel the NEXPLANON implant, use a non-hormonal birth control method (such as condoms) until your health care provider confirms that the implant is in place.   You may need special tests to check that the implant is in place or to help find the implant when it is time to take it out. http://www.nexplanon.com/en/consumer/about-it/what-is-nexplanon /

39. What if I need birth control for more than 3 years? The NEXPLANON implant must be removed after 3 years. Your healthcare provider can insert a new implant under your skin after taking out the old one if you choose to continue using NEXPLANON for birth control .

40. What if I change my mind about birth control and want to stop using NEXPLANON before 3 years? Your healthcare provider can remove the implant at any time. You may become pregnant as early as the first week after removal of the implant. If you do not want to get pregnant after your healthcare provider removes the NEXPLANON implant you should start another birth control method right away.

41. How does NEXPLANON work? NEXPLANON prevents pregnancy in several ways. The most important way is by stopping the release of an egg from your ovary. NEXPLANON also thickens the mucus in your cervix and this change may keep sperm from reaching the egg. NEXPLANON also changes the lining of your uterus.

42. How well does NEXPLANON work? When the NEXPLANON implant is placed correctly, your chance of getting pregnant is very low less than 1 pregnancy per 100 women who use NEXPLANON for 1 year. It is not known if NEXPLANON is as effective in very overweight women because studies did not include many overweight women . http://www.merck.com/product/usa/pi_circulars/n/nexplanon/nexplanon_ppi.pdf

43. What things should I think about when choosing a birth control method? To choose the right birth control method for you, consider the following: How well it prevents pregnancy How easy it is to use Whether you need a prescription to get it Whether it protects against  sexually transmitted diseases (STDs) Whether you have any health problems

44. Do I need to have a pelvic exam to get birth control from my health care provider? A   pelvic exam  is not needed to get most forms of birth control from a health care provider except for the intrauterine device (IUD), diaphragm, and cervical cap. If you have already had sex, - you may need to have a pregnancy test and STD test before birth control can be prescribed .

45. Which birth control methods are the best at preventing pregnancy? The following table shows all of the birth control methods and how well they protect against pregnancy.

46. Which birth control methods also protect against sexually transmitted diseases (STDs)? The male latex or polyurethane condom gives the best protection against STDs. The female condom provides some protection. With all other methods, you also should use a male or female condom to protect against STDs .

47. What is the birth control pill? The birth control pill is a pill that you have to take every day - at the same time each day . It contains  hormones  that prevent pregnancy. There are many types of birth control pills. Your health care provider can help you choose the right one for you. - If you miss a pill, you need to know what to do. Read the directions that came with your pack of pills. You also may want to contact your health care provider .

48. What is the skin patch? The patch is a small (1.75 square inch) adhesive patch that is worn on the skin. It contains hormones that are slowly released into your body through the skin. A new patch is worn for a week at a time for 3 weeks in a row . During the fourth week, a patch is not worn, and you will have your menstrual period.

49. What is the vaginal ring? The ring is a flexible plastic ring that you insert into the upper  vagina . It releases hormones into your body. It is worn inside the vagina for 21 days and then removed for 7 days. During those 7 days, you will have your menstrual period. Then you insert a new ring.

50. What is the birth control shot? This shot is given in the upper arm or buttock every 3 months. It contains hormones that prevent pregnancy . DMPA –> Depo-Provera Injection Depo Medroxy Provera Acetate

51. What is the implant? The implant is a small plastic rod about the size of a matchstick that the health care provider inserts under the skin of the upper arm. It releases hormones. The implant protects against pregnancy for 3 years.

52. What is the intrauterine device (IUD)? The intrauterine device (IUD) is a small, T-shaped, plastic device* that is inserted and left inside the uterus. The IUD must be inserted and removed by a health care provider. Three types are available in the United States . Two contain hormones and last for 3 years and 5 years. The third type is the copper IUD. It lasts for as long as 10 years.

53. What are spermicides? These are chemicals that are put into the vagina to make  sperm  inactive. There are many types of spermicides: foam , gel, cream, film (thin sheets), or suppositories (solid inserts that melt after they are inserted into the vagina). Frequent use of spermicides may increase the risk of getting  human immunodeficiency virus (HIV)  from an infected partner. Spermicides should only be used if you are at low risk of HIV infection.

54. What are condoms? Condoms come in male and female versions. The male condom ("rubber") covers the  penis  and catches the sperm after a man ejaculates. The female condom is a thin plastic pouch that lines the vagina. It prevents sperm from reaching the  uterus . Condoms work better to prevent pregnancy when used with a spermicide. Spermicides should only be used if you are at low risk of HIV infection .

55. What is the diaphragm? The diaphragm is a small dome-shaped device made of latex or silicone that fits inside the vagina and covers the  cervix . You need a prescription for it. A health care provider needs to do a pelvic exam to find the right size of diaphragm for you. It always is used with a spermicide. Birth control methods that need spermicides to work should only be used if you are at low risk of HIV infection .

56. What is the cervical cap? The cervical cap is a small, thin latex or plastic dome shaped like a thimble. It fits tightly over the cervix. You need a prescription for it. A health care provider needs to do a pelvic exam to find the right size for you. The cervical cap must be used with a spermicide . Birth control methods that need spermicides to work should only be used if you are at low risk of HIV infection.

57. What is the sponge? The sponge can be bought without a prescription at drugstores and other stores. It is a doughnut-shaped device made of soft foam that is coated with spermicide . It is pushed up in the vagina to cover the cervix. Birth control methods that have spermicides should only be used if you are at low risk of HIV infection .

58. What is emergency birth control? E mergency birth control can be used to prevent pregnancy if you have sex without using any birth control if the birth control method did not work ( for instance, the condom broke during sex ) or if you are raped. Emergency birth control is available in pill form or as a copper IUD. The pills must be taken or the IUD inserted within 5 days of having unprotected sex .

59. What are the types of emergency birth control pills? There are three types of emergency birth control pills: 1 ) the progestin-only pill 2) regular birth control pills taken in certain amounts 3 ) ulipristal .

60. Where can I get emergency birth control? Ulipristal and combination birth control pills are available only by prescription. One type of progestin-only pill (Plan B One- Step) is available on pharmacy store shelves without a prescription to anyone of any age. Another type of progestin-only pill (Next Choice One Dose) is available behind the pharmacy counter without a prescription to anyone 17 years or older if you show proof of age and by prescription if you are younger than 17 years. If you need more information about emergency birth control or need to find a health care provider who can provide a prescription, go to www.not-2-late.com or call the emergency birth control hotline at 1-888-NOT-2-LATE.

61. Glossary http://www.acog.org/Patients/FAQs/Birth-Control-Especially-for-Teens Cervix :  The lower, narrow end of the uterus at the top of the vagina. Hormones:  Substances made in the body by cells or organs that control the function of cells or organs. An example is estrogen, which controls the function of female reproductive organs. Human Immunodeficiency Virus (HIV):  A virus that attacks certain cells of the body’s immune system and causes acquired immunodeficiency syndrome (AIDS). Pelvic Exam:  A physical examination of a woman’s reproductive organs. Penis:  An external male sex organ. Sexually Transmitted Diseases (STDs):  Diseases that are spread by sexual contact, including chlamydia, gonorrhea, human papillomavirus infection, herpes, syphilis, and infection with human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]). Sperm:  A cell produced in the male testes that can fertilize a female egg cell. Uterus:  A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy. Vagina:  A tube-like structure surrounded by muscles leading from the uterus to the outside of the body. If you have further questions, contact your obstetrician–gynecologist. Copyright December 2013 by the American College of Obstetricians and Gynecologists

62. The following strategies can reduce barriers and increase use of implants and IUDs : 1. Provide counseling on all contraceptive options, including implants and IUDs, even if the patient initially states a preference for a specific contraceptive method. 2. Encourage implants and IUDs for all appropriate candidates, including nulliparous women and adolescents. 3. Adopt same-day insertion protocols. 4. Screening for chlamydia, gonorrhea, and cervical cancer should not be required before implant or IUD insertion but may be obtained on the day of insertion, if indicated .

63. 5. Avoid unnecessary delays, such as waiting to initiate a method until after a post abortion or miscarriage follow-up visit or to time insertion with menses. 6. Support efforts to lower the up-front costs of LARC methods. 7. Advocate for coverage of all contraceptive methods by all insurance plans, both private and public. 8. Become familiar with and support local, state, federal (including Medicaid), and private programs that improve affordability of all contraceptive methods, including implants and IUDs .

64. IUDs and Birth Control Implants: Resource Overview Intrauterine devices (IUDs) and contraceptive implants are long-acting reversible contraception (LARC). Over time, LARC methods are 20 times more effective than birth control pills, the patch, or the vaginal ring. ACOG’s LARC Program works to reduce unintended pregnancy in the US. Ob-gyns , physicians whose primary responsibility is women’s health, play a leading role in providing scientific information and access to contraceptive methods, including IUDs and implants for their patients. Here are the key publications and resources for ob-gyns, other women’s health care providers, and patients from the American College of Obstetricians and Gynecologists (ACOG) and other sources. http:// www.acog.org/Womens-Health/IUDs-and-Birth-Control-Implants#Patient

65. Sexual Behavior and Contraceptive Use Among American Adolescents In the United States, 42% of adolescents aged 15–19 years have had sexual intercourse. Although almost all sexually active adolescents report having used some method of contraception during their lifetimes, they rarely select the most effective methods. Adolescents most commonly use contraceptive methods with relatively high typical use failure rates such as condoms, withdrawal, or oral contraceptive (OC) pills.

66. Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices Nonuse, inconsistent use, and use of methods with high typical use failure rates are reflected in the high rate of unintended adolescent pregnancies in the United States. Eighty-two percent of adolescent pregnancies are unplanned, accounting for one fifth of all unintended pregnancies in the United States, a statistic that indicates an unmet need for acceptable, reliable, and effective contraceptive methods for adolescents .

67. Long-acting reversible contraception ( LARC) methods are increasing in popularity with use increasing from 2.4% of all U.S. women using contraception in 2002 to 8.5% in 2009. Approximately 4.5% of women aged 15–19 years who are currently using a method of contraception use LARC, with most using an IUD. The etonogestrel single-rod contraceptive implant, approved by the U.S. Food and Drug Administration in 2006, is used by less than 1% of U.S. women using contraception and 0.5% of those aged 15–19 years . In a study of 4,167 females aged 14–45 years that compared continuation rates for LARC and short-acting contraceptive methods, the continuation rate for LARC was 86% at 12 months compared with 55% for short-acting contraceptive methods.

68. Short-acting contraceptive methods including condoms, OCs, the contraceptive patch, the vaginal ring, and depot medroxy -progesterone acetate (DMPA) injections, are mainstays of adolescent contraceptive choices, but these contraceptives have lower continuation rates and higher pregnancy rates than LARC methods. Of 1,387 females aged 15–24 years who initiated short-acting hormonal methods, only 11% using the contraceptive patch, 16% receiving DMPA injections, and approximately 30% using the vaginal ring and OCs were still using the same method after 12 months.

69. Continuation of Method Poor continuation coupled with higher failure rates decrease the efficacy of short-acting contraception in young women . Barriers to wide use of LARC methods by adolescents include a lack of familiarity with or misperceptions about the methods, the high cost, the lack of access, and health care providers’ concerns about the safety of LARC use in adolescents.

70. Counseling, Consent, Confidentiality, and Cost Increasing adolescent access to LARC is a clinical and public health opportunity for obstetrician–gynecologists. With top-tier effectiveness, high rates of satisfaction and continuation, and no need for daily adherence, LARC methods should be first-line recommendations for all women and adolescents. As with all nonbarrier methods, to decrease the risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), health care providers should advise sexually active adolescents to consistently use condoms along with LARC methods.

71. Counseling, Consent, Confidentiality, and Cost Like all women seeking reproductive health services, adolescents have the right to decline the use of LARC as well as the right to discontinue LARC without barriers. Coercive insertion of long-acting contraception was used in the past as a means of fertility control in marginalized women.

72. Confidentiality is of particular importance to adolescents In many states, adolescents have the right to receive confidential contraceptive services without parental consent, and health care providers should be familiar with laws concerning provision of contraception to minors in their own states . Information regarding these laws can be found at: http://www.guttmacher.org/statecenter/adolescents.html .

73. Cost High up-front costs for LARC methods can be a deterrent to use. Adolescents who have insurance coverage through their parents may not want to use the benefit because of confidentiality concerns others may be uninsured or have insurance that excludes coverage for LARC methods. In all of these cases, referral to a publicly funded clinic may be appropriate. Proposed health care reform provisions to cover all FDA-approved contraceptive methods, including LARC methods, without copayments or deductibles for these preventive health services, may ease this burden .

74. Guidance for Adolescent Health Care Providers to Address Common Misconceptions Health care providers’ concerns about LARC use by adolescents are a barrier to access. Health care provider training and continuing education programs should address common misconceptions and review the key evidence and benefits of adolescent LARC use.

75. Intrauterine devices are safe to use among adolescents Current evidence demonstrates the safety of modern IUDs. Although few studies have focused exclusively on adolescents who use currently available IUDs, good evidence suggests that the relative risk of pelvic inflammatory disease (PID) is increased only in the first 20 days after IUD insertion and then returns to baseline, while the absolute risk remains small. Bacterial contamination associated with the insertion process is the likely cause of infection, not the IUD itself. The risk of PID with IUD placement is 0–2% when no cervical infection is present and 0–5% when insertion occurs with an undetected infection. Women with positive chlamydia cultures after IUD insertion are unlikely to develop PID, even with retention of the IUD, if the infection is promptly treated. The levonorgestrel intrauterine system may lower the risk of PID by thickening cervical mucus and thinning the endometrium.

76. Intrauterine devices do not increase an adolescent’s risk of infertility. Infertility is not more likely after discontinuation of IUD use than after discontinuation of other reversible methods of contraception. In a large case–control study that examined determinants of tubal infertility, the presence of chlamydial antibodies, not previous IUD use, was associated with infertility. Baseline fecundity returns rapidly after IUD removal .

77. Intrauterine devices may be inserted without technical difficulty in most adolescents and nulliparous women. Little evidence suggests that IUD insertion is technically more difficult in adolescents compared with older women. More than one half of young nulliparous women report discomfort with IUD insertion. Anticipatory guidance regarding pain and provision of analgesia during IUD insertion should be individualized and may include supportive care, and medications nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, anxiolytics.

78. Adolescents should be routinely screened for STIs ( eg , gonorrhea and chlamydia) at the time of IUD insertion Women aged 15–19 years have the second highest rates of chlamydia and the highest rates of gonorrhea of any age group. Thus , all adolescents should be screened for STIs at the time of or before IUD insertion. It is reasonable to screen for STIs and place the IUD on the same day (and administer treatment if the test results are positive) or when the test results are available. If an STI is diagnosed after the IUD is in place, it may be treated without removing the IUD. Routine antibiotic prophylaxis is not recommended before IUD insertion .

79. Intrauterine device expulsion is uncommon in adolescents. Intrauterine device expulsion rates range from 3% to 5% for all IUD users and from 5% to 22% in adolescents. Young age, previous IUD expulsion, and nulliparity may slightly increase the risk of expulsion, … but research on current IUDs is limited. Prior expulsion should not be considered a contraindication for another IUD provided that appropriate counseling is given.

80. Intrauterine devices cause changes in bleeding patterns. Adolescents using either copper IUDs or the levonorgestrel intrauterine system can expect changes in their menstrual bleeding especially in the first months of use. The copper IUD may cause heavier menses that can be treated with NSAIDs. Women using the levonorgestrel intrauterine system will have a decrease in bleeding over time that will lead to light bleeding, spotting, or amenorrhea. Health care providers should counsel adolescents so they understand that these changes are common and expected .

81. The Contraceptive Implant The contraceptive implant causes changes in bleeding patterns . Adolescents who use the contraceptive implant can expect changes in menstrual bleeding patterns throughout the duration of use.

82. A change in bleeding pattern Change in bleeding is the most common reason for implant discontinuation. Anticipatory guidance regarding bleeding patterns may improve satisfaction and continuation. The bleeding pattern women experience in the first 3 months is broadly predictive of future bleeding patterns. Common strategies for treating problematic bleeding include the use of short courses of combined OCs or NSAIDs

83. Patien t Choice In the absence of contraindications P atient choice should be the principal factor in prescribing one method of contraception over another, and adolescents have the right to decline any method of contraception.

84. The contraceptive implant has secondary health benefits. High rates of infrequent bleeding or amenorrhea lead to higher hemoglobin levels in etonogestrel implant users (less anemia) Other non-contraceptive benefits of the contraceptive implant include 1. reductions in dysmenorrhea (cramping) 2. pelvic pain A prospective study of etonogestrel implant users showed no difference in the change in bone mineral density compared with copper IUD users after 2 years of use .

85. The contraceptive implant has minimal or no effect on weight. A small percentage of women (2.3%) in the clinical trials for the etonogestrel implant discontinued use because of reported weight gain however , actual weight gain was not documented. In contrast, DMPA injections are associated with weight gain, with overweight adolescents more susceptible to weight gain than normal weight adolescents .

86. Table 1.  U.S. Medical Eligibility Criteria for Contraceptive Use Condition Implant Copper IUD LNG- IUD Clarification/Evidence/Comments Age Menarche to younger than 18 y 1       Menarche to younger than 20 y 1 2 2 Comment: Concern exists about the risk for expulsion from  nulliparity and for STIs from sexual behavior in younger age  groups. Postpartum Less than 10 min after delivery of the placenta   1 2 Evidence: Immediate postpartum insertion of a copper IUD, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates.  Immediate insertion may happen after vaginal or cesarean  birth. 10 min after delivery of the placenta to less than 4 wk 2 2 2   Less than 4 wk and not breastfeeding 1 2 2   Less than 4 wk and breastfeeding 2 2 2   4 wk or later and breastfeeding or not breastfeeding 1 1 1   Puerperal sepsis   4 4 Comment: Insertion of an IUD might substantially worsen  the condition. 1 = A condition for which there is no restriction for the use of the contraceptive method. 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. 4 = A condition that represents an unacceptable health risk if the contraceptive method is used. Abbreviations: IUD, intrauterine device; LNG-IUD, levonorgestrel -releasing intrauterine device. Modified from U S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86.

87. Table 1. U.S. Medical Eligibility Criteria for Contraceptive Use Condition Implant Copper IUD LNG- IUD Clarification/Evidence/Comments Age Menarche to younger than 18 y 1       Menarche to younger than 20 y 1 2 2 Comment: Concern exists about the risk for expulsion from  nulliparity and for STIs from sexual behavior in younger age  groups. Postpartum Less than 10 min after delivery of the placenta   1 2 Evidence: Immediate postpartum insertion of a copper IUD, particularly when insertion occurs immediately after delivery of the placenta, is associated with lower expulsion rates.  Immediate insertion may happen after vaginal or cesarean  birth. 10 min after delivery of the placenta to less than 4 wk 2 2 2   Less than 4 wk and not breastfeeding 1 2 2   Less than 4 wk and breastfeeding 2 2 2   4 wk or later and breastfeeding or not breastfeeding 1 1 1   Puerperal sepsis   4 4 Comment: Insertion of an IUD might substantially worsen  the condition. 1 = A condition for which there is no restriction for the use of the contraceptive method. 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. 4 = A condition that represents an unacceptable health risk if the contraceptive method is used. Abbreviations: IUD, intrauterine device; LNG-IUD, levonorgestrel -releasing intrauterine device. Modified from U S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86.

88. Conclusion When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women. Counseling about LARC methods should occur at all health care provider visits with sexually active adolescents, including preventive health, abortion, prenatal, and postpartum visits. Complications of IUDs and the contraceptive implant are rare and differ little between adolescents and older women. Health care providers should consider LARC methods for adolescents and help make these methods accessible to them. http:// www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-and-Long-Acting-Reversible-Contraception