Long-Acting Reversible Contraception (LARC)

With the introduction of birth-control (contraception) in the early 1960’s, women have had the opportunity to control if, when and how many children they choose to conceive. Contraceptives have improved over the years, come in many varieties, and there are several ways to group them: hormonal or non-hormonal, male or female, permanent or reversible, long or short-acting, etc. While most methods require daily, weekly or monthly use, one group, called Long-Acting Reversible Contraception  (LARC), is designed for use/ renewal every three to 10 years.

Most methods of contraception are very effective. The most common reason for failure is forgetting to use the method. The more often you are required to remember, the greater the chance you could forget. With LARC methods, requiring renewal every three or more years means less chance of failing to remember. LARC methods offer very effective contraception with less than a one-percent failure rate, which is similar to permanent, non-reversible sterilization, but remain completely reversible. LARC methods are a good birth control choice for women of all ages, especially those who have difficulty remembering to use their contraceptives or want the convenience of LARCs. They are safe for teens and women who have never had children.

Remember, however, that LARCs do not protect against sexually transmitted infections, and a male or female condom should always be used together with any contraceptive method. Currently, LARC methods consist of either a birth-control implant or an intrauterine device (IUD). Each LARC method has its own set of characteristics, advantages and disadvantages.

Birth Control Implant – Nexplanon®

Nexplanon is an implantable rod that slowly releases progestin into the body preventing ovulation (the release of the egg from the ovary). It also thickens the mucous of the cervix, which inhibits the passage of sperm into the uterus. The implantable rod is placed under the skin on the inside of the arm above the elbow in a quick five-minute office procedure. The insertion site is only a few millimeters wide, as the implant is about the size of a matchstick. It lasts up to three years and can be removed at any time in an office visit with a quick return to fertility. Once placed, it is 99.9-percent effective, and nothing else needs to be done to prevent pregnancy.

Because the implant cannot be easily seen, usage can be kept confidential/private. It can be placed immediately after a pregnancy or miscarriage, and there are very few medical conditions that prevent use. Because it thins the lining of the uterus, over 50-percent of women state their cycles are absent or report much lighter flow and less menstrual pain than before placement of Nexplanon®. For others, bleeding can be unpredictable. Despite being unpredictable, on average, the number of days of bleeding over a three-month period with Nexplanon® are the same as those in women not using any birth-control method. However, the bleeding can be intermittent and unexpected. As with any long-acting hormonal method, it can take three to six months for the cycles to stabilize into a regular pattern.

The implant can be removed at any time in a simple office procedure, similar to the placement. At the end of three years, if you choose to continue this method, another implant can be placed in the same site once the expired one is removed. Once the implant is removed, the hormone is out of your system in less than a week and ovulation can occur within the next menstrual cycle, restoring fertility.

Intrauterine Devices (IUD)

An intrauterine device (IUD) is a small, T-shaped plastic device that is placed into the uterus during an office visit. There are two types of IUDs:

1.  Hormonal IUDs that release progestin locally into the uterus and are approved for either three or five years;
2.  Copper IUDs that only contain copper and can be used for up to 10 years.

Similar to Nexplanon®, an IUD is confidential, does not interfere with sex, spontaneity or daily activities, and requires little maintenance once placed. You can use tampons with an IUD. Menstrual cramps and/or bleeding may be irregular initially and could completely disappear several months after insertion.

Skyla® or Mirena® are the hormonal IUD devices that are placed in the uterus during an office procedure similar to getting a Pap smear. They primarily work by thickening the mucous of the cervix so that sperm are unable to enter the uterus. The amount of the progestin hormone that is released works locally within the uterus and very little is absorbed into the bloodstream. Because the levels of hormone are low, ovulation is not prevented and the body’s production of female hormones is at or near the same level as before the IUD was placed. This also means that the IUD has the fastest return to fertility once removed. Since it does not prevent ovulation, it does not cause or prevent the pain associated with ovulation or ovarian cysts. Bleeding patterns can vary, but in general the timing of bleeding is typically similar to before the Mirena was placed, only the flow tends to be lighter. Some women may have no bleeding as the lining of the uterus is very thin. In addition to preventing pregnancy, the hormonal IUD has been approved by the FDA for the treatment of heavy menstrual bleeding.

Once placed, the IUD is 99.8-percent effective in preventing pregnancy for three or five years. At expiration, if another IUD is desired, the new one can be placed the same time the expired one is removed, requiring only one office ce visit.

Paragard® is an IUD that instead of a hormone, contains copper. The copper irritates the lining of the uterus causing a reaction that destroys or incapacitates sperm as they enter the uterus. It is 99.2-percent effective in preventing pregnancy. Since there is no hormone, ovulation is not prevented, and the cervical mucous is not altered. This means the Paragard® also has a quick return to fertility once removed. Period frequency is not usually altered and tends to follow the same pattern as before IUD placement. Due to the irritation caused by the Paragard®, some women may experience heavier periods and/or more cramping within the first year of use. Anti-inflammatory medication like ibuprofen can ease this side effect.

Serious complications from current IUDs are rare, but minor complications can and do occur. In about 5-percent of users in the first year, it can fall out of the uterus. Your provider will help you recognize symptoms to determine if this has happened. About one in 1,000 women will experience a uterine perforation. This occurs if the IUD penetrates the uterus. Although it is rarely associated with significant health concerns, it will need to be removed. The risk of a pelvic infection is only slightly increased in the first three weeks after placement, with the incidence of fewer than one in 100 women. After three weeks, the risk is similar to women who do not use an IUD. In fact, the hormonal IUDs have a lower risk of infection because they cause a thickening of the cervical mucus, which prevents the passage of bacteria carrying sperm into the uterus.

The birth-control implant and the IUD are the most effective forms of reversible contraception with failure rates less than one-percent. They can be used by most women despite other medical conditions. They can be used by teenagers, women who have had children, those who have not had children and for bleeding control. In addition to effective prevention of pregnancy, some women will also experience a decrease in bleeding and/ or cramping. They are relatively easy to place, remove, require minimal maintenance, are convenient, and do not interfere with spontaneity of intimacy. If you are interested in a long-acting reversible contraceptive method, you should discuss options with your healthcare provider.

Dr. deHoop is a KRMC physician practicing at Kalispell OB/GYN – In 2011 he moved to Kalispell from Cincinnati, Ohio where he was an Associate Professor of Obstetrics and Gynecology at the University of Cincinnati Medical Center for 16 years. He practices general obstetrics and gynecology, with a special interest in robotic and minimally invasive surgery. He came to Kalispell with more than five years of experience using the daVinci® robotic surgery system.

This article originally appeared in 406 Women Magazine Feb/March 2016.

PLEASE NOTE: This information is not intended to be medical advice.  It is general health information and does not take into account your particular health status nor is it a substitute for personal medical care.  Kalispell OB/GYN shall not be liable for any damages arising out of the use of the content herein.