Ruth McDonald, MD
Vice President, Associate Chief Medical Officer, Seattle Children’s
Long-acting reversible contraception (LARCs) are safe, top-tier contraception and appropriate for most adolescents and women, according to the American College of Obstetrics and Gynecology (ACOG). The American Academy of Pediatrics also endorsed LARCs as a first-line contraceptive.
LARCs have a higher continuation rate than shorter-acting methods of birth control, are cost-effective, and have a low failure rate because they are “forgettable” once implanted. LARCs are a good choice for sexually active adolescent females who have a high risk of unintended pregnancy.
New data on safety and efficacy
New clinical evidence shows excellent safety and prolonged efficacy of certain LARCs:
- Mirena (52 mg levonorgestrel) can be used for seven years, up from five
- Nexplanon (etonorgestrel) can be used for five years, up from three
- Paragard (copper) can be used for 12 years, up from 10
In addition, newer options – Liletta (52 mg levonorgestrel), Kyleena (19.5 mg levonorgestrel) and Skyla (13.5 mg levonorgestrel) – are now on the market.
The Contraceptive CHOICE Project studies adolescents who chose to use 52 mg levonorgestrel IUD, the copper IUD or the etonorgestrel implant over shorter acting methods. The teens who chose LARC methods were 20 times less likely to get pregnant that those who used non-LARC methods.
Common clinical considerations
While the risk of PID is increased for two weeks after insertion of an IUD, this is usually related to a pre-existing sexually transmitted infection (STI). We recommend screening all teens for GC/CT at the time of IUD insertion. Those with a positive test should be treated according to the CDC’s MMWR guidelines, but the IUD may not need to be removed.
Pain upon insertion is another concern. Strategies to decrease pain and anxiety – such as NSAIDs, heating pads, smaller speculums, anxiety medication and encouraging the patient to listen to their favorite music – enable most patients to tolerate the procedure well in clinic.
Overall, rates of pregnancy after removal of IUD and etonogestrel implant are excellent and equal to other contraceptive methods.
No STI protection
It’s important that adolescents understand that LARCs do not protect against infections like chlamydia, gonorrhea, warts, herpes, HIV – and that they know how to prevent them. Condoms should be used with all sexual encounters. Teens should be screened for STIs according to the CDC guidelines (annually for adolescents and more frequently if they have a new partner).
New challenges to access
Adolescents’ access to free and low-cost birth control may be severely limited pending the resolution of initiatives by the current administration.
Earlier this year, federal judges blocked a proposed rule change that would allow employers to refuse to cover birth control by citing religious or moral objections.
In addition, Washington was one of more than 20 states that filed suit against the Trump Administration over proposed changes to the federal reproductive healthcare program known as Title X. Title X provides reproductive health care for low income and uninsured patients and serves more than 90,000 Washington residents each year. This program provides contraception, sexually transmitted infection screening and treatment, and HPV vaccination. Title X does not fund abortion. The new rules would block Title X funding to family planning providers (like Planned Parenthood) that also offer abortion services. It also prevents providers who work at Title X-funded programs from counseling patients about abortion or providing a referral to a center that provides abortion services. Preliminary injunctions by federal judges in Oregon and Washington in late April temporarily blocked the new regulations, which were set to take affect May 3. This situation continues to unfold.
Resources
- Bedsider,an online site that helps young women find the birth control that works best for them, lets people set reminders to take daily birth control and has information about sexual health and preventing STDs. There’s also a section for healthcare providers.
- Planned Parent Online Video Visitsfor birth control and mail order STD tests in Washington, Idaho, Minnesota, Hawaii and Alaska.
- Information for providers on providing a teen-friendly reproductive health visit.
- Statement from the AAP on Title X: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/FinalTitleXRegulationstatement.aspx