Appropriate choice of long-acting reversible contraception in primary care

Development group: Connolly, Mansour, Raine & Siddiqi.
This management algorithm was developed by a multidisciplinary expert panel: Connolly A et al with the support of a grant from Bayer.


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This management algorithm was developed by a multidisciplinary expert panel: Connolly A et al with the support of a grant from Bayer. See bottom of page for full disclaimer.


  • Women should be offered a choice of reliable methods of contraception alongside access to useful information about the options
  • Women should be offered a contraceptive method that best suits the woman’s individual needs and lifestyle, therefore, making it more likely that contraception will be used effectively
  • The most effective contraceptive methods during typical use are generally those that do not require adherence (see Figure 1, below)

Figure 1: Failure rates with typical use, per 100 woman-years

Long-acting reversible contraception

  • Long-acting reversible contraceptives (LARCs) have a number of advantages over non-LARCs:
    • their effectiveness does not rely on daily use
    • they are more cost-effective than the combined oral contraceptive pill, even after 1 year of use
    • improving access and increasing uptake of LARC has been proven to reduce the number of unwanted pregnancies and abortions
    • they have proven higher continuation rates than non-LARC methods—87% vs. 57% after one year of use
    • they have proven improved user satisfaction compared with non-LARC methods—84% vs. 53% were satisfied after one year of use
  • For difficult cases (e.g. complicated medical history, complicated insertions, or outside clinician’s expertise), refer to the local pathway for expert advice

Training

  • Healthcare professionals who fit women with intrauterine devices, intrauterine systems, or contraceptive implant devices should ensure that they are properly trained to carry out the procedure and hold a letter of competence from the Faculty of Sexual & Reproductive Healthcare (FSRH), or equivalent proof of suitable training in line with Medical Defence Union guidance
  • The FSRH offers training on the administration of LARCs; visit the 'Careers and Training' page for more information (www.fsrh.org/careers-and-training)

Management of problematic bleeding

  • Problematic bleeding refers to breakthrough bleeding, spotting, prolonged or frequent bleeding
  • Before starting any form of hormonal contraception, women should be advised about expected bleeding patterns both initially and long-term
  • Take a clinical history to assess:
    • the woman’s concerns
    • correct use of contraceptive method, use of interacting medication, illness altering absorption of orally administered hormones
    • other symptoms (e.g. pain, dyspareunia, abnormal discharge, heavy/postcoital bleeding)
  • Exclude sexually transmitted infections
  • Check cervical screening history
  • Consider the need for a pregnancy test

Medical options to manage problematic bleeding

  • Refer to the FSRH guidance for full details on medical options and the management of women who experience problematic bleeding
  • Potential options for women using the contraceptive injection include:
    • reducing the injection interval for depot medroxyprogesterone acetate (DMPA) has not been shown to improve bleeding; however, DMPA may be given after a 10-week interval
    • to reduce the duration of bleeding episodes with DMPA, mefenamic acid 500 mg twice- (or as licensed use up to three times) daily or tranexamic acid 1 g four-times daily for 5 days may be effective in the short term, but provides no long-term benefit
  • If usual management of problematic bleeding is unsuccessful, consider repeating cervical and pelvic examination, plus investigations to exclude endometrial pathology (e.g. ultrasound scan)

Dispelling common myths about LARCs

  • Weight gain
    Use of the contraceptive injection has been associated with early weight gain (over 5% baseline weight gain) within the first 6 months of use in approximately one-quarter of users
  • Loss of sex drive
    There is no evidence for loss of libido, so any symptoms may be due to other lifestyle factors
  • Infertility
    Fertility will return immediately after removal of the IUD, IUS, and implant; however, there could be a delay in the return of fertility of up to 1 year following use of the contraceptive injection
  • Protection against STIs
    LARCs do not protect against STIs, therefore a condom should be used if concerned
  • Mood changes
    There is no robust evidence for mood changes, and changes may be caused by other factors
  • Use in nulliparous women
    LARCs can be used in women of any age, including young women and those who have not yet had children
  • Bone health
    • The SIGN guideline on Management of osteoporosis and the prevention of fragility fractures states that women using the contraceptive injection should be advised that treatment can reduce bone density, but that the effects reverse when treatment is stopped and the overall risk of fracture is low
    • There are no such concerns regarding bone health associated with the use of other LARC methods
LARCs=long-acting reversible contraceptives; IUD=intrauterine device; IUS=intrauterine system; STI=sexually transmitted infections; SIGN=Scottish Intercollegiate Guidelines Network.

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References

about this management algorithm…

sponsor—

This algorithm has been developed by MGP Ltd, the publisher of Guidelines, and the expert group was convened by MGP Ltd. Final editorial decisions rested with the Chair. Bayer provided funding for the development of this algorithm but has had no input into the content or the selection of the expert group members.

group members

Dr Anne Connolly (Chair, GP with a special interest in Gynaecology), Dr Diana Mansour (Consultant in Community Gynaecology and Reproductive Healthcare), Shelley Raine (Nurse Specialist in Contraception), Dr Shabina Siddiqi (GP)

further information

call MGP Ltd (01442 876100)

Date of preparation: November 2016


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