Long-acting reversible contraception

Introduction

LARC is defined in this guideline as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:

• copper intrauterine devices
• progestogen-only intrauterine systems
• progestogen-only injectable contraceptives
• progestogen-only subdermal implants

The guideline offers the best-practice advice for all women of reproductive age who may wish to regulate their fertility by using LARC methods. It covers specific issues for the use of these methods during the menarche and before the menopause, and by particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years.

1.1 Contraception and principles of care

1.1.1 Contraceptive provision

1.1.1.1 Women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods.

1.1.1.2 Women should be provided with the method of contraception that is most acceptable to them, provided it is not contraindicated.

1.1.1.3 Contraceptive service providers should be aware that:

• all currently available LARC methods (intrauterine devices [IUDs], intrauterine systems^[A] [IUSs], injectable contraceptives and implants) are more cost effective than the combined oral contraceptive pill even at 1 year of use
• IUDs, IUSs and implants are more cost effective than the injectable contraceptives
• increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies.

1.1.2 Provision of information and informed choice

1.1.2.1 Women considering LARC methods should receive detailed information – both verbal and written – that will enable them to choose a method and use it effectively. This information should take into consideration their individual needs and should include:

• contraceptive efficacy
• duration of use
• risks and possible side effects
• non-contraceptive benefits
• the procedure for initiation and removal/discontinuation
• when to seek help while using the method.

See the implementation resource, which provides links to up to date, relevant and valid information about LARC methods.

1.1.2.2 Counselling about contraception should be sensitive to cultural differences and religious beliefs.

1.1.2.3 Healthcare professionals should have access to trained interpreters for women who are not English speaking, and to advocates for women with sensory impairments or learning disabilities.

1.1.3 Contraceptive prescribing

1.1.3.1 A medical history – including relevant family, menstrual, contraceptive and sexual history – should be taken as part of the routine assessment of medical eligibility for individual contraceptive methods.

1.1.3.2 Healthcare professionals helping women to make contraceptive choices should be familiar with nationally agreed guidance on medical eligibility and recommendations for contraceptive use.

1.1.3.3 When considering choice of LARC methods for specific groups of women and women with medical conditions, healthcare professionals should be aware of and discuss with each woman any issues that might affect her choice (see the implementation resource, which provides links to up to date, relevant and valid information about LARC methods).

1.1.3.4 Healthcare professionals should exclude pregnancy by taking menstrual and sexual history before initiating any contraceptive methods.

1.1.3.5 Healthcare professionals should supply an interim method of contraception at first appointment if required.

1.1.3.6 Healthcare professionals should ensure that informed consent is obtained from the woman whenever any method of LARC is being used outside the terms of the UK Marketing Authorisation. This should be discussed and documented in the notes.

1.1.3.7 Women who have a current venous thromboembolism (VTE) and need hormonal contraception while having treatment for the VTE should be referred to a specialist in contraceptive care.

1.1.4 Contraception and sexually transmitted infection

1.1.4.1 Healthcare professionals providing contraceptive advice should promote safer sex.

1.1.4.2 Healthcare professionals providing contraceptive advice should be able to assess risk for sexually transmitted infections (STIs) and advise testing when appropriate.

1.1.4.3 Healthcare professionals should be able to provide information about local services for STI screening, investigation and treatment.

1.1.5 Contraception for special groups

1.1.5.1 Healthcare professionals should be aware of the law relating to the provision of advice and contraception for young people and for people with learning disabilities. Child protection issues and the Fraser guidelines should be considered when providing contraception for women younger than 16 years^[B].

1.1.5.2 Women with learning and/or physical disabilities should be supported in making their own decisions about contraception.

1.1.5.3 Contraception should be seen in terms of the needs of the individual rather than in terms of relieving the anxieties of carers or relatives.

1.1.5.4 When a woman with a learning disability is unable to understand and take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman’s contraceptive need and to establish a care plan.

1.1.6 Training of healthcare professionals in contraceptive care

1.1.6.1 Healthcare professionals advising women about contraceptive choices should be competent to:

• help women to consider and compare the risks and benefits of all methods relevant to their individual needs
• manage common side effects and problems.

1.1.6.2 Contraceptive service providers who do not provide LARC in their practice or service should have an agreed mechanism in place for referring women for LARC.

1.1.6.3 Healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide these methods.

1.1.6.4 IUDs and the IUS should only be fitted by trained personnel with continuing experience of inserting at least one IUD or one IUS a month.

1.1.6.5 Contraceptive implants should be inserted and removed only by healthcare professionals trained in the procedure.

More information

You can also see this guideline in the NICE Pathway on long-acting reversible contraception. To find out what NICE has said on topics related to this guideline, see our web page on contraception.

See also the guideline committee’s discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.

Footnotes

[A] The MHRA issued a Drug Safety Update in January 2016 highlighting that levonorgestrel- releasing intrauterine systems should always be prescribed by brand name because products have different indications, durations of use, and introducers.

[B] See the Department of Health’s Best practice guidance for doctors and other healthcare professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health (July 2004).