Contraception Knowledge Centre
Hormonal Methods
Long-Acting Reversible Contraception
Guidance on long acting reversible contraception (LARC)
In October 2005 the National Institute for Health and Clinical Excellence (NICE) published guidelines relating to LARC covering intrauterine devices (IUDs), the intrauterine system (IUS), injectable contraceptives, and the subdermal implant.
The key messages of the guidance are:
- Women requiring contraception should be given information about and offered a choice of all methods. Consider the choice of method most appropriate for the woman
- For those worried about the cost, all currently available LARC methods are more cost effective than the combined oral contraceptive pill; IUDs, the IUS and implants being more cost effective than the injectable contraceptives.
- Increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies.
Women considering LARC methods should receive detailed information to enable them to choose a method and use it effectively. The Family Planning Association (FPA) website contains all the information in those essential leaflets and is a great resource to share with women.
If you do not provide LARC within your own practice, have an agreed mechanism in place for referring women on. Special training and skills are needed to provide intrauterine and subdermal contraceptives.
Women requesting contraception should be given information tailored to their needs, so the clinician needs to make an assessment based on the woman's history, identifying any contraindications, and then provide information on appropriate methods. Remember to advise regarding safer sex.
If you are unable to initiate the chosen method, refer on, considering an interim method to provide immediate contraception and thereby facilitating the timing of when the other method can be fitted.
Features of LARC methods to discuss with women are as follows:
- how the method works
- its duration of use
- the failure rate
- risks
- effects on periods
- return to fertility
- advice at time of fitting.
The effect on periods is particularly important to stress as it is the most common reason for stopping all LARC methods.
| IUD | IUS | Injectable | Implant | |
|---|---|---|---|---|
| Effect on periods | Heavier bleeding +/- pain likely | Irregular bleeding and spotting common for first six months. | Light or no bleeding likely by 12 months | No bleeding common, persistent bleeding may occur. Bleeding pattern likely to remain irregular, 20% have amenorrhoea. |
| Stopping method early | Up to 50% at <5 years | Up to 60% at <5 years | Up to 50% at <1 year | Up to 43% at <3 years |
| IUD | IUS | Injectable | Implant | |
|---|---|---|---|---|
| Weight | No effect | No effect | May gain 2-3 kgs over one year | No effects |
| Acne | No comment | May occur | No effect | No effect |
| Bone mineral density | No comment | No comment | Small loss; largely recovered after discontinuation | No effect |
| Headaches | No comment | No comment | No effect | No effect |
| Libido | May be small effect | May be small effect | No comment | No effect |
Change in mood |
May be small effect | May be small effect | No effect | No effect |
IUD
Women aged 40 years or older when their IUD is inserted can keep it until they no longer need contraception, even if this is beyond the duration of the UK licence.
Download the IUS patient leaflet
Injectable
Care is needed with adolescents and women over 40. When considering depo medro-oxy progesterone acetate (DMPA) use beyond two years, review the woman's clinical situation.
Repeat injections of DMPA may be given up to two weeks late without the need for additional contraceptives.
Download the Hormone Injection patient leaflet
Implant
These are not suitable for women on enzyme-inducing drugs.
Implanon is a single rod implant that is placed directly under the skin on the inside of the upper arm. Once inserted, it continuously releases the progestagen Etonogestrel that effectively prevents pregnancy up to 3 years. The implant can be removed at any time before the three years have elapsed in case this would be desired by the Implanon-user.
Jadelle is subdermal implant system consisting of two rods and is the successor of the 6 rod implant Norplant which has been withdrawn from the market. The two rods are releasing the progestagen Levonorgestrel which prevents pregancy for up to 5 years. The implant can also be removed and replaced at any time. Jadelle is marketed in only very few countries.
Further information
Download the full NICE guideline: Long-acting reversible contraception (October 2005)