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Long-acting reversible contraceptives (LARC) are methods of
birth control Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unwanted pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth contr ...
that provide effective
contraception Birth control, also known as contraception, anticonception, and fertility control, is the use of methods or devices to prevent unwanted pregnancy. Birth control has been used since ancient times, but effective and safe methods of birth contr ...
for an extended period without requiring user action. They include injections, intrauterine devices (IUDs), and subdermal
contraceptive implant A contraceptive implant is an implantable medical device used for the purpose of birth control. The implant may depend on the timed release of hormones to hinder ovulation or sperm development, the ability of copper to act as a natural spermicide ...
s. They are the most effective reversible methods of contraception because their efficacy is not reliant on patient compliance. The typical use failure rates of IUDs and implants, less than 1% per year, are about the same as perfect use failure rates. LARCS are convenient, enjoyable and cost effective. Typically, users save thousands of dollars over a five-year period compared to those who buy
condom A condom is a sheath-shaped barrier device used during sexual intercourse to reduce the probability of pregnancy or a sexually transmitted infection (STI). There are both male and female condoms. With proper use—and use at every act of in ...
s and
birth control pill The combined oral contraceptive pill (COCP), often referred to as the birth control pill or colloquially as "the pill", is a type of birth control that is designed to be taken orally by women. The pill contains two important hormones: progest ...
s. About 15.5% of women worldwide use IUDs, and 3.4% use subdermal implants. LARCS are recommended to
adolescents Adolescence () is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with the te ...
to decrease the
teen pregnancy Teenage pregnancy, also known as adolescent pregnancy, is pregnancy in a female adolescent or young adult under the age of 20. This includes those who are Legal adult, legally considered adults in their country. The WHO defines adolescence as the ...
rate. They work in women of any age and number of births. Women may consider
family planning Family planning is the consideration of the number of children a person wishes to have, including the choice to have no children, and the age at which they wish to have them. Things that may play a role on family planning decisions include marita ...
advice beforehand.


Methods

LARC methods include IUDs and the subdermal implant: * Hormonal intrauterine device (
Mirena A hormonal intrauterine device (IUD), also known as a intrauterine system (IUS) with progestogen and sold under the brand name Mirena among others, is an intrauterine device that releases a progestogenic hormonal agent such as levonorgestrel int ...
– also known as IUC or IUS)Your guide to long-acting reversible contraception (LARC)
. www.fpa.org.uk.
Public Health England Public Health England (PHE) was an executive agency of the Department of Health and Social Care in England which began operating on 1 April 2013 to protect and improve health and wellbeing and reduce health inequalities. Its formation came as a ...
.
* Nonhormonal
intrauterine device with copper Intrauterine device (IUD) with copper, also known as intrauterine coil or copper coil, is a type of intrauterine device which contains copper. It is used for birth control and emergency contraception within five days of unprotected sex. It is o ...
(US –
ParaGard Intrauterine device (IUD) with copper, also known as intrauterine coil or copper coil, is a type of intrauterine device which contains copper. It is used for birth control and emergency contraception within five days of unprotected sex. It is one ...
) * Subdermal
contraceptive implant A contraceptive implant is an implantable medical device used for the purpose of birth control. The implant may depend on the timed release of hormones to hinder ovulation or sperm development, the ability of copper to act as a natural spermicide ...
(US – Nexplanon/Implanon/Implanon NXT; internationally – Norplant/Jadelle) Some shorter-acting methods are sometimes considered LARC: *
Progestogen-only injectable contraceptive Progestogen-only injectable contraceptives (POICs) are a form of hormonal contraception and progestogen-only contraception that are administered by injection and providing long-lasting birth control. As opposed to combined injectable contraceptive ...
*
Combined injectable contraceptive Combined injectable contraceptives (CICs) are a form of hormonal birth control for women. They consist of monthly injections of combined formulations containing an estrogen and a progestin to prevent pregnancy. CICs are different from progestoge ...


Medical use

The effectiveness of LARC methods has been shown to be superior to other types of birth control. A study in 2012, with the largest cohort of IUD and implant users to date, found that the risk of contraceptive failure for those using oral contraceptive pills, the birth control patch, or the vaginal ring was 17 to 20 times higher than the risk for those using long-acting reversible contraception. For those under 21, who typically have lower adherence to drug regimens, the risk is twice as high as the risk among older participants. A statistically significant association has been observed in England between a decrease in teenage conception and increased LARC usage. The discrepancy between LARC methods and other forms of birth control lies in the difference between "perfect use" and "typical use". Perfect use indicates complete adherence to medication schedules and guidelines. Typical use describes effectiveness in real-world conditions, where patients may not fully adhere to medication regimens. LARC methods require little to no user action after insertion; therefore, LARC perfect use failure rates are the same as their typical use failure rates. LARC failure rates rival that of sterilization, but unlike sterilization LARC methods are reversible. Other reversible methods, such as oral contraceptive pills, the birth control patch, or the vaginal ring require daily, weekly, or monthly action by the user. While the perfect use failure rates of those methods may equal LARC methods, the typical use failure rates are significantly higher. Even methods such as the DMPA injection require users to return to their provider every 12 weeks for the intramuscular shot or every 4 weeks for the subcutaneous shot. So, DMPA typical use failure rates are also higher than perfect use failure rates as more than 40% of women discontinue DMPA in the first year. In both effectiveness and continuation, LARC methods are considered the first-line option for contraception.


Side effects

Contraceptive implant A contraceptive implant is an implantable medical device used for the purpose of birth control. The implant may depend on the timed release of hormones to hinder ovulation or sperm development, the ability of copper to act as a natural spermicide ...
s may cause irregular bleeding which some women find unacceptable as a side effect ("Irregular bleeding and spotting common in first 6 months" associated with IUS; similar to side effects observed with IUD, injection or implant. "Changes in bleeding pattern which are likely to remain irregular") or a complete cessation of menstrual flow (
amenorrhea Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen, most commonly, during pregnancy and lactation (breastfeeding). Outside the reproductive years, there is absence of menses ...
). Side effects that are observed less often may include
emotional lability In medicine and psychology, emotional lability is a sign or symptom typified by exaggerated changes in mood or affect in quick succession. Sometimes the emotions expressed outwardly are very different from how the person feels on the inside. Thes ...
, weight gain, headache, and acne. Side effects for LARC are mostly similar to combined and progesterone only oral contraceptives, with a possibility of a small change in mood or libido observed in IUD and IUS use. The risk of
acne vulgaris Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and po ...
may be higher in IUS users, but is an uncommon reason for stopping use. Weight gain has been observed with
depot medroxyprogesterone acetate Medroxyprogesterone acetate (MPA), also known as depot medroxyprogesterone acetate (DMPA) in injectable form and sold under the brand name Depo-Provera among others, is a hormonal medication of the progestin type. It is used as a method of birt ...
(Depo-Provera). IUDs present a slight risk of infection at the time of insertion but have a low risk of
pelvic inflammatory disease Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...
(<1% for women at low risk of STIs), and uterine perforation (<1 in 1000). If a person becomes pregnant while they have an IUD inserted then the IUD should be removed within the first 12 weeks of gestation. In such a case, the mother has low risk of
ectopic pregnancy Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. ...
– approximately 1 in 20. Women who cease using depot medroxyprogesterone acetate can find that they have a delay of up to a year before being able to get pregnant, while there is no evidence of a delay in IUD, IUS or implant users.


Society and culture


Cost and benefit

LARC methods traditionally have a higher up-front cost, between $800 and $900 in the United States, than methods such as pills, patches and vaginal rings, but are more cost-effective in the long run. Like all contraceptive methods, access to LARC methods can reduce the rate of unintended pregnancy and result in significant cost savings to publicly funded health systems. Women switching from short-acting reversible contraceptive to long-acting intrauterine systems are likely to generate cost savings from unplanned pregnancy-related expenses and long term savings in contraceptive costs. Regardless, the initial out of pocket cost is still too high for many patients and is one of the biggest barriers to LARC use. Two recent studies done in California and St. Louis have shown that rates of LARC usage are dramatically higher when the costs of the methods are either covered or removed. A program geared toward increasing use of LARC among adolescents in Iowa demonstrated a significant decrease in the unintended pregnancy and abortion rate in that state along with a projected savings of $17.23 for every dollar spent on contraception for 14- to 19-year-olds. The Colorado Family Planning Initiative (CPFI), a six-year $23 million privately funded program to expand access to LARCs, decreased unplanned adolescent pregnancies in the state by about 40% and returned $5.85 in savings for each dollar spent. There was a similar decline of unplanned pregnancies in unmarried women under 25 who have not finished high school, another at risk group. Use of LARC methods by children of child-bearing age in the state increased to 20% during the 2009-2014 period. A 2017 study found that CPFI "reduced the teen birth rate in counties with clinics receiving funding by 6.4 percent over five years. These effects were concentrated in the second through fifth years of the program and in counties with relatively high poverty rates."


Promotion

The United Kingdom Department of Health has actively promoted LARC use since 2008, particularly for young people; following on from the October 2005
National Institute for Health and Clinical Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies withi ...
guidelines, which promoted LARC provision in the United Kingdom, accurate and detailed counseling for women about these methods, and training of healthcare professionals to provide these methods. Giving advice on these methods of contraception has been included in the 2009
Quality and Outcomes Framework The Quality and Outcomes Framework (QOF) is a system for the performance management and payment of general practitioners (GPs) in the National Health Service (NHS) in England, Wales, Scotland and Northern Ireland. It was introduced as part of a n ...
"good practice" for primary care. The use of long-acting reversible contraceptives in the United States has increased nearly fivefold from 1.5% in 2002 to 7.2% in 2011–2013. Increasing access to long-acting reversible contraceptives was listed by the
Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
as one of the top public health priorities for reducing teen pregnancy and unintended pregnancy in the United States. One study of female family planning providers showed that they were significantly more likely to use LARCs than the general population (41.7% compared to 12.0%) suggesting that the general population has less information or access to LARCs. Guidelines released in 2009 by the
American Congress of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts of ...
state that LARC methods are considered to be the first-line option for birth control in the United States, and are recommended for the majority of women. According to the CDC Medical Eligibility Criteria for Contraceptive Use, LARC methods are recommended for the majority of women who have had their first menstruation, regardless of whether they have had any pregnancies. The
American Academy of Pediatrics The American Academy of Pediatrics (AAP) is an American professional association of pediatricians, headquartered in Itasca, Illinois. It maintains its Department of Federal Affairs office in Washington, D.C. Background The Academy was founded ...
(AAP) in a policy statement and technical report published in October 2014 recommended LARC methods for adolescents.


References


External links


UK National Health Service Long-acting Reversible Contraception Guidelines

Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception

Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy
from the American Congress of Obstetricians and Gynecologists {{Birth control methods Methods of birth control