Long acting reversible contraception (LARC) options include the progesterone containing intrauterine devices (IUDs) — Mirena, Kyleena, Skyla, and Liletta, the copper IUD (Paragard), and Nexplanon (formerly Implanon), a progesterone-containing rod that is implanted in the upper arm.
These contraception devices are very effective forms of reversible contraception because once they are inserted, their effectiveness is not user-dependent. Although less commonly used than traditional hormone contraception (like birth control pills, Nuva ring and the Patch), many studies show that LARC have the highest continuation rates and satisfaction scores at 1 year.
These devices provide excellent contraception for anywhere from 3-10 years depending on device, but may be removed at any time. LARC do not affect future fertility and once an IUD or Nexplanon is removed, a patient may try to conceive after her first spontaneous menstrual cycle.
What are Intrauterine Devices (IUDS)?
IUDs are small, T-shaped devices that provide long acting reversible contraception for up to 3, 5, 8 or 10 years, depending on device. There are two categories of IUDs available in the US, the progesterone containing IUDs (Mirena, Kyleena, Skla, and Liletta) and the copper (Paragard) IUD.
IUDs are inserted in the office, similar to performing a pap smear. The IUD is gently inserted through the cervix and placed within the uterine cavity. There are thin strings that trail from the bottom edge of the IUD through the cervix; these are trimmed at the end of the procedure. The strings are used to remove the IUD at a future date and may be felt for on a monthly basis to confirm that the IUD is still in place. They typically curl up and lie flush against the cervix.
Sometimes a patient’s partner may be able to feel these strings during intercourse. If this is the case, and they are bothersome, the strings may be trimmed further at the 4-6 week follow up appointment.
The most common side effects at time of IUD insertion are cramping and light bleeding. Taking ibuprofen (Motrin or Advil) prior to the IUD insertion appointment will relieve some of this discomfort. The main risks of IUD insertion include: bleeding, infection, and uterine perforation, meaning that the IUD is inserted through the wall of the uterus into the abdominal cavity. The latter two (infection and uterine perforation) occur less than 1/1000 insertions. If uterine perforation occurs, it requires laparoscopic surgery to remove the IUD from the abdominal cavity.
The IUD may also be expelled, or pushed out of the uterus, through the cervix. The expulsion rate is the highest during the 1st month after insertion. It is very important to return for a follow up appointment after any IUD insertion to confirm that the IUD is in the correct location. IUDs may be safely inserted in patients who have never been pregnant or whom have never given birth. IUDs may also be inserted during the post-partum period and used while breast-feeding without affecting milk supply.
The IUDs may be removed at any time, meaning they do not need to stay in for the allotted 3-10 years. It is possible to become pregnant as early as one week after IUD removal, so if pregnancy is not desired, it is important to immediately begin an alternative form of birth control.
Progesterone Containing IUDs
The Mirena, Kyleena, Skyla, and Liletta IUDs contain a progesterone hormone called levonorgestrel and provides long acting reversible contraception for up to 8 years. The levonorgestrel hormone primarily acts locally on the uterine lining, with minimal systemic effects. In fact, most women ovulate normally with these IUDs in place. Rarely women may experience systemic hormone side effects such as headaches, breast tenderness and depression.
The progesterone containing IUDs primarily prevent pregnancy during the pre-fertilization period by inhibiting sperm, affecting egg transport and damaging the egg itself. This progesterone also thins the uterine lining and changes the consistency of the cervical mucus. Most women will experience significantly lighter periods with the these IUDs, with menses becoming progressively lighter over time.
However, during the first 1-3 months after insertion, frequent or unpredictable light bleeding is common. At 3 months post-insertion ~ 30% of women will have either infrequent periods or stop menstruating altogether; at 2 years this number increases to 70%. In fact, the progesterone containing IUDs are also FDA approved for the treatment of heavy menstrual bleeding. Even though any long-term menstrual bleeding with these IUDs is light, the unpredictable nature of the bleeding is often the most bothersome.
With the progesterone containing IUDs, we recommend back up contraception should be used for 7 days.
The Copper IUD (Paragard) contains a tightly coiled copper wire and provides long acting reversible contraception for up to 10 years. The Paragard IUD is hormone free and has no associated systemic side effects. The most common local side effects include abnormal bleeding and pelvic pain. However, the symptoms of heavy menstrual bleeding and painful menses typically improve with time.
Keep in mind that most patients’ menstrual flow will be equal to their natural, “not-on-birth-control” periods. Many women perceive this flow as heavier, but only as compared to their periods on birth control pills or other hormonal contraception. Bleeding may be relatively heavier, but it is usually predictable, and spotting between menses is rare.
Similar to the progesterone containing IUDs, the copper IUD primarily prevents pregnancy during the pre-fertilization period by inhibiting sperm, affecting egg transport and damaging the egg itself.
Back up contraception is not needed after Paragard IUD insertion. The Paragard IUD may also be used as emergency contraception if placed within 5 days of unprotected intercourse.
Nexplanon is a hormone-releasing birth control implant that may be used to prevent pregnancy for up to 3 years. The implant is a thin, plastic rod (about the size of a matchstick) that contains a progesterone hormone called etonogestrel. It is latex-free and does not contain any estrogen hormone. Nexplanon is inserted beneath the skin on the inner part of the upper arm as a simple in-office procedure with local anesthesia and a tiny incision.
Ideally, the implant is inserted during the menstrual period, and if insertion occurs within 5 days of starting menses, no back-up contraception is needed. If placed at other times, backup contraception or abstinence is needed for 7-10 days. Nexplanon is also an excellent postpartum contraception option for mothers who are breastfeeding and does not affect milk production .Nexplanon has replaced the original Implanon. Nexplanon is identical to Implanon in size, etonogestrel concentration and efficacy, but the newer Nexplanon has an improved insertion device and the implant itself contains a radio-opaque material so that that implant can be identified on x-ray or CT scan if necessary.
Nexplanon primarily prevents pregnancy by preventing ovulation, but is also thickens the cervical mucus and changes the uterine lining, making it more difficult for pregnancy to occur. Nexplanon is greater than 99% effective at preventing pregnancy. The most common side effect of Nexplanon is irregular, unpredictable menstrual bleeding. Other side effects may include weight gain (6-12%), worsening acne (10-14%), mood swings, or depressed mood.
Nexplanon may be removed at any time. It is possible to become pregnant as early as one week after Nexplanon is removed; so if pregnancy is not desired, it is important to immediately begin an alternative form of birth control.