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Tuesday, 14 February 2017

DOCTORS DON'T CRY

at February 14, 2017

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Long-acting reversible contraception, or LARC, methods provide reliable, long-term, highly effective prevention of pregnancy after one-time placement of a device. LARC methods are safe for use in almost all women, including young and nulliparous women. LARC methods include IUDs (hormonal IUDs and nonhormonal copper-containing IUDs) and the subdermal hormonal implant. Increasing access to these most effective, reversible methods of contraception is a key strategy to further decrease the rate of unintended pregnancy in the United States. A new Review Article explains. Clinical Pearl What pregnancy rates are associated with the use of IUDs? The copper-containing IUD, ParaGard, is a nonhormonal device and contains 380 mm2 of copper around the arms and stem. The four levonorgestrel-releasing IUDs (LNG-IUDs) include two devices that contain 52 mg of levonorgestrel (Mirena and Liletta), a device that contains 19.5 mg (Kyleena), and a slightly smaller device that contains 13.5 mg (Skyla). Less than 1% of women become pregnant during the first year of IUD use, with pregnancy rates with the LNG-IUD (0.1 to 0.2%) generally reported as lower than the rates with the copper-containing IUD (0.5 to 0.8%). ParaGard is approved by the FDA for 10 years of use, Mirena and Kyleena for 5 years, and Skyla for 3 years. As of November 2016, Liletta is approved for 3 years of use, but data are being collected to assess 5-year use. Clinical Pearl Is screening for STDs required before placement of an IUD? Women generally do not require screening for STDs at the time of IUD insertion if they have already been screened according to the STD Treatment Guidelines of the Centers for Disease Control and Prevention (e.g., annual screening for chlamydial infection for women younger than 25 years of age or for older women at increased risk for STDs). If a woman with risk factors for STDs has not been screened according to the guidelines, screening can be performed at the time of insertion of the IUD, and insertion should not be delayed. More research is needed to determine the most appropriate timing of IUD placement after a pelvic infection. Evidence is lacking to guide health care providers in determining when an infection has resolved sufficiently for IUD placement. In women who test positive for gonococcal infection or chlamydial infection at the time of IUD placement, the device should be left in place and treatment should be initiated. Morning Report Questions Q: How effective is a subdermal hormonal implant? A: Currently, Nexplanon is the only hormonal implant available in the United States. Nexplanon, which slowly releases the progestin etonogestrel, differs from a similar previous implant, Implanon, in that it has an improved inserter and contains barium to facilitate the radiologic detection of implants that cannot be palpated. The contraceptive effectiveness of the implant is high, with an estimated 0.1% of users becoming pregnant in the first year of use, and does not seem to vary with body-mass index. The etonogestrel-releasing implant is approved by the FDA for 3 years of use. The most common side effect of implants is unpredictable bleeding, and women should be counseled about this risk before implant placement. Q: Can IUDs and hormonal implants be placed immediately post partum or post abortion? A: Both IUDs and implants are safe for use in the postpartum and postabortion periods, including immediately post partum and post abortion; immediate placement has been associated with lower rates of repeat pregnancy and repeat abortions than the rates with other contraceptives. Insertion of an IUD immediately post partum is associated with low rates of adverse events such as perforation (0 in three studies of over 3000 women in total), infection (1% in one study of 554 women), and the need for removal of the IUD as a result of bleeding and pain (5 to 11% over 12 months in three studies of approximately 7500 women in total); these rates generally did not differ from those observed with IUD insertion at times other than the postpartum period. Although IUDs are generally safe for use in the postpartum period, the relative risk of expulsion of IUDs that are placed immediately post partum is higher than the risk with IUDs placed at 6 weeks post partum or later.

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