1. Long-Acting Reversible Contraception (LARC)
ACOG Guidelines
•IUD / IUS
•Implant
Presented By:
Barbara L. Scanlon, MSN
Nurse-Family Partnership Supervisor
PMCHNNJ

2. What are long-acting reversible contraception
(LARC) methods?
• Long-acting reversible contraception (LARC) methods include
the intrauterine device (IUD)
the birth control implant
• Both methods are highly effective in preventing pregnancy, last for
several years, and are easy to use.
• Both are reversible—if you want to become pregnant or if you want to
stop using them, you can have them removed at any time.

3. How effective are LARC methods?
• The IUD and the implant are the most effective forms
of reversible birth control available.
• During the first year of typical use –
fewer than 1 in 100 women using an IUD or an implant will become pregnant.
• This rate is in the same range as that for sterilization.

4. How do LARC methods compare with other
methods of contraception?
• Over the long term, LARC methods are 20 times more effective than
birth control pills
the patch
the vaginal ring

5. What is the intrauterine device (IUD)?
• The IUD is a small,T-shaped, plastic device
• Which is inserted into and left inside the uterus

6. There are two types of IUDs:
• 1.The hormonal IUD releases progestin.
One hormonal IUD is approved for use for up to 5 years.
Another is approved for use for up to 3 years.
• 2.The copper IUD does not contain hormones.
It is approved for use for up to 10 years.

7. What are the benefits of the IUD?
• The IUD has the following benefits:
• Once it is in place, you do not have to do anything else to prevent pregnancy.
• No one can tell that you are using birth control.
• It does not interfere with sex or daily activities.
• It can be inserted immediately after an abortion, a miscarriage, or childbirth
and while breastfeeding.
• Almost all women are able to use an IUD.
• If you wish to become pregnant or if you want to stop using it,
you can simply have the IUD removed.
• The hormonal IUD helps decrease menstrual pain and heavy menstrual bleeding.
• The copper IUD also is the most effective form of emergency contraception.

8. How does the IUD work?
• Both types of IUDs work mainly by preventing fertilization of the egg by
the sperm.
• The hormonal IUD also thickens cervical mucus, which makes it harder for
sperm to enter the uterus and fertilize the egg, and keeps the lining of the
uterus thin, which makes it less likely that a fertilized egg will attach to it.

9. How is the IUD inserted?
• A health care provider must insert and remove the IUD.
• He or she will review your medical history and will perform a pelvic exam.
• To insert the IUD, the health care provider puts the IUD in a slender plastic tube.
• The health care provider places the tube into the vagina and guides it through
the cervix into the uterus.
• The tube is withdrawn, leaving the IUD in place.

10. Will I feel anything when the IUD is inserted?
• Insertion of the IUD may cause some discomfort.
• Taking over-the-counter pain relief medication before the procedure
may help.
• The IUD has a string made of thin plastic threads.
• After insertion, the strings are trimmed so that 1–2 inches extend past
the cervix into the vagina.
• The strings should not be bother some or noticeable.

11. What are possible side effects of use of the IUD?
• With the copper IUD, menstrual pain and bleeding may increase.
• Bleeding between periods may occur.
• Both effects are common in the first few months of use.
• Pain and heavy bleeding usually decrease within 1 year of use.
• Both hormonal IUDs may cause spotting and irregular bleeding in the first 3–6
months of use.
• The amount of menstrual bleeding and the length of the menstrual period
usually decrease over time.
• Menstrual pain also usually decreases.
• A few women also may have side effects related to the hormones in these IUDs.
• These side effects may include headaches, nausea, depression,
and breast tenderness.

12. What are possible risks of use of the IUD?
• Serious complications from use of an IUD are rare.
• However, some women do have problems.
These problems usually happen during or soon after insertion:
• The IUD may come out of the uterus.
• This happens in about 5% of users in the first year of using the IUD.
• The IUD can perforate (or pierce) the wall of the uterus during insertion.
• It is rare and occurs in only about 1 out of every 1,000 insertions.

13. Pelvic inflammatory disease (PID)
• PID is an infection of the uterus and fallopian tubes.
• PID may cause scarring in the reproductive organs, which may make it
harder to become pregnant later.
• The risk of PID is only slightly increased in the first 20 days after insertion
of an IUD, but the overall risk still is low (fewer than 1 in 100 women).
• Rarely, pregnancy may occur while a woman is using an IUD.
• In the rare case that a pregnancy occurs with the IUD in place,
there is a higher chance that it will be an ectopic pregnancy.

14. What is the birth control implant?
• The birth control implant is a single flexible rod about the size
of a matchstick that is inserted under the skin in the upper arm.
• It releases progestin into the body.
• It protects against pregnancy
• For up to 3 years.

15. How does the birth control implant work?
• The progestin in the implant prevents pregnancy mainly by
stopping ovulation.
• In addition, the progestin in the implant thickens cervical mucus,
• Which makes it harder for sperm to enter the uterus and fertilize the egg.
• Progestin also keeps the lining of the uterus thin, making it less likely that
a fertilized egg will attach to it.

16. What are the benefits of
the birth control implant?
• The implant has the following benefits:
• Once it is in place, you do not have to do anything else to prevent pregnancy.
• No one can tell that you are using birth control.
• It can be inserted immediately after an abortion, a miscarriage, or childbirth
and while breastfeeding.
• It does not interfere with sex or daily activities.
• Almost all women are able to use the implant.
• If you wish to become pregnant or if you want to stop using it,
you can simply have the implant removed.

17. How is the birth control implant inserted?
• The implant is inserted into your arm by a health care provider.
• A small area on your upper arm is numbed with a local anesthetic.
• No incision is made.
• Your health care provider places the implant under the skin with
a special inserter.
• The procedure takes only a few minutes.

18. How is the birth control implant removed?
• To remove the implant
• The health care provider again numbs the area.
• One small incision is made.
• The implant then is removed.

19. What are possible side effects of use of
the birth control implant?
• The most common side effect of the implant is unpredictable bleeding.
• For some women, these bleeding patterns improve over time.
• Some women have less menstrual pain while using the implant.
• In some women, bleeding stops completely.
• Other common side effects include mood changes, headaches, acne,
and depression.
• Some women have reported weight gain while using the implant,
but it is not clear whether it is related to the implant.

20. What are possible risks of use of the birth
control implant?
• Possible risks include problems with insertion or removal of the implant.
• These problems occur in less than 2% of women.
• Although rare, if a woman becomes pregnant while the implant is inserted
there is a slightly increased risk that it will be an ectopic pregnancy.

21. Glossary
• Birth Control Implant: A small, single rod that is inserted under the skin in the upper arm by a health
care provider. It releases a hormone and protects against pregnancy for up to 3 years.
• Cervix: The lower, narrow end of the uterus at the top of the vagina.
• Ectopic Pregnancy: A pregnancy in which the fertilized egg begins to grow in a place other than inside
the uterus, usually in one of the fallopian tubes.
• Egg: The female reproductive cell produced in and released from the ovaries; also called the ovum.
• Emergency Contraception: Methods that are used to prevent pregnancy after a woman has had sex
without birth control,
• Fertilization: Joining of the egg and sperm.
• Intrauterine Device (IUD): A small device that is inserted and left inside the uterus to prevent
pregnancy.
• Ovulation: The release of an egg from one of the ovaries.
• Pelvic Exam: A physical examination of a woman’s reproductive organs.
• Pelvic Inflammatory Disease (PID): An infection of the uterus, fallopian tubes, and nearby pelvic
structures.
• Progestin: A synthetic form of progesterone that is similar to the hormone produced naturally by the
body.
• Sperm: A cell produced in the male testes that can fertilize a female egg.
• Sterilization: A permanent method of birth control.
• Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus
during pregnancy.
• Vagina: A tube-like structure surrounded by muscles leading from the uterus to the outside of the body.
• If you have further questions, contact your obstetrician–gynecologist.

22. Copyright July 2014 by the American College
of Obstetricians and Gynecologists
• http://www.acog.org/Patients/FAQs/Long-Acting-Reversible-
Contraception-LARC-IUD-and-Implant

23. Recommendations
• Although lowering unintended pregnancy rates requires multiple
approaches,
• individual obstetrician–gynecologists may contribute by increasing
access to LARC methods for their patients.
•
• http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-
Gynecologic-Practice/Increasing-Use-of-Contraceptive-Implants-and-Intrauterine-Devices-
To-Reduce-Unintended-Pregnancy

24. LARC’s
The IUD (Intrauterine Device)
• Is a smallT-shaped device (no larger than 32 mm x 36 mm)
• It is inserted into the uterus by a healthcare provider to
prevent pregnancy.
• IUDs are categorized as long-acting reversible
contraceptive methods (LARCs).
• There are three different types of IUDs available in the U.S.

25. The Copper IUD Mirena
Skyla
The Copper IUD, known as
ParaGard, can stay in place for
up to 10 years.[iii]
Two types of hormonal IUDs, known as Mirena or Skyla, can
stay in place for up to 5 or 3 years,[iv] respectively. These IUDs
continuously release a small amount of progestin
(Levonorgestrel) to prevent pregnancy.[v]
http://iudtaskforce.org/IUDBasics

26. Based of the most recent estimate (2006),
• nearly half of all pregnancies in the U.S. are unintended (49%),
• and 43% of these pregnancies end in abortion.
• In the U.S. each year, there are an estimated 1.5 million births
resulting from unintended pregnancies.

27. IUDs are HIGHLY EFFECTIVE
in preventing pregnancy
• IUDs are 99% effective in preventing pregnancy.
• They are one of the most effective forms of birth control.
• IUDs do not require daily compliance or attention
like oral contraceptives (the pill).

28. WOMENWANT IUDS and LIKE IUDs
once they have them
• Two-thirds of women of child-bearing age in the U.S. currently use
birth control, and the use of IUDs is on the rise within this group:
from 2% in 2002 to 7.7% in 2009.
• In a recent study 10,000+ women received contraceptive counseling and
were provided any contraceptive method free of charge, 67% of women
chose LARC methods (56% IUDs, 11% implants).
• The same study found that at 24 months after choosing their birth control
method - women continued using IUDs longer than any other birth control
method: 77% and 79% for Paragard and Mirena
• respectively, compared to 43% for the pill.

29. IUDs are SAFE and RECOMMENDED
for use by most women
• The American College of Obstetricians & Gynecologists (ACOG) recommends
that LARCs be offered as first-line contraceptive methods and encouraged as
options for most women, including adolescents.
• Skyla and Paragard are FDA-approved for use among women who have never
had children (referred to clinically as nulliparous women).
• Mirena is FDA-recommended for women who have had at least one child
and women seeking a birth control method that helps treat heavy menstrual
bleeding.
• IUDs can be safely inserted directly postpartum and postabortion.
• Inserting an IUD or implant immediately after an abortion significantly
reduces the risk of subsequent abortions.
• Infertility is not more likely after discontinuation of an IUD than after
discontinuation of other reversible methods of contraception.

30. Selected Practice Recommendations
for Contraceptive Use
• In 2013, the CDC developed the United States Selected Practice
Recommendations for Contraceptive Use, which provides guidance on how
contraceptive methods can be used and how to remove unnecessary barriers
for patients in accessing and successfully using contraceptive methods.
• The report offers guidance on when to initiate IUDs and clinical guidance
on special considerations, advisable testing, routine follow-up and IUD
management.
• In 2010 the Centers for Disease Control and Prevention (CDC) developed
the United States Medical Eligibility Criteria for Contraceptive Use
• This provides guidance on the safety of contraceptive methods, including
IUDs, for women with specific characteristics and medical conditions.

31. IUDs can be LONG-LASTING
but are easily removed at any time
• IUDs can last from 3 to 10 years, depending on IUD type
• They can be easily removed at any time by a healthcare provider.
• Rates of continuation and removal of IUDs are similar for adults
and adolescents.

32. IUDs can be AFFORDABLE
• Under the Affordable Care Act, all contraceptive methods (including IUDs)
and associated services (insertion, removal, and maintenance) must be covered
by a health plan without cost-sharing.
• The National Women’s Law Center and Bayer HealthCare Pharmaceuticals
(manufacturer of Mirena and Skyla) have developed materials to help women
and providers navigate obtaining health insurance coverage of IUDs without
cost-sharing.
• IUD manufacturers (Teva Women’s Health and Bayer HealthCare Pharmaceuticals)
provide IUDs at reduced cost to medical facilities that qualify for the 340B federal
drug pricing program.
• IUD manufacturers also have patient assistance programs that offer IUDs free
of charge for those who qualify and are uninsured.

33. Currently available IUDs
• work by preventing sperm from fertilizing ova
• although some aspects of the precise mechanism of action are not known.
• IUDs are not abortifacients; they do not interrupt an implanted pregnancy.
• Pregnancy is prevented by a combination of the ‘foreign body effect’
of the plastic frame and the specific action of the medication
(copper or Levonorgestrel) that is released
• This impairs sperm function and implantation
• and prevents fertilization.

34. American College of Obstetricians
and Gynecologists
• ACOG Recommendations regarding Long-Acting Reversible
Contraceptives (LARCs)
• "Although lowering unintended pregnancy rates requires multiple
approaches, individual obstetrician–gynecologists may contribute
by increasing access to LARC methods for their patients.
• The following strategies can reduce barriers
and increase use of implants and IUDs:

35. 1. Provide counseling on all contraceptive options, including implants and
IUDs
2. even if the patient initially states a preference for a specific contraceptive
method.
3. Encourage implants and IUDs for all appropriate candidates, including
nulliparous women and adolescents.
4. Adopt same-day insertion protocols. Screening for chlamydia, gonorrhea,
and cervical cancer should not be required before implant or IUD insertion
but may be obtained on the day of insertion, if indicated.
5. Avoid unnecessary delays, such as waiting to initiate a method until after
a post-abortion or miscarriage follow-up visit or to time insertion with
menses.

36. 1. Support efforts to lower the up-front costs of LARC methods.
2. Advocate for coverage of all contraceptive methods by all insurance plans,
both private and public.
3. Become familiar with and support local, state, federal (including
Medicaid),
and private programs that improve affordability of all contraceptive
methods, including implants and IUDs."
• Source: (etonogestrel implant)
http://www.acog.org/Resources_And_Publications/Committee_Opinio
ns/Committee_on_Gynecologic_Practice/Increasing_Use_of_Contrace
ptive_Implants_and_Intrauterine_Devices_To_Reduce_Unintended

37. What is NEXPLANON?
• NEXPLANON is a hormone-releasing birth control implant
for use by women to prevent pregnancy for up to 3 years.
• The implant is a flexible plastic rod about the size of a matchstick
that contains a progestin hormone called etonogestrel.
• It contains a small amount of barium sulfate so that the implant
can be seen by X-ray, and may also contain magnesium stearate.
• Your healthcare provider will insert the implant just under the skin
of the inner side of your upper arm.
• You can use a single NEXPLANON implant for up to 3 years.
• NEXPLANON does not contain estrogen.

38. Important Safety Information About
NEXPLANON
• You should not use NEXPLANON if you are pregnant or think you may
be pregnant
• have or have had blood clots; have liver disease or a liver tumor;
have unexplained vaginal bleeding; have breast cancer or any other cancer
that is sensitive to progestin (a female hormone), now or in the past
• are allergic to anything in NEXPLANON.
• Talk to your health care provider about using NEXPLANON if you have diabetes,
high cholesterol or triglycerides, headaches, gallbladder or kidney problems,
history of depressed mood, high blood pressure, allergy to numbing medicines
(anesthetics) or medicines used to clean your skin (antiseptics).
• As local anesthetic medicines that be used when the implant
is placed into or removed from your arm.
• http://iudtaskforce.org/IUDBasics

39. Immediately after the NEXPLANON implant
has been placed
• You and your health care provider should check that the implant
is in your arm by feeling for it.
• If you and your health care provider cannot feel the NEXPLANON implant,
use a non-hormonal birth control method (such as condoms) until your
health care provider confirms that the implant is in place.
• You may need special tests to check that the implant
is in place or to help find the implant when it is time
to take it out.
• http://www.nexplanon.com/en/consumer/about-it/what-is-nexplanon/

40. What if I need birth control for more than 3 years?
• The NEXPLANON implant must be removed after 3 years.
• Your healthcare provider can insert a new implant
under your skin after taking out the old one
if you choose to continue using NEXPLANON
for birth control.

41. What if I change my mind about birth control
and want to stop using
NEXPLANON before 3 years?
• Your healthcare provider can remove the implant at any time.
• You may become pregnant as early as the first week after removal
of the implant.
• If you do not want to get pregnant after your healthcare provider
removes the NEXPLANON implant
• you should start another birth control
method right away.

42. How does NEXPLANON work?
• NEXPLANON prevents pregnancy in several ways.
• The most important way is by stopping the release
of an egg from your ovary.
• NEXPLANON also thickens the mucus in your cervix
and this change may keep sperm from reaching
the egg.
• NEXPLANON also changes the lining of your uterus.

43. How well does NEXPLANON work?
• When the NEXPLANON implant is placed correctly,
your chance of getting pregnant is very low
• less than 1 pregnancy per 100 women who use NEXPLANON for 1 year.
• It is not known if NEXPLANON is as effective
in very overweight women because studies did
not include many overweight women.
• http://www.merck.com/product/usa/pi_circulars/n/nexplanon/nexplanon_ppi.pdf

45. What things should I think about
when choosing a birth control method?
• To choose the right birth control method for you,
consider the following:
• How well it prevents pregnancy
• How easy it is to use
• Whether you need a prescription to get it
• Whether it protects against sexually transmitted diseases (STDs)
• Whether you have any health problems

46. Do I need to have a pelvic exam to get birth
control from my health care provider?
• A pelvic exam is not needed to get most forms of birth control from
a health care provider
• except for the intrauterine device (IUD), diaphragm, and cervical cap.
• If you have already had sex,
- you may need to have a pregnancy test and STD test before birth
control can be prescribed.

47. Which birth control methods are the best at
preventing pregnancy?
• The following table shows all of the birth control methods
• and how well they protect against pregnancy.

49. Which birth control methods also protect against
sexually transmitted diseases (STDs)?
• The male latex or polyurethane condom
gives the best protection against STDs.
• The female condom provides some protection.
• With all other methods, you also should use a male or female condom
to protect against STDs.

50. What is the birth control pill?
• The birth control pill is a pill that you have to take every day
- at the same time each day.
• It contains hormones that prevent pregnancy.
• There are many types of birth control pills.
• Your health care provider can help you choose the right one for you.
- If you miss a pill, you need to know what to do.
• Read the directions that came with your pack of pills.
• You also may want to contact your health care provider.

51. What is the skin patch?
• The patch is a small (1.75 square inch) adhesive patch
that is worn on the skin.
• It contains hormones that are slowly released into your body
through the skin.
• A new patch is worn for a week at a time for 3 weeks in a row.
• During the fourth week, a patch is not worn, and you will have
your menstrual period.

52. What is the vaginal ring?
• The ring is a flexible plastic ring that you insert into the upper vagina.
• It releases hormones into your body.
• It is worn inside the vagina for 21 days and then removed for 7 days.
• During those 7 days, you will have your menstrual period.
• Then you insert a new ring.

53. What is the birth control shot?
• This shot is given in the upper arm or buttock every 3 months.
• It contains hormones that prevent pregnancy.
• DMPA –> Depo-Provera Injection
Depo Medroxy Provera Acetate

54. What is the implant?
• The implant is a small plastic rod about the size of a matchstick that
the health care provider inserts under the skin of the upper arm.
• It releases hormones.
• The implant protects against pregnancy for 3 years.

55. What is the intrauterine device (IUD)?
• The intrauterine device (IUD) is a small,T-shaped, plastic device* that is
inserted and left inside the uterus.
• The IUD must be inserted and removed by a health care provider.
• Three types are available in the United States.
• Two contain hormones and last for 3 years and 5 years.
• The third type is the copper IUD. It lasts for as long as 10 years.

56. What are spermicides?
• These are chemicals that are put into the vagina to make sperm inactive.
• There are many types of spermicides:
foam, gel, cream, film (thin sheets),
or suppositories (solid inserts that melt after they are inserted
into the vagina).
• Frequent use of spermicides may increase the risk of getting human
immunodeficiency virus (HIV) from an infected partner.
• Spermicides should only be used if you are at low risk of HIV infection.

57. What are condoms?
• Condoms come in male and female versions.
• The male condom ("rubber") covers the penis and catches the sperm
after a man ejaculates.
• The female condom is a thin plastic pouch that lines the vagina.
• It prevents sperm from reaching the uterus.
• Condoms work better to prevent pregnancy when used
with a spermicide.
• Spermicides should only be used if you are at low risk of HIV infection.

58. What is the diaphragm?
• The diaphragm is a small dome-shaped device made of latex or silicone
that fits inside the vagina and covers the cervix.
• You need a prescription for it.
• A health care provider needs to do a pelvic exam to find the right size
of diaphragm for you.
• It always is used with a spermicide.
• Birth control methods that need spermicides to work
should only be used if you are at low risk of HIV infection.

59. What is the cervical cap?
• The cervical cap is a small, thin latex or plastic dome shaped like a thimble.
• It fits tightly over the cervix.
• You need a prescription for it.
• A health care provider needs to do a pelvic exam
to find the right size for you.
• The cervical cap must be used with a spermicide.
• Birth control methods that need spermicides to work
should only be used if you are at low risk of HIV infection.

60. What is the sponge?
• The sponge can be bought without a prescription at drugstores
and other stores.
• It is a doughnut-shaped device made of soft foam that is coated
with spermicide.
• It is pushed up in the vagina to cover the cervix.
• Birth control methods that have spermicides
should only be used if you are at low risk of HIV infection.

61. What is emergency birth control?
• Emergency birth control can be used to prevent pregnancy if
1. you have sex without using any birth control
2. if the birth control method did not work
(for instance, the condom broke during sex)
3. or if you are raped.
• Emergency birth control is available in pill form or as a copper IUD.
• The pills must be taken or the IUD inserted within 5 days of having
unprotected sex.

62. What are the types of
emergency birth control pills?
There are three types of emergency birth control pills:
• 1) the progestin-only pill
• 2) regular birth control pills taken in certain amounts
• 3) ulipristal.

63. Where can I get emergency birth control?
• Ulipristal and combination birth control pills are available only by
prescription.
• One type of progestin-only pill (Plan B One- Step) is available on pharmacy
store shelves without a prescription to anyone of any age.
• Another type of progestin-only pill (Next Choice One Dose) is available behind
the pharmacy counter without a prescription to anyone 17 years or older if
you show proof of age and by prescription if you are younger than 17 years.
• If you need more information about emergency birth control or need to find
a health care provider who can provide a prescription,
• go to www.not-2-late.com
• or call the emergency birth control hotline at 1-888-NOT-2-LATE.

64. Glossary
http://www.acog.org/Patients/FAQs/Birth-Control-Especially-for-Teens
• Cervix:The lower, narrow end of the uterus at the top of the vagina.
• Hormones: Substances made in the body by cells or organs that control the function of cells or
organs. An example is estrogen, which controls the function of female reproductive organs.
• Human Immunodeficiency Virus (HIV): A virus that attacks certain cells of the body’s immune
system and causes acquired immunodeficiency syndrome (AIDS).
• Pelvic Exam: A physical examination of a woman’s reproductive organs.
• Penis: An external male sex organ.
• SexuallyTransmitted Diseases (STDs): Diseases that are spread by sexual contact, including
chlamydia, gonorrhea, human papillomavirus infection, herpes, syphilis, and infection with
human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome
[AIDS]).
• Sperm: A cell produced in the male testes that can fertilize a female egg cell.
• Uterus: A muscular organ located in the female pelvis that contains and nourishes the
developing fetus during pregnancy.
• Vagina: A tube-like structure surrounded by muscles leading from the uterus to the outside
of the body.
• If you have further questions, contact your obstetrician–gynecologist.
• Copyright December 2013 by the American College of Obstetricians andGynecologists

65. The following strategies can reduce barriers
and increase use of implants and IUDs:
1. Provide counseling on all contraceptive options, including implants
and IUDs, even if the patient initially states a preference for a specific
contraceptive method.
2. Encourage implants and IUDs for all appropriate candidates, including
nulliparous women and adolescents.
3. Adopt same-day insertion protocols.
4. Screening for chlamydia, gonorrhea, and cervical cancer should not
be required before implant or IUD insertion but may be obtained on the
day of insertion, if indicated.

66. 5. Avoid unnecessary delays, such as waiting to initiate a method until
after a post abortion or miscarriage follow-up visit or to time insertion
with menses.
6. Support efforts to lower the up-front costs of LARC methods.
7. Advocate for coverage of all contraceptive methods by all insurance
plans, both private and public.
8. Become familiar with and support local, state, federal (including
Medicaid), and private programs that improve affordability of all
contraceptive methods, including implants and IUDs.

68. IUDs and Birth Control Implants:
Resource Overview
• Intrauterine devices (IUDs) and contraceptive implants are long-acting
reversible contraception (LARC).
• Over time, LARC methods are 20 times more effective than birth control
pills, the patch, or the vaginal ring.
• ACOG’s LARC Program works to reduce unintended pregnancy in the US.
• Ob-gyns, physicians whose primary responsibility is women’s health,
play a leading role in providing scientific information and access to
contraceptive methods, including IUDs and implants for their patients.
• Here are the key publications and resources for ob-gyns, other women’s
health care providers, and patients from the American College of
Obstetricians and Gynecologists (ACOG) and other sources.
• http://www.acog.org/Womens-Health/IUDs-and-Birth-Control-
Implants#Patient

69. Sexual Behavior and Contraceptive Use
Among American Adolescents
• In the United States, 42% of adolescents aged 15–19 years have had
sexual intercourse.
• Although almost all sexually active adolescents report having used some
method of contraception during their lifetimes, they rarely select the
most effective methods.
• Adolescents most commonly use contraceptive methods with relatively
high typical use failure rates such as condoms, withdrawal, or oral
contraceptive (OC) pills.

70. Adolescents and Long-Acting
Reversible Contraception:
Implants and Intrauterine Devices
• Nonuse, inconsistent use, and use of methods with high typical use failure
rates are reflected in the high rate of unintended adolescent pregnancies
in the United States.
• Eighty-two percent of adolescent pregnancies are unplanned, accounting
for one fifth of all unintended pregnancies in the United States, a statistic
that indicates an unmet need for acceptable, reliable, and effective
contraceptive methods for adolescents.

71. Long-acting reversible contraception
• (LARC) methods are increasing in popularity with use increasing from
2.4% of all U.S. women using contraception in 2002 to 8.5% in 2009.
• Approximately 4.5% of women aged 15–19 years who are currently using
a method of contraception use LARC, with most using an IUD.
• The etonogestrel single-rod contraceptive implant, approved by the U.S.
Food and Drug Administration in 2006, is used by less than 1% of U.S.
women using contraception and 0.5% of those aged 15–19 years.
• In a study of 4,167 females aged 14–45 years that compared continuation
rates for LARC and short-acting contraceptive methods, the continuation
rate for LARC was 86% at 12 months compared with 55% for short-acting
contraceptive methods.

72. Short-acting contraceptive methods
• including condoms, OCs, the contraceptive patch, the vaginal ring, and
depot medroxy-progesterone acetate (DMPA) injections, are mainstays of
adolescent contraceptive choices, but these contraceptives have lower
continuation rates and higher pregnancy rates than LARC methods.
• Of 1,387 females aged 15–24 years who initiated short-acting hormonal
methods, only 11% using the contraceptive patch, 16% receiving DMPA
injections, and approximately 30% using the vaginal ring and OCs were still
using the same method after 12 months.

73. Continuation of Method
• Poor continuation coupled with higher failure rates decrease the efficacy
of short-acting contraception in young women.
• Barriers to wide use of LARC methods by adolescents include a lack of
familiarity with or misperceptions about the methods, the high cost,
• the lack of access, and health care providers’ concerns about the safety
of LARC use in adolescents.

74. Counseling, Consent, Confidentiality, and Cost
• Increasing adolescent access to LARC is a clinical and public health
opportunity for obstetrician–gynecologists.
• With top-tier effectiveness, high rates of satisfaction and continuation,
and no need for daily adherence, LARC methods should be first-line
recommendations for all women and adolescents.
• As with all nonbarrier methods, to decrease the risk of sexually
transmitted infections (STIs), including human immunodeficiency virus
(HIV), health care providers should advise sexually active adolescents to
consistently use condoms along with LARC methods.

75. Counseling, Consent, Confidentiality, and Cost
• Like all women seeking reproductive health services,
adolescents have the right to decline the use of LARC
as well as the right to discontinue LARC without barriers.
• Coercive insertion of long-acting contraception was used in the past
as a means of fertility control in marginalized women.

76. Confidentiality is
of particular importance
to adolescents
• In many states, adolescents have the right to receive confidential
contraceptive services without parental consent,
• and health care providers should be familiar with laws concerning
provision of contraception to minors in their own states.
• Information regarding these laws can be found at:
http://www.guttmacher.org/statecenter/adolescents.html.

77. Cost
• High up-front costs for LARC methods can be a deterrent to use.
• Adolescents who have insurance coverage through their parents
may not want to use the benefit because of confidentiality concerns
• others may be uninsured or have insurance that excludes coverage
for LARC methods.
• In all of these cases, referral to a publicly funded clinic may be
appropriate.
• Proposed health care reform provisions to cover all FDA-approved
contraceptive methods, including LARC methods, without copayments
or deductibles for these preventive health services, may ease this burden.

78. Guidance for Adolescent Health Care Providers
to Address Common Misconceptions
• Health care providers’ concerns about LARC use by adolescents
are a barrier to access.
• Health care provider training and continuing education programs
should address common misconceptions and review the key evidence
and benefits of adolescent LARC use.

79. Intrauterine devices are safe
to use among adolescents
• Current evidence demonstrates the safety of modern IUDs.
• Although few studies have focused exclusively on adolescents who use
currently available IUDs, good evidence suggests that the relative risk of pelvic
inflammatory disease (PID) is increased only in the first 20 days after IUD
insertion and then returns to baseline, while the absolute risk remains small.
• Bacterial contamination associated with the insertion process is the likely
cause of infection, not the IUD itself.
• The risk of PID with IUD placement is 0–2% when no cervical infection is
present and 0–5% when insertion occurs with an undetected infection.
• Women with positive chlamydia cultures after IUD insertion are unlikely to
develop PID, even with retention of the IUD, if the infection is promptly treated.
• The levonorgestrel intrauterine system may lower the risk of PID by thickening
cervical mucus and thinning the endometrium.

80. Intrauterine devices do not increase an
adolescent’s risk of infertility.
• Infertility is not more likely after discontinuation of IUD use than
after discontinuation of other reversible methods of contraception.
• In a large case–control study that examined determinants of tubal
infertility, the presence of chlamydial antibodies, not previous IUD use,
was associated with infertility.
• Baseline fecundity returns rapidly after IUD removal.

81. Intrauterine devices may be inserted without
technical difficulty in most adolescents and
nulliparous women.
• Little evidence suggests that IUD insertion is technically more difficult
in adolescents compared with older women.
• More than one half of young nulliparous women report discomfort with
IUD insertion.
• Anticipatory guidance regarding pain and provision of analgesia during
IUD insertion should be individualized and may include supportive care,
and medications
nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, anxiolytics.

82. Adolescents should be routinely screened for STIs
(eg, gonorrhea and chlamydia)
at the time of IUD insertion
• Women aged 15–19 years have the second highest rates of chlamydia and
the highest rates of gonorrhea of any age group.
• Thus, all adolescents should be screened for STIs at the time of or before
IUD insertion.
• It is reasonable to screen for STIs and place the IUD on the same day (and
administer treatment if the test results are positive) or when the test
results are available.
• If an STI is diagnosed after the IUD is in place, it may be treated without
removing the IUD.
• Routine antibiotic prophylaxis is not recommended before IUD insertion.

83. Intrauterine device expulsion is uncommon in
adolescents.
• Intrauterine device expulsion rates range from 3% to 5%
for all IUD users and from 5% to 22% in adolescents.
• Young age, previous IUD expulsion, and nulliparity
may slightly increase the risk of expulsion,
… but research on current IUDs is limited.
• Prior expulsion should not be considered a contraindication
for another IUD provided that appropriate counseling is given.

84. Intrauterine devices cause changes
in bleeding patterns.
• Adolescents using either copper IUDs or the levonorgestrel intrauterine
system can expect changes in their menstrual bleeding especially in the first
months of use.
• The copper IUD may cause heavier menses that can be treated with NSAIDs.
• Women using the levonorgestrel intrauterine system will have a decrease in
bleeding over time that will lead to light bleeding, spotting, or amenorrhea.
• Health care providers should counsel adolescents so they understand that
these changes are common and expected.

85. The Contraceptive Implant
• The contraceptive implant causes changes in bleeding patterns.
• Adolescents who use the contraceptive implant can expect changes
in menstrual bleeding patterns throughout the duration of use.

86. A change in bleeding pattern
• Change in bleeding is the most common reason for implant
discontinuation.
• Anticipatory guidance regarding bleeding patterns may improve
satisfaction and continuation.
• The bleeding pattern women experience in the first 3 months
is broadly predictive of future bleeding patterns.
• Common strategies for treating problematic bleeding include
the use of short courses of combined OCs or NSAIDs

87. Patient Choice
• In the absence of contraindications
• Patient choice should be the principal factor in prescribing one method
of contraception over another, and adolescents have the right to decline
any method of contraception.

88. The contraceptive implant has
secondary health benefits.
• High rates of infrequent bleeding or amenorrhea lead to higher
hemoglobin levels in etonogestrel implant users (less anemia)
• Other non-contraceptive benefits of the contraceptive implant include
1. reductions in dysmenorrhea (cramping)
2. pelvic pain
• A prospective study of etonogestrel implant users showed
no difference in the change in bone mineral density
compared with copper IUD users after 2 years of use.

89. The contraceptive implant has minimal
or no effect on weight.
• A small percentage of women (2.3%) in the clinical trials for the
etonogestrel implant discontinued use because of reported weight gain
• however, actual weight gain was not documented.
• In contrast, DMPA injections are associated with weight gain, with
overweight adolescents more susceptible to weight gain than normal
weight adolescents.

90. Table 1. U.S. Medical Eligibility Criteria for Contraceptive Use
Condition Implant
Copper
IUD
LNG-
IUD
Clarification/Evidence/Co
mments
Age
Menarche to younger than 18
y 1
Menarche to younger than 20
y 1 2 2
Comment: Concern exists
about the risk for expulsion
from
nulliparity and for STIs from
sexual behavior in younger
age
groups.
Postpartum
Less than 10 min after
delivery
of the placenta 1 2
Evidence: Immediate
postpartum insertion of a
copper IUD,
particularly when insertion
occurs immediately after
delivery of the placenta, is
associated with lower
expulsion rates.
Immediate insertion may
happen after vaginal or
cesarean
birth.
10 min after delivery of the
placenta to less than 4 wk 2 2 2

91. Less than 10 min after
delivery
of the placenta 1 2
Evidence: Immediate
postpartum insertion of a
copper IUD,
particularly when insertion
occurs immediately after
delivery of the placenta, is
associated with lower
expulsion rates.
Immediate insertion may
happen after vaginal or
cesarean
birth.
10 min after delivery of the
placenta to less than 4 wk 2 2 2
Less than 4 wk and not
breastfeeding 1 2 2
Less than 4 wk and
breastfeeding 2 2 2
4 wk or later and
breastfeeding
or not breastfeeding 1 1 1
Puerperal sepsis 4 4
Comment: Insertion of an IUD
might substantially worsen
the condition.
1 = A condition for which there is no restriction for the use of the contraceptive method.
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks.
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
Abbreviations: IUD, intrauterine device; LNG-IUD, levonorgestrel-releasing intrauterine device.
Modified from U S. Medical Eligibility Criteria for Contraceptive Use, 2010.Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep
2010;59(RR-4):1–86.

92. Conclusion
• When choosing contraceptive methods,
adolescents should be encouraged to consider LARC methods.
• Intrauterine devices and the contraceptive implant are the best reversible
methods for preventing unintended pregnancy, rapid repeat pregnancy,
and abortion in young women.
• Counseling about LARC methods should occur at all health care provider
visits with sexually active adolescents, including preventive health,
abortion, prenatal, and postpartum visits.
• Complications of IUDs and the contraceptive implant are rare
and differ little between adolescents and older women.
• Health care providers should consider LARC methods for adolescents
and help make these methods accessible to them.
• http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-
Care/Adolescents-and-Long-Acting-Reversible-Contraception