Duration of use of a levonorgestrel IUS amongst nulliparous and adolescent women

Expulsion and continuation rates of the 52 mg levonorgestrel intrauterine system in adolescents and adult women

OBJECTIVE

To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women.

METHODS

We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups.

RESULTS

Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039).

CONCLUSION

Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis

BACKGROUND

Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population.

METHODS

Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence.

RESULTS

Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%).

CONCLUSION

Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.

Intrauterine device use is safe among nulligravidas and adolescent girls

The use of intrauterine devices (IUDs), including the copper-bearing device and the levonorgestrel intrauterine system (LNG-IUS), is safe among nulligravidas and adolescent girls. However, several misconceptions limit their use in clinical practice; health-care providers are hesitant to prescribe IUDs, and several myths associated with their usage in nulligravidas and adolescents exist among both providers and women themselves. The high rates of unplanned pregnancies (which in many settings constitute a public health issue, primarily among adolescent females) can be attributed at least partially to lack of awareness and limited use of highly effective contraceptives such as IUDs. In this review, we discuss the role of non-hormonal and hormonal IUDs as effective contraceptives in nulligravidas and adolescent girls. We present a literature review of data that highlight contraceptive efficacy, side effects (including reasons for discontinuation), and continuation rates with the method. We searched the PubMed/MEDLINE, Cochrane Library, Embase, and Scopus databases for all articles published in English between January 1990 through September 2020. A large body of evidence confirmed the effectiveness of IUD/IUS, independent of age and parity. Studies showed a high expulsion rate among adolescents but not among nulligravidas. Additionally, bleeding patterns among adolescents and nulligravidas were similar to those observed among adults and parous women. The high early removal rates observed in adolescents were attributable to bleeding and/or pain, which indicate that compared with adults, adolescents are less likely to accept IUD-induced side effects. IUD placement is an excellent strategy to avoid the high rates of unplanned pregnancies in adolescents and nulligravidas. IUDs are more effective than short-acting reversible contraceptives with failure rates that are equivalent to those observed with permanent contraception. However, few long-term studies have investigated this category of women to definitively establish the role of IUD/IUS as effective means of contraception.

Practical Tips for Intrauterine Device Counseling, Insertion, and Pain Relief in Adolescents: An Update

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed intrauterine devices as first-line contraceptive choices for nulliparous and parous adolescents. Practical concerns about intrauterine devices might be barriers to use for teens and clinicians; this review is devoted to "practical tips" for clinicians, on the basis of an update of the available literature as well as the author's clinical experience. Counseling about contraceptive choices, preventive guidance about possible side effects, informed consent, and pain management are addressed to promote successful use of this long-acting reversible contraption option.

Frequency of 6-week follow-up appointment scheduling after intrauterine device insertion

INTRODUCTION

Long-acting reversible contraception (LARC) is widely recommended to reduce unintended pregnancy in the USA. As intrauterine device (IUD) use increases, evaluating the role of post-insertion follow-up is important.

METHODS

A retrospective patient record review was conducted to assess the follow-up experience of women who had an IUD placed at the University of Kansas Medical Center from 1 January to 30 June 2015. Data were collected on patient demographics, IUD placement, follow-up visit attendance, and outcomes in the 12 months following placement. The primary outcome of interest was the proportion of patients who attended a 6-week follow-up visit. Secondary outcomes included adverse events detected at the 6-week visit and IUD removal within a year of placement.

RESULTS

Among 380 women who had an IUD inserted, physician documentation of a recommended 6-week follow-up visit was present in 91.3% of patient medical records. Two-thirds (66.6%) of patients receiving a recommendation returned for a follow-up visit. Of the 380 women who had an IUD placed, 66 (17.4%) had their IUD removed within 1 year of placement. Of those, 50 women attended the 6-week follow-up visit and 16 did not (19.8% vs 12.6%, p=0.08). Of the IUD removals, 14 occurred at the 6-week visit. After excluding IUD removals which occurred at the 6-week visit, attending a 6-week follow-up visit was not associated with IUD removal or retention (p=0.52).

CONCLUSION

Despite recommendations to forgo the 6-week follow-up visit, visits were still common, with no demonstrated value added.

Provider and Health System Factors Associated with Usage of Long-Acting Reversible Contraception in Adolescents

STUDY OBJECTIVE

Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents. Surveys of primary care providers suggest that physician and clinic factors might influence LARC counseling, but their effect on usage is unknown. Our objective was to explore provider and clinic characteristics associated with LARC usage in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional study of 5363 women ages 15-21 years receiving primary care within a large health system in Massachusetts in 2015. We used data abstracted from electronic medical records to characterize rates of LARC usage. We analyzed the association of provider (specialty, degree, gender, resident status, LARC credentialing) and clinic (Title X funding, onsite LARC provision, onsite obstetrician-gynecologist) factors with adolescents' LARC usage using multivariate logistic regression.

RESULTS

Overall, 3.4% (95% confidence interval [CI], 2.9-3.9) of adolescents were documented as currently using a LARC method. Older adolescents were significantly more likely to use a LARC method (adjusted odds ratio, 2.41; 95% CI, 1.62-3.58 for women ages 20-21 years compared with ages 15-17 years). Adolescents whose primary care provider was a resident were significantly more likely to use a LARC method (adjusted odds ratio, 1.65; 95% CI, 1.02-2.68). Provider specialty, degree, gender, onsite LARC provision, and onsite obstetrician-gynecologist were not significantly associated with LARC usage in adolescents.

CONCLUSION

Being older and having a primary care provider early in their training increased the odds of LARC usage among adolescents in a large Massachusetts health system. Across primary care specialties, educating providers about the appropriate uses of LARC methods in nulliparous adolescents might facilitate LARC usage.

The safety of intrauterine devices among young women: a systematic review

OBJECTIVE

The objective was to determine the association between use of intrauterine devices (IUDs) by young women and risk of adverse outcomes.

METHODS

We searched Pubmed, CINAHL, Embase, Popline and the Cochrane Library for articles from inception of database through December 2015. For outcomes specific to IUD use (IUD expulsion and perforation), we examined effect measures for IUD users generally aged 25 years or younger compared with older IUD users. For outcomes of pregnancy, infection, pelvic inflammatory disease (PID), and heavy bleeding or anemia, we examined young IUD users compared with young users of other contraceptive methods or no method.

RESULTS

We identified 3169 articles of which 16 articles from 14 studies met our inclusion criteria. Six studies (Level II-2, good to poor) reported increased risk of expulsion among younger age groups compared with older age groups using copper-bearing (Cu-) IUDs. Two studies (Level II-2, fair) examined risks of expulsion among younger compared with older women using levonorgestrel-releasing (LNG-) IUDs; one reported no difference in expulsion, while the other reported increased odds for younger women. Four studies (Level II-2, good to poor) examined risk of expulsion among Cu- and LNG-IUD users combined and reported no significant differences between younger and older women. For perforation, four studies (Level II-2, fair to poor) found very low perforation rates (range, 0%-0.1%), with no significant differences between younger and older women. Pregnancies were generally rare among young IUD users in nine studies (Level I to II-2, fair to poor), and no differences were reported for young IUD users compared with young combined oral contraceptive (COC) or etonogestrel (ENG) implant users. PID was rare among young IUD users; one study reported no cases among COC or IUD users, and one reported no difference in PID among LNG-IUD users compared with ENG implant users from nationwide insurance claims data (Level I to II-2, fair). One study reported decreased odds of bleeding with LNG-IUD compared with COC use among young women, while one study of young women reported decreased odds of removal for bleeding with LNG-IUD compared with ENG implant (Level I to II-2, fair).

CONCLUSION

Overall evidence suggests that the risk of adverse outcomes related to pregnancy, perforation, infection, heavy bleeding or removals for bleeding among young IUD users is low and may not be clinically meaningful. However, the risk of expulsion, especially for Cu-IUDs, is higher for younger women compared with older women. If IUD expulsion occurs, a young woman is exposed to an increased risk of unintended pregnancy if replacement contraception is not initiated. IUDs are safe for young women and provide highly effective reversible contraception.

Comparison of two cohorts of women who expulsed either a copper-intrauterine device or a levonorgestrel-releasing intrauterine system

AIM

To assess if there is a difference in the characteristics of the women who expelled a copper-intrauterine device (TCu-IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS) and the frequency of expulsions over different periods of observation.

METHODS

We retrospectively analyzed 19 697 medical charts of women consulting between January 1980 and December 2013 who requested a TCu-IUD or a LNG-IUS.

RESULTS

The medical records of 17 644 Cu-IUD and 2053 LNG-IUS users returning to the clinic for a follow-up visit after insertion of an IUC were reviewed. Of these, 1532 Cu-IUD and 254 LNG-IUS parous users were found to have expelled the IUC for a first time. The mean age at insertion (± standard deviation) was 26.3 ± 6.6 years (range 16-49) for Cu-IUD users and 31.7 ± 7.6 years (range 18-48) for LNG-IUS users (P < 0.001). A total of 263 (13.4%) and 12 (4.3%) of the Cu-IUD and the LNG-IUS users were ≤19 years old, and 49.1% and 54.1% of the expulsions among the Cu-IUD and LNG-IUS users, respectively, were reported in the first six months after placement. A regression model showed that the variables significantly associated with an expulsion of either a Cu-IUD or LNG-IUS were age < 25 years, less than two deliveries and using a Cu-IUD.

CONCLUSION

Our findings showed that the characteristics associated with IUC expulsion were age under 25 years, having had less than two deliveries and being users of Cu-IUD.

Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers

Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.

Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications

OBJECTIVE

The objective of the study was to evaluate success and safety of intrauterine device (IUD) placement in a large cohort of adolescents.

STUDY DESIGN

We examined the medical records of patients aged 13-24 years at the Children's Hospital Colorado Adolescent Family Planning Clinic with at least 1 attempt at IUD placement. We abstracted demographic, reproductive, and procedural variables. The primary outcome was successful placement at first IUD insertion visit. We compared nulliparous with parous adolescents and patients younger than 18 years with those 18 years of age and older.

RESULTS

Between April 2009 and December 2011, 1177 adolescent women aged 13-24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement, 1012 (86%) of which were with an advanced practice clinician. The first attempt was successful for 1132 women (96.2%). The first-attempt success rate was 95.8% for nulliparous women and 96.7% for parous women (P = .45). The first-attempt success rate was 95.5% (n = 169) for women aged 13-17 years compared with 96.3% (n = 963) for women aged 18-24 years (P = .6). Only 1.8% (n = 21) of all first-attempt successful insertions required ancillary measures. Of the 45 patients with a failed first insertion attempt, 40% (n = 18) had a second attempt with a physician, of which 78% (n = 14) were successful. Within the first 6 months of IUD placement, no perforations were identified and 24 patients (3.0%) expelled the IUD. Insertion failures and IUD expulsions were not related to IUD type, age, or parity.

CONCLUSION

Intrauterine devices can be inserted in nulliparous adolescents of any age with similar success to parous adolescents, by both physicians and advanced practice clinicians. Inability to provide ancillary measures such as paracervical block or cervical dilation should not limit access to this first-line contraceptive method.

Association of age and parity with intrauterine device expulsion

OBJECTIVE

To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs).

METHODS

This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion.

RESULTS

A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78).

CONCLUSION

IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type.

LEVEL OF EVIDENCE

: II.

Factors associated with contraceptive satisfaction in adolescent women using the IUD

STUDY OBJECTIVE

To estimate satisfaction and to identify factors contributing to an adolescent woman's satisfaction with the levonorgestrel-containing or copper intrauterine device (IUD).

DESIGN

Adolescent women presenting to an urban clinic within 1 month of IUD insertion completed survey questionnaires about prior use of contraception, gynecologic/obstetric history, and a pain scale. Participants were contacted at 3 and 6 months post-insertion to complete surveys regarding satisfaction with the IUD, their menstrual bleeding patterns, and pain and cramping due to the IUD. Chi-square test, Fisher exact test, and logistic regression were used for analysis.

SETTING

Mount Sinai Adolescent Health Center in New York City.

PARTICIPANTS

Seventy-nine adolescent women aged 15-24 y.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Satisfaction was measured at 3 and 6 months post-IUD insertion as a 10-point Likert item.

RESULTS

82% and 76% percent of participants were available for follow-up at 3 and 6 months, respectively. Satisfaction with the IUD was high overall with 75.4% (49/65) of participants choosing a satisfaction rating of eight or higher on the 10-point scale at 3 months and 76.7 % (46/60) at 6 months. Prior history of pregnancy and selecting the levonorgestrel containing IUD were predictive of higher satisfaction at 3 months, but not at 6 months. Parity and prior use of contraceptive methods were not predictive of satisfaction.

CONCLUSION

The finding of high satisfaction across participants supports the current recommendation for the IUD as a first-line contraceptive for adolescents. Nulliparous young women and those who are naïve to contraception should be considered as candidates for the IUD.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use

OBJECTIVE

To measure discontinuation within 6 months among users of the levonorgestrel intrauterine system, copper intrauterine device (IUD), and etonogestrel implant and identify baseline characteristics associated with early discontinuation.

METHODS

This was an analysis of the Contraceptive CHOICE Project, a cohort study of 9,256 participants provided with no-cost contraception and followed with telephone interviews at 3 and 6 months. We used logistic regression to investigate characteristics associated with early discontinuation of the two IUDs and implant and described reasons for discontinuation.

RESULTS

A total of 6,167 participants were eligible for this analysis. Follow-up data were available for 5,928 participants; 5,495 (93%) were using their method at 6 months and 433 (7%) had discontinued. Discontinuation rates were 7.3%, 8.0%, and 6.9% for the levonorgestrel intrauterine system, copper IUD, and implant, respectively. After adjusting for age, race, marital status, low socioeconomic status, and history of sexually transmitted infection, we found that unmarried women were slightly more likely to discontinue compared with married women (adjusted odds ratio [OR] 1.26, 95% confidence interval [CI] 1.01-1.59 and adjusted OR 1.62, 95% CI 1.11-2.37, respectively). No other baseline characteristics, including younger age (14-19 years), were associated with early discontinuation. The most common reason given for discontinuation was cramping among IUD users and irregular or frequent bleeding among implant users.

CONCLUSION

Rates of discontinuation of long-acting reversible contraception at 6 months is low and not increased in adolescents and young women. Intrauterine devices and the implant should be considered as first-line contraceptive options among all women to reduce unintended pregnancy.

LEVEL OF EVIDENCE

: II.

Myths and misconceptions about long-acting reversible contraception (LARC)

PURPOSE

To discuss common myths and misconceptions about long-acting reversible contraception (LARC) among patients and health care providers.

METHODS

We address some of these common myths in an effort to provide clinicians with accurate information to discuss options with patients, parents, and referring providers. The list of myths was created through an informal survey of an online listserv of 200 family planning experts and from the experiences of the authors.

RESULTS

When presented with information about LARC, adolescents are more likely to request LARC and are satisfied with LARC. Clinicians have an important role in counseling about and providing LARC to their adolescent patients as well as supporting them in managing associated side effects.

CONCLUSIONS

This review article can be used as a resource for contraceptive counseling visits and for the continuing education of health professionals providing adolescent reproductive health care.

Practical tips for intrauterine devices use in adolescents

The American Congress of Obstetricians and Gynecologists (ACOG) has endorsed intrauterine devices (IUDs) as first-line contraceptive choices for both nulliparous and parous adolescents. The committee opinion did address some of the practical elements of IUD use in adolescents, but because these practical concerns may be barriers to use for both teens and clinicians, this review is devoted to "practical tips," based on the available literature as well as the author's clinical experience. Counseling, informed consent, techniques of pain management, and preventive guidance about possible side effects are addressed in an effort to promote successful use of this long-acting reversible contraception (LARC) option.

Long-acting reversible contraceptive methods for adolescents with chronic medical problems

Adolescents with chronic medical problems are just as at-risk for unintended pregnancy as their healthy counterparts, but pregnancy in these adolescents can carry greater health risks. The objective of this article is to provide an overview of the United States Medical Eligibility Criteria for Contraceptive Use, the concept of contraceptive effectiveness, and a risk-benefit algorithm. Together these tools provide an evidence-based and clinically sound method of providing contraception to adolescents with chronic medical problems. Three cases of adolescents with chronic medical problems are used to illustrate this approach. To best avoid the complicated problem of a teenager with a chronic medical problem becoming pregnant, LARC should be considered as first-line contraception. In most cases, LARC methods are safe to prescribe, and preferable to less effective methods.

Continuation of copper-containing intrauterine devices at 6 months

BACKGROUND

Intrauterine devices (IUDs) are highly effective at preventing pregnancy and cost-effective. Suboptimal continuation of IUDs places women at risk of unintended pregnancy. Little is known about prevalence or predictors of discontinuation of IUDs within the first 6 months.

STUDY DESIGN

A retrospective cohort analysis was conducted among 306 family planning patients who had a CuT380A IUD inserted from November 2008-August 2011. Rates of continuation among 283 users were calculated using survival analyses, and predictors of removal within 6 months of insertion were assessed using logistic regression.

RESULTS

Among 306 IUD insertions, 13 (4.2%) full or partial expulsions occurred within the first 6 months: 9 (10.7%) among nulliparous and 4 (2.0%) among parous women (chi-square, p<.001). In the first 6 months, four (1.3%) pregnancies occurred among women without prior removal or expulsion of the device (unadjusted Pearl Index: 2.61 per 100 woman-years at 6 months), all among parous women. Of 283 women in continuation analyses, 26% were under 20 years old and 29% nulliparous. Most (84%) received health education specific to IUDs before insertion. Overall, 11% had their IUD removed within 6 months of insertion. In an adjusted logistic regression model, women who did not receive health education were significantly more likely (Adjusted Odds Ratio=3.37, 95% confidence interval: 1.35-8.39) to have a removal within 6 months, but no significant association was found for age, race/ethnicity or parity.

CONCLUSION

Early discontinuation of IUDs was prevalent but lower among women who received method-specific health education.

Long-acting reversible contraception for adolescents

PURPOSE OF REVIEW

Teen pregnancy continues to plague the United States. This review will discuss long-acting reversible contraceptive (LARC) method use in teens, comprising intrauterine devices and subdermal implants.

RECENT FINDINGS

The American College of Obstetricians and Gynecologists along with the American Academy of Pediatrics, the Centers for Disease Control, and the World Health Organization have recognized the potential impact of LARC (comprising intrauterine contraception and subdermal implants) to reduce unintended pregnancies. They have affirmed the safety of such devices, and no effects on long-term fertility have been identified. Teen users of these methods have been shown to have high continuation and satisfaction rates. On the contrary, oral contraceptive pills, the patch, and the contraceptive vaginal ring have significantly higher contraceptive failure rates, and these rates are magnified in young women.

SUMMARY

LARC methods should be considered first-line options for teens seeking contraception.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider

PURPOSE OF REVIEW

This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population.

RECENT FINDINGS

Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates.

SUMMARY

The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.

Clinical practice: Contraception in adolescents

In affluent societies, median age at menarche has dropped to below 13 years. Younger age at menarche is associated with earlier sexual activity. To avoid unintended teenage pregnancies, barriers to contraception provision must be kept low, i.e. availability without prescription or through a low-threshold prescription system, low-cost options and long-term prescriptions or easy refills. Since many adolescents are (over)concerned about side effects, these should be addressed. A gynaecological examination prior to prescription is no longer recommended. All effective reversible contraceptive methods are available to adolescents: user-based hormonal contraceptives, trimonthly depot medroxyprogesterone acetate (DMPA), and long-acting reversible contraception (LARC). User-based hormonal contraceptives carry a small absolute risk of venous thromboembolism (~4 per 10,000 patient-years), but the risk is more than tenfold higher among young women with an inherited clotting defect. DMPA reduces bone mineral accumulation, but this is a reversible effect; the metabolic risks, including weight gain and insulin resistance, appear to be greater. LARC, including intrauterine contraceptive devices and the progestogen-containing implant, is gaining popularity among teenagers; abnormal bleeding is the main side effect. Any effective contraceptive should preferably be combined with consistent condom use to prevent sexually transmitted infections ("the double Dutch").