MARGARET PYKE TRUST

Complementing the earlier talk on non-long-acting reversible contraception (non-LARC), Dr Sarah Pillai, Associate Specialist, Contraception and Sexual Health, Barnet, and practising GP, addressed issues around the use of long-acting reversible methods of contraception (LARC).

Prescribing records from 2010-2015 show that there has been no decrease in the number of intrauterine systems (IUSs) and implants being fitted by GPs, although copper IUDs are reducing, most likely due to the increase in use of the IUS known as Mirena.

“In terms of cost effectiveness, LARC methods are more cost-effective if they have been in place for at least one year, however if they are removed earlier then the initial costs make the method more expensive,” she remarked.

IUSs and implants are the most effective methods of contraception available with a typical use failure rate in the first year of 0.05% with an implant, 0.2% for an levonorgestrel-IUD, and 0.8% for a copper IUD. “Long acting methods have no user failure rate which is what affects the other non-LARC methods,” Dr Pillai pointed out.

There are a number of different types of IUSs on the market. “Don’t assume that everybody has a Mirena,” Dr Pillai stressed. “There are two smaller versions of Mirena [32 mm x 32 mm] called Kyleena and Jaydess [28 mm x 30 mm] and a version of Mirena called Levosert, which if prescribed generically might be given in place of Mirena. It’s important to note that Levosert does not have a licence for endometrial protection with HRT.”

Levosert and Mirena both contain 52 mg of hormone, while Jaydess and Kyleena contain 13.5 mg and 19.5 mg, respectively. The smaller IUSs potentially cause a lower incidence of amenorrhoea. 12% of Jaydess users develop amenorrhoea within three years of insertion, compared to 20% of Kyleena users and 23% of Mirena users.

Mirena is the only IUS licenced for endometrial protection.

Dr Pillai next turned her attention to the latest IUD, known as the intrauterine ball, which came on the market in the UK in 2017. She pointed out that safety, effectiveness and acceptability data from robust, independent studies and studies comparing the SCu300B MIDI with other copper IUDs are lacking. The intrauterine ball lasts for five years, costs £38, and contains 300 mm³ copper.

For those women who are breastfeeding and in the postnatal period, Dr Pillai noted that it was not advised to avoid insertions, but to be more aware of perforations. “EURAS-IUD [the European Active Surveillance Study for Intrauterine Devices] says the risk extends up to 42 weeks postnatally. The peak for perforations in our local study was at 13 weeks,” said Dr Pillai. Risk of a perforation is cumulative, approximately 1:250 if a woman is either breastfeeding or postnatal, and 1:160 if both breastfeeding and postnatal. “Make sure someone experienced does the insertion and the woman is counselled as to the risk,” she added.

Infection after intrauterine insertion also needs to be considered, highlighted Dr Pillai. “Risk assessment is key. Some practices routinely screen all patients for chlamydia, but if there is a low prevalence, a risk assessment should be sufficient.”

Moving her attention away from IUDs, Dr Pillai indicated that Nexplanon, the contraceptive implant, is imminently likely to be associated with new advice on where it should be inserted.

The existing advice on insertion notes that the implant should be inserted ‘at the inner side of the non-dominant upper arm about 8-10 cm above the medial epicondyle of the humerus, avoiding the sulcus between the biceps and triceps muscle.’ However, it adds that, ‘The insertion device cannot be relied upon to safeguard against deep insertion.’

The new advice is likely to suggest insertion over the triceps in order to avoid deep insertion which might be associated with a small risk of insertion into a blood vessel with possible migration or touching a nerve. “With all these things, counselling and documentation is essential,” said Dr Pillai.

Finally, she mentioned the Sayana Press contraceptive injection that is self-administered every three months and contains 104 mg of medroxyprogesterone acetate (MPA), the same hormone as DepoProvera. “Many women love it; it reduces practice nurse time but can be associated with skin atrophy at the site of injection.”