Key learning points:
- What is a long acting reversible contraception (LARC)?
- Benefits and cost effectiveness of LARCs
- Training available for nurses to gain competence in inserting/fitting LARC methods of contraception
Long acting reversible contraception (LARC) have been defined by National Institute for Health and Care Excellence (NICE) as any contraceptive methods that require administration less than once per cycle or month (1).
LARC methods of contraception are very effective in preventing a pregnancy and this is important when it is estimated that almost half of all pregnancies in Great Britain are either unplanned or the women are ambivalent about them.
There are four LARC methods available in the United Kingdom (UK):
- Copper intra uterine devices (IUDs) effective up to 10 years, depending on device used.
- The intrauterine system (IUS) – effective for five years.
- The contraceptive sub dermal implant (SDI) – effective for three years.
- Progestogen-only injectable injections (subcutaneous) effective for 13 weeks.
Copper intra uterine device (IUD)
IUDs have been available since the 1960s and they have evolved over the years from rather cumbersome devices to more slim line options. The main mode of action is thought to be related to the copper. Copper is toxic to ovum and sperm and the IUD works primarily by inhibiting fertilisation and also by the endometrial inflammatory reaction.
IUDs are effective from five to 10 years depending on type used, fitting the device with the longer life is preferred as this reduces any risk of infection or perforation at the time of fitting. IUDs must be fitted by a specially trained clinician.
The benefit of the IUD is that it can remain in place for up to 10 years and women who have contraindications to hormonal methods can use it.
Additionally the copper bearing IUD can be offered to women as an emergency method of contraception and if the woman decides she likes the method, it can remain in place.
Intrauterine system (IUS)
The IUS is a medicated system containing progestogen and the mode of action is the effect of the hormone on the endometrium (lining of the uterus) that inhibits implantation.
In addition, there is an effect on sperm penetration through the cervical mucus and this contributes to contraceptive effect.
The IUS is licensed for five years for contraception and also licensed for three years for unscheduled bleeding and as a progestogen replacement during the menopause.
The IUS is effective in reducing menstrual blood loss, something most women welcome.
Subdermal Implant (SDI)
The sub demal implant called Nexplanon is a single radiopaque, non-biodegradable, progestogen-only implant. This rod is inserted in the non dominant arm and can be left in place for three years. Each implant contains 68mg of a progestogen called etonogestrel that releases over time.
The primary mode of action is to prevent ovulation. Implants also prevent sperm penetration by altering the cervical mucus and inhibit normal endometrial development. The pregnancy rate is very low, with one in 1,000 over three years’ use.
Progestogen – only injectable contraceptives
Currently there are three types of injectable contraceptives available, Depo Provera (150mg Medroxyprogesterone acetate in 1ml, every 12 weeks, NET-En (Noristerat) every 10 weeks (less commonly used) and the newer subcutaneous Sayana Press every 13 weeks, however the Faculty of Sexual and Reproductive Healthcare (2014) recommend that this period may be extended slightly (2).
These methods of contraception are not user dependent and once inserted/fitted; women are free from regular visits to a clinic or general practice (GP). The main side effects are altered bleeding patterns and there is an association with slight weight gain in some women.
None of the above listed long acting reversible methods of contraception protect against sexually transmitted infections and women and their partners should be advised about the use of barrier contraception, for example condoms.
Why should we consider LARC for women?
In 2005, the National Institute for Health and Care Excellence (NICE) published guidelines on LARC and highlighted that these contraceptive methods were both more effective and cost efficient when compared with other popular user dependent methods. NICE also mentioned that every £1 invested in contraceptive care, generates a saving of £11 to the NHS in the costs associated with addressing the consequences of unplanned or unintended pregnancies. The figure increased is to £13.42 for every £1 invested in LARC methods.
Despite major initiatives in the field of sexual and reproductive health care over the past 10-12 years, the abortion rate and the number of unintended pregnancies are still much higher than most other Western Europe countries (3).
Since the late 1990s the British government launched major strategies to address teenage pregnancy and abortion rates in England. This was in part the development of strategies specific to teenage pregnancy and the wider sexual health, as well as focusing on improving access to contraception through national campaigns.
Teenage pregnancy rates decreased in England between 2001 and 2007 arguably this coincides with an increase in the use of LARC methods, especially among young people.
Knowledge of LARC among women
Knowledge amongst women of LARC still remains low and it is clear from a poll carried out in July 2013 that some health care professionals are still reluctant to discuss LARC methods with women accessing contraception advice and care. The poll titled Love, Life and LARC surveyed almost 3,000 women aged between 16-14 years of age. In the survey, 77% of the students said that their GP, practice nurse or family planning provider did not have a conversation with them about LARC in the past year.
In addition, 27% of those currently using contraception were worried about failure through omission or mistiming of medication. This poll was supported by BMD, a pharmaceutical company (4).
Between June 2012 and May 2013, Marie Stopes International (MSI) interviewed 430 women aged 16–24 who booked an abortion at its centres and the following was observed:
- Fifty seven per cent of women surveyed were using contraception at the time they fell pregnant.
- Short-term methods, such as the pill (54%) or condoms (40%) were most commonly used.
- Some 28% of women had previously had one or more abortions (5).
The UK still has one of the highest teenage pregnancy rates in western Europe and is estimated that the cost of unintended pregnancies in the National Health Service (NHS) in England alone is estimated to be around £755 million annually (6).
As 75-80% of all contraception care is delivered in general practice, practice nurses are in an ideal position to advise women about contraception but the nurses need education and training to provide that advice and funding may not always be easy.
The reconfigured responsibilities for commissioning and governance arrangements for contraceptive services and provision changed with the Health and Social Care Bill (2013), this resulted in three different organisations having responsibility for commissioning services.
The Local Authorities (LAs) commission the following:
- Community contraceptive services.
- General practice enhanced services.
- Pharmacy contraceptive services.
Clinical commissioning groups commission the following:
- Sexual health education and training for general practice staff.
- Abortion services that should include the contraceptive element of the care.
- Vasectomy and female sterilisation.
NHS England commissions the following:
- General practice contraceptive services.
- Contraception within other specialist services.
This fragmentation of commissioning is a challenging one and greater challenges may lie ahead when LAs are expected to make £20 billion efficiency savings by 2015.
If nurses are to take on the role of advising and providing women about all contraceptive methods, training must be available for them.
Courses for nurses in contraception are available from local universities and at the Faculty of Sexual and Reproductive Healthcare (FSRH), much of this is on-line with clinical placements needed locally.
The FSRH also provide nurses who have completed the education and training modules, the opportunity to gain a Letter of Competence (LoC) in intrauterine techniques and sub dermal implants (SDI). This is identical for doctors, is the national standard and is strongly recommended (7).
Nurses can access competencies criteria from the Royal College of Nursing (RCN) for long-acting reversible methods of contraception (8).
A 35-year-old lady complains of heavy periods and is thinking of using the IUD. She says she is not good at remembering to take pills. What would the nurse discuss with her?
Answer all available methods discussing benefits, effects and how to use them. Explore other causes for her bleeding. Draw her attention to the benefit of the IUS because of her bleeding problems.
She should be asked to consider the IUS because of the bleeding pattern; she had not heard of the IUS and decided to try it.
She was seen three months later and the bleeding had greatly reduced and she felt better.
Best practice guidelines
The United Kingdom Medical Eligibility Criteria (UKMEC) is available from the FSRH and this provides up to date guidance on each method of contraception, including LARC and should be familiar to all nurses.
These guidelines are updated/reviewed every few years or when new evidence comes to light. Myths still exist among some professionals and these are often based on guidance from many years ago (9).
In conclusion, nurses can gain a better understanding of all methods by checking the FSRH guidelines and if unable to provide LARC methods at their practice, ensure they know the referral pathway for access. Women should be made aware of all methods of contraception and be able to access their chosen method easily.
1. National Institute for Heath and Care Excellence (NICE) Long Acting Reversible Contraception. https://www.nice.org.uk/searchq=long+acting+reversible+contraception+2005 (accessed 18 February 2015)
2. Faculty of Sexual and Reproductive Healthcare Progestogen -only Injectable Contraception 2014 1-19. http://www.fsrh.org/pdfs/CEUGuidanceProgestogenOnlyInjectables.pdf (accessed January 2015)
3. Connolly A, Britton A. Investment in contraceptive care is an urgent requirement. www.eguidelines.co.uk.eguidelinesmain/gip/vol_16/jan_/connolly-contracpe... (accessed 16th January 2015)
4. MSD in partnership for Love, Life and LARCs. http://www.pharmafield.co.uk/pf-fox-news/general/2013/09/MSD-in-partners... (accessed 16th January 2015)
5. Marie Stopes International (MSI) Research reveals that more than half of young women who have abortions were using contraception when they fell pregnant. http://www.mariestopes.org/media/research-reveals-more-half-young-women-... (accessed 16th January 2015)
6. Connolly A, Pietri G, Yu Jingbo, Humphreys A. Association between long-acting reversible contraception use, teenage pregnancy and abortion rates in England International Journal of Women’s Health 2014;6: 961-968
7. Faculty of Sexual and Reproductive Healthcare for training criteria. www.fsrh.org (accessed January 2015)
8. Royal College of Nursing. RCN competencies for nurses assessing and counselling women who request and/or receive long-acting reversible methods of contraception (LARC) 2011 www.rcn.org.uk (accessed January 2015)
9. Faculty of Sexual and Reproductive Healthcare United Kingdom Medical Eligibility Criteria (UKMEC). www.fsrh.org/guidelines 2009 (accessed January 2015)
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