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LARCs and the implications for primary care nurses

Sarah Jarvis
MA BM BCh DRCOG FRCGP
GP and Women's Health Spokesperson for the RCGP
London

For the average primary care nurse, contraception advice and/or provision forms an integral part of day-to-day practice. Indeed, figures for numbers of women seeking contraception from well-woman clinics suggest that primary care is the main source of contraception provision for the majority of UK women of all ages (see Table 1).(1) Practice nurses have long been the mainstay of well-woman services in primary care and are closely involved in screening services such as cervical cytology.

[[NIP26_table1_69]]

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The well-woman checkup or cervical cytology appointment is the ideal opportunity for the practice nurse to offer advice and input on the provision of contraception. Unfortunately, low uptake rates of certain methods of contraception in the UK have limited the average practice nurse's exposure to the full range of contraceptive options.
It is this inequity that is addressed in the recently published NICE guideline on long-acting reversible contraception (LARC).(2) In this guideline, the LARCs include all methods of contraception that require administration less than once per cycle or month (see Box 1). The guideline starts by outlining the relatively low uptake of LARC methods in the UK. For instance, among women in the 16-49 age group, use of:

  • Oral contraceptive pills is 25%.
  • Male condoms is 23%.
  • LARC methods is 8% (compared with up to 20% in other European countries).(3,4)

[[NIP26_box1_69]]

The guidance goes on to consider the high rate (30%) of unplanned pregnancies in the UK. Teenage pregnancy is a particular concern - the UK has the highest teenage pregnancy rate in western Europe, with levels twice those of Germany, three times those of France and six times those of Holland.(5) However, rates of termination of pregnancies are rising in the UK across all age groups (see Figure 3).
It considers the use of LARCs, concluding that their more widespread use could have a significant effect on reducing rates of unwanted pregnancy. The rationale for this conclusion is based on several factors:

  • The effectiveness of the barrier methods and oral contraceptive pills depends on their correct and consistent use.
  • The maximum "window of opportunity" to comply with the required dosing regimen for oral contraceptive pills is 12 hours, and can be as low as three hours for POPs.
  • The effectiveness of LARC methods does not depend on daily concordance.
  • All LARC methods are at least as effective as the most reliable short-acting method, even if that short-acting method is complied with perfectly.
  • Some LARC methods (such as the Mirena IUS and Implanon - a progestogen-only subdermal implant) have an efficacy equivalent to sterilisation, but offer the advantage of an immediate return to fertility upon their removal.
  • Tolerability of LARC methods is broadly comparable to that of short-acting methods.

The role of the practice nurse in LARC guidance
All the methods discussed in the guidance, with the exception of the progestogen-only injectable contraceptives, require specialist training for fitting. However, the use of injectable contraceptives has been greatly restricted by the Committee on Safety of Medicines' (CSM) warning about the risk of osteoporosis associated with the use of depot contraception, especially in younger women (under 19 years).(6) The practical implications are summarised in Box 2.

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Additional risks and side-effects that have implications for recommendation of progestogen-only injectable contraceptives include:

  • Weight gain of up to 2-3 kg over one year.
  • Oligo- or amenorrhoea.
  • Persistent bleeding.
  • Delay of up to one year in return of fertility on discontinuing.
  • Side-effects cannot be reversed (unlike IUS, IUD and progestogen-only subdermal implants) by removing the device.

The good news, however, is that while most primary care nurses will not be trained to fit other LARCs, they are perfectly placed to offer advice on these methods. As practice-based commissioning and skill-mix become increasingly important drivers of primary care services, it is also likely that more and more practice nurses may be offered the opportunity to undertake the training required to carry out insertion and checking.
There are many advantages to practices of increasing provision of LARC, in addition to the population benefits outlined in the guidance above.

  • The NICE guidance reminds us that all LARC methods are more cost-effective than the combined oral contraceptive pill, even if used only for one year.
  • The IUS, IUD and progestogen-only subdermal implants are more cost-effective than progestogen-only injectable contraceptives.
  • Insertion of each IUS and IUD is recognised as a National Enhanced Service under the new GMS Contract. As such, insertion attracts a fitting payment of £75 from 2003/2004, increased by 3.225% every year.(3)
  • Under the same National Enhanced Service, IUS and IUD attract an annual review fee of £20 from 2003/2004, increased by 3.225% every year.(3)
  • The cost-effectiveness of this IUS/IUD annual review fee is further increased by the recommendation from the NICE guideline that routine annual checks are not necessary, provided the woman has been counselled to return if she has any problems. While it is not clear how the GMS Contract requirement for annual review and the NICE recommendation that routine checking of IUS/IUD is not required should be reconciled, it seems reasonable to suggest that a standard annual letter to all patients using these methods would fulfil both criteria.
  • The criteria for offering IUS/IUD fitting as a National Enhanced Service include details of the specialist training required to undertake and to update the skills needed for IUS/IUD training. The standard training is carried out via the Faculty of Family Planning and Reproductive Health Care (FFPRHC), and only they can provide a letter of competence in intrauterine techniques (LoCIUT). However, an LoCIUT is not a legal requirement - the National Enhanced Service criteria give leeway for other bodies to provide training, as long as it is a similar standard to that provided by the FFPRHC. Once theoretical training is completed, the FFPRHC should be able to put you in touch with a locally approved trainer, who can observe you carrying out a minimum of seven IUD insertions, and then certify you for the practical training.
  • LARCs offer an alternative to women who have completed their families and who want neither daily oral contraception nor irreversible sterilisation.
  • All IUDs and IUS are effective for five years, and progestogen-only subdermal implants are licensed for up to three years.(2)
  • IUS is also licensed (and recommended by the RCOG) as a treatment of menorrhagia -a particularly common problem in women approaching the menopause.(7)
  • IUS is now licensed as the progestogen component of combined HRT.(8)
  • IUS is showing real promise as a consistently effective treatment for the pain and menstrual disorder associated with endometriosis.(9)
  • If inserted after the age of 45, although not specifically licensed for this purpose, the IUS can be left in situ until the woman no longer needs contraception.(2)
  • IUD insertion up to five days after presumed ovulation provides an efficient option for emergency contraception, which can be offered after the three-day "window" for hormonal postcoital contraception has expired.(3)
  • If inserted after 40 years of age, the IUD can be left in situ until the patient no longer needs contraception.(2)

Conclusion
The NICE guidance on LARC is of enormous relevance to practice nurses, who play a significant and increasing role in the provision of contraceptive advice. The guidance outlines a strong case for increasing the uptake of LARC methods in the UK. It is particularly timely in light of the CSM warning about progestogen-only injectable contraception, which has resulted in many women being advised to reconsider their method of contraception.
The guidance highlights the need for increased uptake of LARC methods to counter the extremely high levels of unwanted pregnancies across all age groups in the UK. It offers practical details of all LARC methods, highlighting advantages to patients, cost-effectiveness advantages to practices and the importance of patient choice and informed consent.
The timing of the NICE guidance on LARC is particularly appropriate, coming as it does at a time when both practice-based commissioning and the new GMS Contract are causing primary care to consider ever more carefully the financial implications of prescribing choices. As such, it may provide just the evidence that interested practice nurses require to persuade their practices of the advantages of allowing them to extend their training to offer these methods.

References

  1. Botting B, Dunnell K. Trends in fertility and contraception in the last quarter of the 20th Century. Available from: http://www.statistics.gov.uk/articles/population_trends/fertconttrends_p...
  2. National Institute of Clinical Excellence. Long-acting reversible contraception. Clinical Guideline 30. October 2005 Available from: http://www.nice.org.uk/pdf/cg030niceguideline.pdf
  3. British Medical Association. Investing in general practice: the new general medical services contract supporting documentation. London: BMA; 2003.
  4. United Nations Department for Economic and Social Information and Policy Analysis. World contraceptive use (wallchart). New York: United Nations; 1994.
  5. Teenage Pregnancy. Report from the Social Exclusion Unit, presented to Parliament by the Prime Minister by command of Her Majesty, June 1999. Available from: http://www.socialexclusion.gov.uk/downloaddoc.asp?id=69
  6. Medicine and Healthcare products Regulatory Agency. Updated prescribing advice on the effect of depo-provera contraception on bones. Available from http://www.mhra.gov.uk/home/groups/pl-p/documents/drugsafetymessage/con0...
  7. Royal College of Obstetricians and Gynaecologists. Guidelines for the initial management of menorrhagia. London: RCOG; 1998.
  8. British Medical Association/Royal Pharmaceutical Society of Great Britain. British National Formulary 50. London: RPSGB; 2005.
  9. Ibraheim M, Ikomi A. Treating endometriosis with the levonorgestrel-releasing intrauterine system: real hope or gimmick? J Fam Plan Reprod Health Care 2005;31(3):182-3.

Resources
National Institute for Health and Clinical Excellence
W:www.nice.org.uk

Faculty of Family Planning and Reproductive Health Care
W:www.ffprhc.org.uk