Long-Acting Reversible Contraception (LARC) (NICE Guideline)

Summary of NICE advice on injections, implant and IUS/IUDs.

Notes:

  • LARC is more cost-effective than the combined oral contraceptive pill even at 1 year
  • IUDs, the IUS and the implant are more cost-effective than injectable contraceptives

 Download a pdf version of the above chart.

TABLE 1: Suitability of LARC methods for different groups of women
 COPPER IUDsIUSDMPA INJECTIONPROGESTOGEN–ONLY (ETONOGESTREL) SUBDERMAL IMPLANT
Adolescents Yes Yes Yes (requires caution; use only if other methods inappropriate) Not licensed for use < 18 years
>40 years Yes Yes Yes (requires caution, but benefits generally outweigh risks) Not licensed for use >40 years
Post-partum (including breastfeeding) Yes (from 4 weeks after childbirth) Yes  (from 4 weeks after childbirth)* Yes Yes
Taking other medication Yes Yes Yes Yes (not recommended with enzyme-inducing drugs)
Epilepsy Yes Yes Yes (may be associated with reduced seizure frequency) Yes (not recommended with enzyme-inducing drugs)
History of VTE Yes
All LARC methods are suitable in nulliparous women, in HIV, diabetes, migraine, or if BMI >30kg/m2, oestrogen contraindicated, risk of STIs, or history of abortion.

 

TABLE 2: Summary of LARC methods
 COPPER IUSsIUSPROGESTOGEN-
ONLY
INJECTIONS
PROGESTOGEN–ONLY (ETONOGESTREL) SUBDERMAL IMPLANT
Key
considerations
Insertion requires training. Most effective IUDs contain ≥380mm2 copper and have banded copper on the arms Insertion
requires training
N/A Insertion
requires training
Mode of action Prevention of fertilisation and inhibition of implantation Prevention of implantation (primarily); prevention of fertilisation Prevention of ovulation (primarily) Prevention of ovulation (primarily)
Effects
of fitting
Possible pain and discomfort for a few hours and light bleeding for a few days. Seizure risk may be increased in women with epilepsy Refer to SPC Refer to SPC
Duration
of use
5—10 years for IUDs with 380mm2 copper, or until contraception no longer needed if woman aged ≥40 years at time of insertion† 5 years, or until contraception no longer needed if woman aged ≥45 years at time of insertion and subsequently has no periods† Per injection: 12 weeks (DMPA) or 8 weeks (NET-EN) 3 years
Failure rate Fewer than 2 in 100 women over 5 years for IUDs with ≥380mm2 copper. Expulsion occurs in fewer than 1 in 20 women in 5 years Fewer than 1 in 100 women over 5 years. Expulsion occurs in fewer than 1 in 20 women in 5 years Fewer than 0.4 in 100 women over 2 years. DMPA has lower failure rate than NET-EN Fewer than 0.1 in 100 women over 3 years
Potential
risks

Risk of ectopic pregnancy is approximately 1 in 20 (lower than with no contraception)

Risk of pelvic inflammatory disease is <1% for women at low risk of STIs

Risk of uterine perforation <1 in="" 1000="" p="">

Possible minor changes in mood or libido

Risk of acne may be increased with IUS, but rarely leads to discontinuation

No evidence of weight gain

DMPA:

Possible weight gain of up to 2—3kg over 1 year

Small loss of bone mineral density; largely reversible

No evidence of increased fracture risk

No evidence of effect on:
– Depression
– Acne
– Headaches

Refer to SPC

Effect on periods

Heavier periods and/or dysmenorrhoea likely

Up to 50% of users discontinue within 5 years mostly because of altered bleeding and pain

Irregular bleeding and spotting likely in first 6 months.

Oligomenorrhoea or amenorrhoea likely within first year

Up to 60% of users discontinue within 5 years because of altered bleeding and pain

Harmless amenorrhoea likely, especially with DMPA or with prolonged use. Persistent bleeding possible

Up to 50% of DMPA users discontinue within 1 year, most because of altered bleeding

Long-term changes in bleeding pattern likely; periods may be absent, infrequent, prolonged or more frequent. Dysmenorrhoea may improve

Up to 43% of users discontinue within 3 years, 33% because of altered bleeding

Return to fertility No evidence of delay Can take up to 1 year, but alternative method of contraception required immediately on discontinuation if pregnancy not desired, even if amenorrhoea persists No evidence of delay

KEY

DMPA – depomedroxyprogesterone acetate
IUD – intrauterine device
IUS – intrauterine system
NET-EN – norethisterone enantate
STI – sexually transmitted infection
†even if outside terms of product licence
*outside terms of product licence

Adapted from: NICE Clinical Guideline 30 (October 2005; updated September 2014) - Long-acting reversible contraception (update).


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