Long-acting reversible contraception (LARC)

Etonogestrel (ENG) implant

99.95% effective

What — Small flexible, plastic rod (40 x 2mm)

Type — hormone. Implant slowly releases progestogen (ENG)

Prescription — must be prescribed by eligible practitioner. Available on PBS

How it works — primarily prevents ovulation

Timing — lasts 3 years. Must be removed/changed before or at 3 years

Fertility return — very quick, can be within 24 hours of removal

Placement

  • Simple to insert by eligible practitioner — with local anaesthetic in upper, non-dominant arm
  • If arm unsuitable — medical consult

Suitable for Quick Start— yes see Contraception — general principles

Who benefits — any woman needing effective and long-lasting contraception including 

Do not use ENG-implant if

Special issues

Bleeding

  • Will change period cycle and bleeding
    • Most women have lighter, irregular bleeding
    • 20% have no periods
    • 25% have frequent or prolonged bleeding
  • If annoying bleeding for more than 6 weeks medical consult — see Managing troublesome bleeding on LARC

Side effects

  • Insertion and removal may cause bruising or a scar
  • Uncommon — mood change, appetite, acne, headache, weight gain
  • Rare — implant moves from original placement site 

Young girls

  • If girl hasn't started her periods — medical consult to consider benefits and harms
    • Includes possible effect on peak bone mass, height, masking of delayed puberty, long term effects on future menses and fertility

Follow-up

Levonorgestrel intrauterine device (LNG-IUD)

99.7–99.9% effective

What — small T shaped plastic device with hormone in stem. (Kyleena brand contains less hormone and is slightly smaller than Mirena brand)

Type — hormone. Slow-release of LNG (progestogen) into uterus

Prescription — must be prescribed by eligible practitioner. Available on PBS

How it works

  • Variable effects
    • May prevent ovulation, thicken cervical mucous, thin endometrium, prevent implantation, alter egg and sperm transport

Timing 

  • 5 years contraception for both Kyleena and Mirena
  • For women over 45 years — Mirena can be used for contraception until menopause
  • Mirena can also be used for 5 years for heavy menstrual bleeding or for endometrial protection as part of MRT

Do not use LNG-IUD as an emergency contraceptive

Fertility return — very quick. Unprotected sex in the 7 days before IUD removal may lead to pregnancy

Placement — requires insertion into uterus by eligible practitioner

Suitable for Quick Start — no

Who benefits

  • Any woman needing effective, long-lasting contraception
  • Women with heavy or painful periods
  • Women with high cardiovascular risk or other risk factors
  • Women on enzyme-inducing medications (no drug interactions)

Do not use LNG-IUD if

  • Contraindication for oestrogen contraception
  • Current active cervical, uterine or pelvic infection (eg chlamydia, gonorrhoea, PID, septic abortion)
  • 48 hours to 4 weeks postpartum (after birth of baby)
  • Gestational trophoblastic disease
  • Severe uterine distortion
  • Long QT syndrome (risk of arrhythmias during insertion) or any cardiac condition where fainting would be a risk
  • Endometrial cancer
  • Cervical cancer awaiting treatment
  • HIV with CD4 less than 200 cells/microlitre
  • Ischaemic heart disease, stroke or transient ischemic attack (TIA) develop during use

Special issues

See IUD insertion, IUD removal, IUD complications​

Bleeding

  • Can have frequent bleeding or spotting in first 3 months. Then usually lighter, shorter or absent
  • Mirena is more likely to cause amenorrhoea or infrequent bleeding than Kyleena
  • If troublesome bleeding for more than 6 weeks — medical consult — see Managing troublesome bleeding on LARC

Side effects

  • Benign ovarian cysts
  • Irregular periods
  • Pain and cramps after insertion 
  • Uncommon — headaches, mood changes, breast tenderness, weight gain, loss of libido, acne 

Follow-up

Copper intrauterine device

99.5% effective

What — small plastic T- or U-shaped stem, wrapped with fine copper wire

Type — non-hormonal

Prescription — must be prescribed by eligible practitioner. Not available on PBS

How it works

  • May stop sperm moving to the upper genital tract
  • Affects egg survival
  • Prevents implantation

Timing

  • Load 375 and TT380 Short brands effective for 5 years. TT380 Standard brand effective for 10 years
  • Can be used as emergency contraception up to 5 days (120 hours) after unprotected sex
    • 99% effective
    • Not affected by obesity or liver-enzyme inducing medication
    • Insertion as emergency contraception may not be practical or accessible

Fertility return — very quick. Unprotected sex in the 7 days before removal may lead to pregnancy

Placement — needs insertion into uterus by eligible practitioner

Suitable for Quick Start — no

Who benefits

  • Any woman needing effective long-lasting contraception without hormones, especially useful if hormone-related risks
  • Those on enzyme-inducing medications (no drug interactions)

Do not use copper IUD if

  • Unexplained abnormal vaginal bleeding
  • Current active cervical, uterine or pelvic infection (eg chlamydia, gonorrhoea, PID, septic abortion)
  • 48 hours to 4 weeks postpartum (after birth of baby)
  • Gestational trophoblastic disease
  • Severe uterine distortion
  • Long QT syndrome (risk of arrhythmias during insertion) or any cardiac condition where fainting would be a risk
  • Endometrial cancer
  • Cervical cancer awaiting treatment
  • HIV with CD4 less than 200 cells/microlitre
  • Severe thrombocytopoenia (very low platelet levels)
  • Allergic to copper
  • Wilson’s disease

Special issues

See IUD insertion, IUD removal, IUD complications

Bleeding

  • Menstrual bleeding is usually heavier and lasts longer
  • Breakthrough bleeding may occur in the first months of use
  • May improve with time

Side effects

  • Bleeding changes, some period cramps

Follow-up

IUD management

IUD insertion

Preparation
Follow-up
  • Inserter usually organises to review 1–6 weeks after insertion
  • After this
    • Advise to feel for threads after each period. If not felt — see Lost threads
    • Set recall for change/removal

IUD removal

  • Removed by eligible practitioner — by gently pulling on IUD threads
    • Minimal discomfort
  • Rapid return to fertility
    • If not wanting pregnancy — advise no unprotected sex for 7 days prior to removal
    • If wanting pregnancy — see Pre-pregnancy counselling 
  • Advise nothing in vagina for 48 hours (eg sex, tampons, swimming)

IUD complications

Lost threads

  • If threads can't be felt/seen
    • When were they last felt/seen
    • Pregnancy test
    • Offer ECP, talk with woman about starting extra, reliable contraception
    • Medical consult for ultrasound (and x-ray if IUD not seen on ultrasound)

PID or STI

  • Do not remove device straight away
    • Mild infections responding to treatment in 48–72 hours do not require IUD removal
    • If severe infection — urgent medical consult
  • See PID or STI management for women

Contraceptive injection (Depo-Provera or Depo-Ralovera)

96% effective

What — deep IM injection

Type — hormone. 150mg long-acting depot medroxyprogesterone acetate (progestogen)

Prescription — must be prescribed by eligible practitioner. Available on PBS

How it works

  • Primary effect — prevents ovulation
  • Secondary effect — thickens cervical mucus

Timing — injection every 12–14 weeks

Fertility return — may be slow. Average 6 months, may be up to 18 months

Placement

  • Smaller women — give in buttock
  • Larger women — give in deltoid (buttock fat may reduce absorption)
  • Do not rub injection site

Suitable for Quick Start — yes, see Contraception — general principles

Who benefits

  • Women who want longer lasting hormonal contraception without an implant or IUD
  • Women who want no periods or reduced bleeding
  • Women who want a discrete method of contraception 
  • Women on enzyme-inducing medicines

Do not use Depo-Provera if

  • Contraindication for oestrogen contraception
  • Multiple risk factors for cardiovascular disease (eg older age, smoking, diabetes, hypertension, obesity)
  • High BP with vascular disease
  • Heart attack, angina, stroke, transient ischemic attack (TIA)
  • Age over 50 years
  • Severe thrombocytopoenia (very low platelet levels)
  • Caution if low bone density or at risk of low bone density

Special issues

Bleeding

  • At first irregular, prolonged or frequent bleeding is common
  • 50–70% women have no periods after 1 year
  • If irregular or heavy bleeding causes trouble — medical consult — see Managing troublesome bleeding on LARC

Fertility return

  • Can't be reversed once given, but will wear off after about 3 months
  • If pregnancy wanted in next 12–18 months — consider changing method

Side effects

  • Weight gain
    • 10% increase in body weight in around 20% of users
    • Use with care in obese adolescents
  • Bone density
    • Can be reduced, recovers when Depo-Provera stopped
    • Use with care if under 18 years or over 45 years
    • Check calcium and vitamin D intake, encourage weight bearing exercise
  • Uncommon — headache, mood, decreased sex drive, acne, breast tenderness

Follow-up

  • Talk with woman about next injection date and set recall
  • Check for any new contraindications
  • Annual  Adult Health Check, STI check
    • Review risk of low bone density, CVD

Late/missed Depo-Provera injections

  • Only late if more than 14 weeks since last injection
  • If late consider risk of pregnancy (eg if unprotected sex since the last injection was due)
  • Do pregnancy test
    • If positive — provide pregnancy options, antenatal counselling 
    • If negative — consider emergency contraception if unprotected sex in the last 5 days and restarting ongoing contraception
  • If women wants to restart Depo-Provera today — see Starting contraception — Quick Start

Managing troublesome bleeding on LARC or Depo-Provera

  • Exclude other causes — see Abnormal vaginal bleeding in non-pregnant women
  • Reassure woman that it isn't harmful
  • Try medicines
    • COC taken continuously or cyclically for 3 months, if no contraindications
    • Mefenamic acid oral — adult 500mg, 2–3 times a day (bd–tds) for 5 days, if no contraindications to NSAIDs
    • Levonorgestrel POP — 30microgram, twice a day (bd) for 20 days
  • If bleeding heavy — tranexamic acid oral — adult 1g, 3 times a day (tds) for 5 days 
  • If medicines don't work
    • Early removal and replacement of ENG-implant or LNG-IUD
    • Shorten interval between Depo-Provera injections to 10 weeks 
    • Try a different contraception method