Long-acting reversible contraception

Effective contraception is vital in the prevention of unplanned pregnancy, reducing abortion rates and avoiding short interpregnancy intervals that are associated with poor pregnancy outcomes​[1]​. Short-acting contraception, including the combined pill, transdermal patch, vaginal ring and progestogen-only pill, provides contraception that is more than 99% effective if used perfectly; however, with typical use, their contraceptive failure rate in the first year of use is around 9%​[2]​. For condoms, typical use failure rate is estimated at around 18%​[2]​. In contrast, once initiated, long-acting reversible contraception (LARC) does not require regular user input to maintain contraceptive effectiveness. By removing the element of human error, LARC offers one of the most effective contraception methods, with contraceptive failure rates under 1% in the first year of use​[2–4]​. LARC is convenient — it provides ‘fit and forget’ contraception and has fewer associated health risks than oestrogen-containing combined contraceptives​[5]​.

Individual contraceptive prescribing decisions must also consider acceptability of the contraceptive to the user, as this can determine continuation and the patient’s ability to use it correctly, as well as their medical eligibility for the method and any relevant drug interactions.

The NHS provides LARC without cost to the user from sexual and reproductive health (SRH) services, GP practices and maternity, gynaecology and abortion care services after pregnancy. NHS data indicate that the COVID-19 pandemic has impacted provision of contraception, including LARC. Data released by NHS Digital show a 37% fall in contraception-related contacts with SRH services in April–September 2020 compared with April–September 2019​[6]​. Data are not yet available to inform the effect of this disruption on contraceptive use and unplanned pregnancy.

Community pharmacists are not currently LARC providers but can advocate for the use of effective contraception during consultations and in routine interactions with patients. This article outlines information on LARC options available that pharmacists can recommend and how to conduct appropriate consultations.

Long-acting reversible contraceptive devices

The LARC methods currently available are the etonogestrel subdermal implant, copper intrauterine device and levonorgestrel-releasing intrauterine system. Information about these devices can be found in the table below.

The progestogen-only contraceptive depot injection (intramuscular or subcutaneous medroxyprogesterone acetate) is sometimes considered to be a LARC method because it does not require daily or weekly administration. Repeated every 13 weeks (users can be taught to self-administer subcutaneous depot medroxyprogesterone acetate at home), perfectly used injectables provide >99% effective contraception by suppressing ovulation​[8]​. However, unlike the LARC methods in the table above, they remain dependent on the user — with typical use, non-compliance results in an estimated first year contraceptive failure rate of around 6%​[2]​. The bleeding pattern can initially be erratic, but bleeding reduces over time and some users achieve amenorrhoea. Injectables can cause weight gain and are associated with reduced bone mineral density, therefore are not first-line options for adolescents and women aged over 50 years​[8]​. Return to fertility can be delayed by a year or more after the last injection, making them unsuitable for use by individuals who want to conceive in the near future​[8]​.

LARC methods all offer highly effective, user-independent contraception. A person’s choice of method may depend on the procedure required for insertion/removal, the effect on menstrual bleeding, the patient’s familiarity with the method and past experience of contraception (as well as the experiences of their family and friends). If LARC is not ideally acceptable to an individual, they may discontinue use; if they prefer a short-acting contraceptive and are confident that they can use it reliably, that may be a better option for them.

Contraindications

The UK Medical Eligibility Criteria (UKMEC) details suitability of each contraceptive method, factoring in personal characteristics and common medical conditions​[9]​. There are relatively few medical contraindications to LARC, which can be used by individuals with characteristics (e.g. older age, smoking, very recent pregnancy) and medical conditions (e.g. hypertension, obesity, migraine with aura) that contraindicate use of oestrogen-containing combined hormonal contraceptives​[9]​. Any identified medical conditions should be checked against UKMEC. UKMEC indicates, for example, that breast cancer, stroke or heart attack during previous use of the method, and severe decompensated liver disease or hepatic adenocarcinoma, generally contraindicate use of hormonal LARC methods; childbirth in the past four weeks, pelvic infection and distortion of the uterine cavity contraindicate use of intrauterine methods​[9]​. It should be noted that the UKMEC list is not exhaustive and the Summary of Product Characteristics (SmPCs) for each LARC should be referred to for information on potential drug interactions.

As with combined hormonal contraceptives and the progestogen-only pill, contraceptive effectiveness of the etonogestrel implant can be reduced by cytochrome P450 enzyme inducers (e.g. carbamazepine and rifampicin), which reduce systemic exposure to etonogestrel. The contraceptive effectiveness of the LNG-IUS, due to its local intrauterine hormonal activity, the non-hormonal Cu-IUD and the high-dose progestogen depot medroxyprogesterone acetate injection are not affected by hepatic enzyme induction. Contraceptive progestogen started within five days after use of ulipristal acetate oral emergency contraception could reduce its effectiveness as emergency contraception​[10,11]​.

Busting long-acting reversible contraception myths and misconceptions

Myths and misconceptions surrounding contraception can be barriers to starting any contraceptive, and are particularly relevant to LARC methods, which are newer and patients can be unfamiliar with. Strongly held but inaccurate beliefs can be difficult to challenge if healthcare professionals are uncertain themselves. Box 1 provides some facts in response to myths that may commonly arise in practice.

The role of the pharmacist

While pharmacists are not LARC providers, they will encounter situations where it is appropriate to advocate LARC use for patients. Box 2 outlines important questions that must be considered/discussed when approaching these consultations. Boxes 3, 4 and 5 provide suggestions for situation-specific dialogue.

A request to a pharmacist for oral emergency contraception is an example of an important opportunity for promotion of, and signposting to, effective contraception, including (but not limited to) LARC. After oral emergency contraception, an individual remains at risk of pregnancy from subsequent unprotected intercourse. Intervention by a pharmacist in this situation to support provision of a Cu-IUD, the most effective method of emergency contraception that also offers effective ongoing LARC, or to facilitate ‘quick start’ initiation of suitable hormonal contraception by signposting directly to SRH or primary care contraceptive services, could be essential to preventing unplanned pregnancy.  It is essential that pharmacists can provide up to date information to facilitate access to local contraceptive services. An example consultation for emergency contraception is shown in Box 3.

With the introduction of the desogestrel progestogen-only pill as a pharmacy medicine, it is important that pharmacists make patients aware of the more effective LARC and how to access it​[15,16]​. Oral contraception can be used as a bridging contraceptive while the user considers and accesses LARC. An example of how this might be discussed in practice is provided in Box 4.

A pharmacist dispensing a teratogenic drug, such as sodium valproate or isotretinoin, has a crucial opportunity to ensure that the individual is on a pregnancy prevention programme to minimise risk of foetal exposure​[17]​. An example for how this can be managed in practice is shown in Box 5.

COVID-19 pandemic: effects on contraceptive provision

Extended use of some LARC methods was temporarily recommended when risk of COVID-19 transmission was highest to avoid risk of transmission during face-to-face medical procedures. One year or more of extended use was recommended for devices with evidence of low risk of pregnancy during that extension​[19]​. Users were advised that contraceptive effectiveness could be lower than during the licensed duration of use and could opt to use a progestogen-only pill or condoms in addition​[19]​.

COVID-19 has disrupted LARC provision, but this period has seen great innovation in telemedicine. For service users, this means that discussion regarding contraceptive choices and information-giving can often now be achieved remotely, with clinic attendance only required for a LARC procedure itself, or for blood pressure measurement ahead of combined hormonal contraception provision. Many services have established free remote provision of the progestogen-only pill​[20]​.