Executive Summary
Research findings from the Contraceptive CHOICE Project, a St. Louis prospective cohort study, examined the short-term bleeding and cramping patterns of long-acting reversible contraception (LARC) methods and the impact on method satisfaction. Findings indicate that regardless of the LARC method chosen, satisfaction at three and six months was very high.
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Analysis findings indicate that at three months, more than 65% of levonorgestrel intrauterine system (LNG-IUS) and implant users reported no change or decreased cramping, while 63% of copper intrauterine device (IUD) users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users.
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At three and six months, most women were somewhat satisfied or very satisfied with their LARC method.
Just-released research findings from the Contraceptive CHOICE Project, a St. Louis prospective cohort study, examined the short-term bleeding and cramping patterns of long-acting reversible contraception (LARC) methods and the impact on method satisfaction.1 Findings indicate that regardless of the LARC method chosen, satisfaction at three and six months was very high.
To perform the current analysis, researchers at the Washington University School of Medicine in St. Louis looked at three- and six-month survey data from intrauterine (IUD) and implant users in the Contraceptive CHOICE Project. Women who received one of the LARC methods — the levonorgestrel-releasing intrauterine system (LNG-IUS), copper IUD, or the etonogestrel implant — and completed their three- and six-month surveys were included in the analysis. Investigators used univariable and multivariable analyses to examine the association of bleeding and cramping patterns with short-term satisfaction.
The analysis included 5,011 project participants: 3,001 LNG-IUS users, 826 copper IUD users, and 1,184 implant users. Analysis findings indicate that at three months, more than 65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. At three and six months, most women were satisfied (somewhat satisfied or very satisfied) with their LARC method. At three months, 95% of LNG IUS users, 94% of copper IUD users, and 94% of implant users were satisfied. At six months. 94% of LNG-IUS users, 93% of copper IUD users, and 90% of implant were satisfied.1
Women who reported increased menstrual cramping (relative risk adjusted [RRadj], 0.78; 95% confidence interval [CI], 0.72-0.85), heavier bleeding (RRadj, 0.83; 95% CI, 0.76-0.92), and increased bleeding frequency (RRadj, 0.73; 95% CI, 0.67-0.80) were less likely to report being very satisfied at six months.(To read more about the project, see the Contraceptive Technology Update articles, "How to make LARC first at your clinic," October 2014, p. 115; "LARC methods: 7 things you need to know," January 2014, p. 4, "Research proves LARC methods are best — What happens now in practice?" August 2012, p. 85, and "New data: Long-acting reversible methods superior in effectiveness," July 2012, p. 73.)
Counseling is key
In previous research, results from a randomized trial found that long-term copper IUD users were more likely to discontinue the device because of heavy menstrual bleeding and dysmenorrhea (9.7 per 100 women using the copper IUD versus 1.3 per 100 women using the levonorgestrel intrauterine system), whereas LNG-IUS users were more likely to discontinue the device because of amenorrhea and spotting compared with copper IUD users (4.3 per 100 women versus 0 per 100 women, respectively).2
What role does counseling regarding bleeding and cramping play in patient satisfaction with LARC methods? "Counseling regarding bleeding and cramping before starting LARC methods is crucial," says Justin Diedrich, MD, a research fellow in the Washington University in Saint Louis’ Department of Obstetrics & Gynecology’s Division of Clinical Research. "Because each person is different, counseling helps patients choose which method is best for them."
Researchers involved in the Contraceptive CHOICE Project found that women with more bleeding and cramping are less likely to choose a method that might worsen their symptoms, says Diedrich, who served as lead author of the current paper. In addition, when providers hear that a woman has very heavy menses or painful periods, they are less likely to recommend a device associated with heavier bleeding or cramping, Diedrich notes.
"At three and six months, women who chose LARC methods were highly satisfied with the method they chose," Diedrich observes. "We believe their high level of satisfaction is related to extensive pre-insertional counseling."
Put steps into practice
Long-acting reversible contraceptive methods have an effect on menstrual bleeding, and patients should be given anticipatory guidance about these effects, according to a practice bulletin from the American College of Obstetricians and Gynecologists.3
The Contraceptive CHOICE Project used a standardized counseling session at the time of method selection, where participants were informed of potential method-specific symptoms.4 Women were reassured that irregular and unpredictable bleeding are side effects of all LARC methods. Women choosing the LNG-IUS were counseled that bleeding typically gets lighter over time and amenorrhea is common. With the copper IUD, menses typically become regular, but flow might be slighter heavier. With the implant, the bleeding pattern is unpredictable, and patients must accept the fact that the implant can cause irregular bleeding. (To read more on the Project’s counseling strategy, see the April 2013 article, "More women moving to LARC methods: Will your facility follow the trend?" p. 37.)
For dysmenorrhea with the copper IUD, evidence supports first-line treatment with nonsteroidal anti-inflammatory medications.5 Research indicates that reports of bleeding and dysmenorrhea decrease over time in copper IUD users.6
A large randomized control trial compared the LNG-IUS and the copper IUD. 7 One-third of LNG-IUS users immediately developed oligomenorrhea (defined as no more than one episode of bleeding in a 90-day interval) or amenorrhea, and 70% of women experienced oligomenorrhea or amenorrhea at the end of two years. Symptoms of dysmenorrhea were reduced in women using the LNG-IUS.
Dysmennorhea impacted
One noncontraceptive benefit of the implant is a significant decrease in dysmenorrhea.8-10 However, unpredictable uterine bleeding patterns associated with contraceptive implant use are cited as the no. 1 most common reason for discontinuation.3
For teens using LARC methods, encourage them to accept changes in bleeding in exchange for the next few years of extremely effective and easy contraception.11
Suggest charting menstrual bleeding on a calendar or with a smartphone app to provide objective evidence of the frequency of bleeding. When such evidence is reviewed, teens might see their "daily" bleeding might or might not be so frequent.11
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Diedrich JT, Desai S, Zhao Q, et al. Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. Am J Obstet Gynecol 2014; doi:10.1016/j.ajog.2014.07.025
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Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994; 49:56-72.
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American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118(1):184-196.
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Madden T, Mullersman JL, Omvig KJ, et al. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 2013; 88(2):243-249.
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Grimes DA, Hubacher D, Lopez LM, et al. Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine device use. Cochrane Database of Systematic Reviews 2006; doi:10.1002/14651858.CD006034.pub2.
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Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time? Contraception 2009; 79:356-362.
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Sivin I, Stern J, Diaz J, et al. Two years of intrauterine contraception with levonorgestrel and with copper: a randomized comparison of the TCu 380A and levonorgestrel 20 mcg/day devices. Contraception 1987; 35:245-255.
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Funk S, Miller MM, Mishell DR Jr, et al. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Implanon US Study Group. Contraception 2005; 71:319-326.
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Mansour D, Korver T, Marintcheva-Petrova M, et al. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008; 13(Suppl 1):13-28.
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Walch K, Unfried G, Huber J, et al. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis — a pilot study. Contraception 2009; 79:29-34.
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Hillard PJ. Practical tips for intrauterine devices use in adolescents. J Adolesc Health 2013; 52(4 Suppl):S40-46.
