Research proves LARC methods are best — What happens now in practice?
Research proves LARC methods are best — What happens now in practice?
The next patient is a 16-year-old young mother who became pregnant at 14 when the condom broke during intercourse and no emergency contraception was used after the method failure. She is going back to school for her general equivalency diploma. Taking a daily pill will be a challenge, she admits. Will discussion of an intrauterine device (IUD) be included in your contraceptive counseling?
Definitive research is now in hand that long-acting reversible contraceptives (LARC methods) are more effective than pills, patches, or rings in preventing unplanned pregnancy.1 The study of the Contraceptive CHOICE project in St. Louis, designed to evaluate reversible birth control methods, found dramatic differences in their effectiveness. Women who used birth control pills, the patch, or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an intrauterine device or implant.
The new research article shows the high uptake of LARC methods when a standard script outlining the advantages and disadvantages of different contraceptive methods is used to counsel women, notes Eve Espey, MD, MPH, associate dean of students in the School of Medicine and professor in the Department of Obstetrics and Gynecology at the University of New Mexico in Albuquerque. Misperceptions about LARC methods that might prevent providers from offering them to most women were removed, and most women counseled chose a LARC method, Espey notes. The study findings also showed high satisfaction and continuation with these methods, she notes.1
"This research should empower clinicians to offer LARC methods to almost all women and to be reassured that complications are rare, and that patient satisfaction and continuation are high," she notes.
In the Contraceptive CHOICE project study, birth control pills and other short-term contraceptive methods, such as the contraceptive patch or ring, were especially unreliable among younger women. For those under 21 who used birth control pills, the patch, or ring, the risk of unplanned pregnancy was almost twice as high as the risk among older women. This finding suggests that increased adolescent use of longer acting contraceptive methods could prevent substantially more unplanned pregnancies.1
Interest is high
Espey discussed LARC methods and their effectiveness in reducing unintended pregnancies for a broad spectrum of women, as well as explained the most recent recommendations and guidelines on LARC methods, at the recent Annual Clinical Meeting of the American College of Obstetricians and Gynecologists (ACOG). The presentation was part of "Advances in Family Planning: Preventing Unintended Pregnancy and Sexually Transmitted Infections," sponsored by the Washington, DC-based Association of Reproductive Health Professionals (ARHP) in partnership with the ACOG LARC Program.
Espey says clinicians are energized and interested in LARC methods and want to understand the potential of these methods to reduce unintended pregnancy.2 However, she notes many clinicians still need "permission" to expand the spectrum of women they consider to be good candidates for LARC.
"Many clinicians still believe, for example, that nulliparous women and teens aren' t good candidates, that women need a separate visit for cultures before inserting a LARC method, and that many women experience serious complications with LARC methods," Espey observes. "The publication of CHOICE project data should go a long way to helping clinicians get over those misperceptions."
Espey serves as chair of ACOG' s LARC Work Group. To help clinicians obtain needed information on the subject, ACOG now offers a dedicated web space to LARC methods (http://bit.ly/MpQ63R). Two new features on that site include a freely-downloaded resource on quick coding for such methods and a billing quiz to help clinicians to more accurately capture costs for LARC procedures. (Go to the ACOG LARC page using the web site above. Select "Updated LARC Quick Coding Guide and Billing Quiz Now Available" to access the two items.)
Is everyone on board?
While recent evidence-based guidelines have expanded the definition of appropriate candidates for intrauterine contraceptive use, restrictive practice patterns among providers persist, indicate results of a new analysis. Researchers at the University of Washington, Seattle surveyed area obstetricians/gynecologists and family practitioners to perform the analysis.3
What prompted the team to research use of the IUD? The investigators wanted to look at physicians' knowledge and attitudes about the IUD because of a concern that providers themselves might be an important factor in limiting more widespread use of the device, says Lisa Callegari, MD, clinical assistant professor in the Department of Obstetrics & Gynecology at the University of Washington.
"Studies have shown that providers do influence women' s contraceptive choices, and we know that, unfortunately, many doctors still have outdated beliefs about the IUD," observes Callegari, lead author of the study. "For example, many providers think that IUDs should not be used for women who have never had a birth, for teen-agers, and for women who have had sexually transmitted diseases in the past."
Based on the most current evidence, the Centers for Disease Control and Prevention (CDC) recommends that the IUD generally is safe to use in all of those situations, says Callegari.4 Clinicians can access the CDC' s United States Medical Eligibility Criteria for Contraceptive Use (US MEC) at http://1.usa.gov/y6alkp. For example, the US MEC rates use of the levonorgestrel IUD and the Copper T IUD in nulliparous women as a "2," which is a condition for which the advantages of the method generally outweigh the theoretical or proven risks.
"We wanted to understand what characteristics of doctors predict whether or not they are following the current CDC guidelines for use of the Mirena IUD [Bayer HealthCare Pharmaceuticals, Wayne, NJ]," explains Callegari. "We surveyed both obstetricians/gynecologists and family practice doctors who reported that they offer patients IUDs, and then asked them about their knowledge, attitudes, and practice related to the Mirena IUD."
The researchers found that physicians who were involved in training residents were more likely to follow evidence-based guidelines. Physicians who reported concerns about the risk of infection from IUD use were less likely to follow evidence-based guidelines, Callegari notes.
"We also found that about 25% of the doctors we interviewed did not correctly answer basic questions about the Mirena IUD," Callegari states. "We concluded that there is a need for more education regarding the Mirena IUD, which will hopefully lead to more doctors offering it to a wider spectrum of women."
Clinicians can get new information on LARC methods at the Sept. 20-22 Reproductive Health 2012 Conference in New Orleans, sponsored by ARHP. An insertion session for the ParaGard IUD (Teva Women' s Health, Sellersville, PA) will be offered. Preregistration is required. (Go to the conference website, http://bit.ly/HPoTbR, for more information.) Also, the Nov. 1-3, 2012, Contraceptive Technology Quest for Excellence conference in Atlanta will offer a clinical training on the contraceptive implant Nexplanon (Merck & Co., Whitehouse Station, NJ). Training capacity is limited to 50 participants, so early registration is suggested. (Go to the conference website, http://bit.ly/Klx3Jc, for more information.)
References
- Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. NEJM 2012; 366(21):1,998-2,007.
- Espey E. Advances in Family Planning: Preventing Unintended Pregnancy and Sexually Transmitted Infections. Presented at the 60th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists. San Diego; May 2012.
- Callegari LS, Darney BG, Prager SW. Evidence-Based Use of the Levonorgestrel IUD among Obstetrician Gynecologists and Family Physicians. Presented at the 60th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists. San Diego; May 2012.
- Centers for Disease Control and Prevention (CDC). U S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep 2010; 59(RR-4):1-86.
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