Contraception

LARCs have higher rates of efficacy than do other forms of contraception.^[15] This difference is likely due to the difference between "perfect use" and "typical use". Perfect use indicates complete adherence to medication schedules and guidelines. Typical use describes effectiveness in real-world conditions, where patients may not fully adhere to medication regimens. LARC methods require little to no user action after insertion; therefore, LARC perfect use failure rates are the same as their typical use failure rates. LARC failure rates are comparable to those of sterilization.^[15] LARCs and sterilization differ in their reversibility.

The implant has a 0.05% failure rate in the first year of use, the levonorgestrel (hormonal) IUD has a 0.1% failure rate in the first year of use, and the copper IUD has a 0.8% failure rate in first year of use. ^[16] These rates are comparable to those of permanent sterilization procedures, leading to conclusions that LARCs should be offered as "first-line contraception." ^[16]

Additional Uses

LARCs can also be used to treat other conditions, primarily by regulating or stopping the bleeding portion of a user's menstrual cycle.^[17] LARCs may be used to treat endometriosis ^[18] and heavy menstrual bleeding.^[19] They can also be useful in treating painful menstruation.^[20]

Additionally, a copper IUD can be used as emergency contraception if inserted within five days of unprotected sex. This timeframe may be extended if the date of ovulation is known; the copper IUD must be inserted within 5 days of ovulation. ^[21]

Side effects

Hormonal IUDs have similar side effects to other forms of hormonal contraception, such as combined and progesterone only oral contraceptives. Hormonal IUDs most frequently cause irregular menstrual bleeding. Other side effects include acne, breast tenderness, headaches, nausea, and mood changes. ^[22][23]

The most common side effects of non-hormonal or copper IUDs are increased pain and heavy bleeding during menstruation, and spotting between menstruation. Impacts on menstruation may decrease over the lifespan of the IUD, but spotting between menstruation may become more frequent over time. For some users, these side effects lead them to discontinue use.^[24]

The most common side effect of the contraceptive implant is irregular bleeding, which includes both reduced and increased levels of bleeding.^[25] Other side effects include mood changes and mild insulin resistance. ^[22]

Risks

IUD use caries some additional risks. Both hormonal and non-hormonal IUDs may lead to developing non-cancerous ovarian cysts. ^{[22] [26]} It is also possible that an IUD may be expelled (fall out) from the uterus. ^[27] The IUD may also perforate (tear) the uterine wall. This is extremely rare and a medical emergency. ^[28]

Cost and benefit

LARC methods traditionally have a higher up-front cost, between $800 and $900 in the United States,^[29] than methods such as pills, patches and vaginal rings, but are more cost-effective in the long run.^[30] Like all contraceptive methods, access to LARC methods can reduce the rate of unintended pregnancy and result in significant cost savings to publicly funded health systems.^[30] Women switching from short-acting reversible contraceptive to long-acting intrauterine systems are likely to generate cost savings from unplanned pregnancy-related expenses and long term savings in contraceptive costs.^[31] Regardless, the initial out of pocket cost is still too high for many patients and is one of the biggest barriers to LARC use. Two recent studies done in California and St. Louis have shown that rates of LARC usage are dramatically higher when the costs of the methods are either covered or removed.^[32][33][34] A program geared toward increasing use of LARC among adolescents in Iowa demonstrated a significant decrease in the unintended pregnancy and abortion rate in that state along with a projected savings of $17.23 for every dollar spent on contraception for 14- to 19-year-olds.^[35]

The Colorado Family Planning Initiative (CPFI), a six-year $23 million privately funded program to expand access to LARCs, decreased unplanned adolescent pregnancies in the state by about 40% and returned $5.85 in savings for each dollar spent. There was a similar decline of unplanned pregnancies in unmarried women under 25 who have not finished high school, another at risk group. Use of LARC methods by children of child-bearing age in the state increased to 20% during the 2009–2014 period.^[29] A 2017 study found that CPFI "reduced the teen birth rate in counties with clinics receiving funding by 6.4 percent over five years. These effects were concentrated in the second through fifth years of the program and in counties with relatively high poverty rates."^[36]

Promotion

The United Kingdom Department of Health has actively promoted LARC use since 2008, particularly for young people;^[38] following on from the October 2005 National Institute for Health and Clinical Excellence guidelines, which promoted LARC provision in the United Kingdom, accurate and detailed counseling for women about these methods, and training of healthcare professionals to provide these methods.^[39] Giving advice on these methods of contraception has been included in the 2009 Quality and Outcomes Framework "good practice" for primary care.^[40]

The use of long-acting reversible contraceptives in the United States has increased nearly fivefold from 1.5% in 2002 to 7.2% in 2011–2013.^[41] Increasing access to long-acting reversible contraceptives was listed by the Centers for Disease Control and Prevention as one of the top public health priorities for reducing teen pregnancy and unintended pregnancy in the United States.^[42] One study of female family planning providers showed that they were significantly more likely to use LARCs than the general population (41.7% compared to 12.0%) suggesting that the general population has less information or access to LARCs.^[43]

Guidelines released in 2009 by the American Congress of Obstetricians and Gynecologists state that LARC methods are considered to be the first-line option for birth control in the United States, and are recommended for the majority of women.^[44] According to the CDC Medical Eligibility Criteria for Contraceptive Use, LARC methods are recommended for the majority of women who have had their first menstruation, regardless of whether they have had any pregnancies.^[45] The American Academy of Pediatrics (AAP) in a policy statement and technical report^[46] published in October 2014 recommended LARC methods for adolescents.^[47]