Contraception with Long-Acting Reversible Contraceptives

Introduction to LARCs

• Long-Acting Reversible Contraceptives (LARCs) are recommended as a first-line contraceptive option due to their high efficacy rates, with failure rates less than 1%, by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists 1, 2
• LARCs are suitable for women of all ages, including nulliparous women, and are recommended as first-line options for adolescents 1, 2

Etonogestrel Implant (Nexplanon)

• Nexplanon remains highly effective, with a 0.05% failure rate, even with weight changes, as reported by the American Academy of Pediatrics 3
• The efficacy of Nexplanon may be reduced with hepatic enzyme-inducing medications like efavirenz, and additional contraceptive methods may be recommended for patients on certain antiretroviral medications (efavirenz, nevirapine, or most protease inhibitors) 1, 3
• Weight loss can cause breakthrough bleeding in patients using Nexplanon (etonogestrel implant) even after years of amenorrhea, according to the American Academy of Pediatrics 3
• Irregular bleeding is common with progestin-only methods like Nexplanon, and bleeding patterns may stabilize as the body adjusts to the new weight, as explained by the American Academy of Pediatrics 3

Comparison of Contraceptive Methods

• The choice between Mirena and Nexplanon should consider patient preference, desired duration of contraception, medical conditions, and previous experience with hormonal contraceptives 1

Special Considerations

• Patients with certain medical conditions, such as hereditary angioedema, may tolerate etonogestrel (Nexplanon) differently than levonorgestrel (Mirena) 4
• IUDs are preferred over the etonogestrel implant for patients with SLE or positive antiphospholipid antibodies 5
• If a patient is taking medications known to affect Nexplanon, such as certain antiretrovirals or anticonvulsants, additional contraceptive methods may be warranted, according to the American Academy of Pediatrics 1

Insertion and Post-Insertion Care

• The etonogestrel implant can be inserted at any time if reasonably certain the woman is not pregnant, and if inserted within the first 5 days of the menstrual cycle, no additional contraception is needed 6
• If inserted after day 5, backup contraception should be used for 7 days, and patients should be reminded that LARCs do not protect against sexually transmitted infections and condoms should be used if needed 6
• Post-insertion care: patients should be instructed on proper wound care, including applying a sterile dressing daily with local disinfection until granulation occurs (usually day 1-7) 3
• Patients should be counseled about potential side effects, particularly irregular bleeding patterns, and that side effects often improve over time 6, 7

Follow-Up and STI Protection

• A follow-up plan should be developed to address any difficulties, and the teach-back method should be used to confirm understanding 6, 7
• The Centers for Disease Control and Prevention (CDC) recommends documenting the patient's understanding of method effectiveness, correct use and duration, lack of STI protection, warning signs and when to seek care, and follow-up plan 7
• Dual method use (LARC + condoms) should be discussed for STI protection 1
• Immediate postpartum LARC placement is safe and effective, and reduces barriers to effective contraception and prevents short-interval pregnancies 8