ACOG updates its guidelines on LARC

Courtesy:http://northlandfamilyplanning.com

The American College of Obstetricians and Gynecologists (ACOG) today updated its guidelines on Long-Acting Reversible Contraception(LARC): Implants and Intrauterine Devices. These updated guidelines were published online October 24 in Obstetrics & Gynecology and replaces the old practice bulletin published in July 2011.

The recent recommendations were jointly developed by Committee on Practice Bulletins—Gynecology and the Long-Acting Reversible Contraception Work Group in collaboration with Eve Espey, MD, MPH; and Lisa Hofler, MD, MPH, MBA.

Two types of LARC are currently available in US: 1) intrauterine devices (IUDs) and 2) the etonogestrel single-rod contraceptive implant. The IUDs available are copper containing IUD and 4 levonorgestrel-releasing intrauterine devices (LNG-IUDs).

The guidelines seek to increase LARC acceptance among patients, at the same time assuring them on the safety and efficacy of the five different intrauterine devices (IUDs) and implant currently available for use.

ACOG-LARC initiative 

DR. ESPEY, author of the Practice Bulletin and Associate Professor of Obstetrics and Gynecology and Director, Section of Reproductive Health, University of New Mexico, Albuquerque, N.M. said in a news release “We have many more contraception options for women of all ages and life stages, especially in the realm of LARC. Many patients may not know they’re a good fit for an IUD or implant, or that IUDs now come in varying sizes and hormone levels.  Counseling will help women to align their contraceptive choice with other health care priorities, whether that’s preventing pregnancy during adolescence or making a plan for contraceptive use following pregnancy.”

Summary of Recommendations based on levels of evidence:

Level A recommendations:

Insertion of IUD immediately after first trimester uterine aspiration is safe and effective option and should be offered routinely to patients.

Similarly, patient can be safely offered contraceptive implant on the same day as first-trimester or second-trimester induced or spontaneous abortion.

Routine antibiotic prophylaxis is not advised before IUD insertion.

Level B recommendations:

IUDs and contraceptive implants are not contraindicated in nulliparous women and adolescents, and carry the same safety and efficacy as in multiparous women. US MEC Category 2, (advantages outweigh the risks).

IUDs and contraceptive implants can be offered anytime during the menstrual cycle as long as pregnancy is ruled out.

IUD insertion is safe immediately after medically induced first trimester abortion.

Immediate postpartum insertion (within 10 minutes of delivery of placenta in vaginal and cesarean birth) is a safe and effective means of post-partum contraception.

Women with history of ectopic pregnancy can safely be offered IUD insertion.

Those women who have not been screened for Sexually Transmitted Infections (STI) or who are at high risk of contracting such infections can be offered screening and IUD insertion at the same visit, while awaiting the screening test results. If the tests are positive, the patient can receive the treatment without removing the IUD.

Level C recommendations

LARCs are suitable, safe and effective, have few contraindications and should be routinely recommended to most women.

The copper containing IUD is the preferred choice for emergency contraception in women who are eligible for IUD insertion.

All patients receiving LARC should undergo adequate counselling and reassurance about irregular bleeding pattern and be assured that it is harmless.

Endometrial biopsy, endocervical sampling, colposcopy, and cervical ablation or excision may all be performed with an IUD in place.

In case of accidental pregnancy with the device in place, it can be safely removed if the strings are visible.

If a woman attains menopause while IUD or implant in place, it is not required to be removed before its expiration date.

Actinomyces detected on cell cytology is an incidental finding, and does not warrant the removal of IUD or antimicrobial treatment in absence of symptoms.