Latebreakers - Contraceptive Technology

So what exactly is the expert consensus on how long someone can use an IUD? There are two branches to that question. First, when is it appropriate to place an IUD when a patient wants only short-term contraception? And second, how effective is the IUD beyond the time period listed in the labeling? Regarding the first question, experts are advising that clinicians reframe the concept of ‘early’ removal. Understandably, clinicians are mindful of the high up-front cost of IUDs borne by their patients. And they have been educated to focus on contraceptive method continuation rates, which can reflect patients’ satisfaction or dissatisfaction with their methods. But that focus on continuation rates, along with the name “long-acting” reversible contraception, can dissuade clinicians and patients from using an IUD for a only a short time, such as 9 months rather than for the several year limit listed in the labeling.[1] According to Contraceptive Technology editor and author Patty Cason, while IUDs have limits duration of use, there is no limit on a minimal time for use.

Cason acknowledges that providers may feel reluctant to remove a device in a timeframe they consider “early.” When patients are considering use of one of a method requiring placement, many wonder whether there will be a provider willing and able to remove the device on demand and whether they will have coverage for the cost of the removal. When discussing the IUD, writes Cason, consider using following phrasing: “This [IUD or implant] is good for up to X years (fill in information for the particular method), but if you want to get pregnant before then or you would like it removed for any reason, come in, we will take it out.” The up to phrase emphasizes that they are not expected to use it for any particular length of time.[2]

The fact that an implant or an IUD is good for “up to” 3 to 20 years is an added advantage but not always relevant, according to Cason. The emphasis is better placed on the phrase “up to” than on the number of years, because the amount of time is relevant only if the patient is seeking contraception for that length of time. Otherwise, other features of the method may be more important. A key feature is that IUDs (and implants) are highly effective, which makes them excellent choices for the short-term, too.

What about the flip side to the issue of duration of IUD use? How protective is the IUD when extended beyond time indicated in the labeling?

The TCu380A is labeled for 10 years of use, although data indicate high effectiveness for 12 years.[3]
The efficacy of the 52 mg IUDs may last as long as 15 years.[4]
Liletta is approved for extended use up to 4 years. The LNG content at 5 years supports continued efficacy at least until 5 years and likely 7.[5]
Mirena is approved for up to 5 years. Data show that it is highly effective for at least 2 additional years of use: 6^th year failure rate 0.25 and 7^th year failure rate 0.43 (n=496).[6]

Cason suggests that healthcare professionals, policy makers, and stakeholders could take advantage of the present information to decide to maintain the same device at least up to 7 years. She notes, too, that amenorrhea could be a good indicator of contraceptive effect from LNG IUDs. Some notable points to keep in mind when considering extending use:

Extended use is off-label. Obtain informed consent.
How important is it to the patient to prevent pregnancy?
Does the patient have affordable and timely access to another IUD or implant?
What is your clinical judgment?
How do the patient’s age, weight, pregnancy history, and comorbidities influence the shared decision about extending use?
Is placement of a new device challenging due to body habitus or comorbidities?
If you remove the IUD, will she adopt a less effective method and be at a higher risk for an unintended pregnancy?

[1] Amico JR, Bennett AH, Karasz A, Gold M. “She just told me to leave it”: Women’s experiences discussing early elective IUD removal. Contraception. 2016;94:357-361.

[2] Cason P, Aiken ARA. Engaging with unintended pregnancy through patient-centered reproductive goals and contraceptive counseling. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[3] Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception 1997;56:341–52.

[4] Bahamondes, L., Fernandes, A., Bahamondes, M. V., Juliato, C. T., Ali, M., & Monteiro, I. Pregnancy outcomes associated with extended use of the 52-mg 20 mug/day levonorgestrel-releasing intrauterine system beyond 60 months: A chart review of 776 women in Brazil. Contraception 2017.

[5] Creinin MD, Jansen R, Starr RM, Gobburu J, Gopalakrishnan M, Olariu A. Levonorgestrel release rates over 5 years with the Liletta(R) 52-mg intrauterine system. Contraception 2016;94:353–6.

[6] McNicholas, C., Swor, E., Wan, L., & Peipert, J. F. (2017). Prolonged use of the etonogestrel implant and levonorgestrel intrauterine device: 2 years beyond Food and Drug Administration-approved duration. Am J Obstet Gynecol, 216(6), 586.e581-586.e586.