LARC

Question 1

what are long acting reversible contraceptives?

Answer 1

Intrauterine
- Levonorgestrel Intrauterine system
- copper IUD

Contraceptive implant

Question 2

what is LNG-IUS indicated for

Answer 2

contraception
emergency contraception
tx of heavy bleeding
painful periods
endometrial protection from estrogens

Question 3

what does the LNG-IUS do?

Answer 3

inhibits sperm movement
thins the lining of the uterus so it is not suitable for implantation
thickens cervical mucus

Question 4

is backup contraception needed after insertion of IUD?

Answer 4

only the first 7 days
(but usually you’ll be fine if you don’t)

Question 5

what are the two LNG-IUS in canada?

Answer 5

Mirena
Kyleena

Question 6

how big is the Mirena, how long does it last, and what is its dosing?

Answer 6

32mm
up to 8 years
20 mcg/day, then 10mcg/day after 5 years

Question 7

how big is the Kyleena, how long does it last, and what is its dosing?

Answer 7

28mm
5 years
17mcg/day, then 15 mcg/d after 2 months, then 7mcg/d by 5 years

Question 8

how much do the IUDs cost?

Answer 8

~$350

Question 9

what are a/e of LNG-IUS

Answer 9

irregular bleeding
spotting within first 3-6 months
painful insertion
mood effects, breast tenderness, headache

Question 10

does a LNG-IUS or COC have more progesterone?

Answer 10

COC, which is why the mood swings are more common with COC and not IUS

Question 11

how does the copper IUD work?

Answer 11

copper ions inhibit sperm movement and ability to fertilize the egg

Question 12

how long do copper IUDs last

Answer 12

5-10 years depending on model

Question 13

what are the diff types of copper IUDs?

Answer 13

10 years - Liberte TT standard, Mona Lisa 10

5 years - Liberte UT and TT short, Mona Lisa 5, Flexi T

Question 14

how much do copper IUDs cost?

Answer 14

~$95

Question 15

what are a/e of copper IUDs?

Answer 15

irregular bleeding/BTB
- more than LNG-IUS

more painful periods/pelvic pain than LNG-IUS

Question 16

why would someone opt for copper IUD than LNG-IUS?

Answer 16

cheaper, no hormonal s/e, works immediately (no 7 day backup contraception needed)

Question 17

what is the most effective option for emergency contraception?

Answer 17

copper IUD

Question 18

what are intrauterine contraception c/I?

Answer 18

pregnancy
current Pelvic Inflammatory Disease
current/past breast cancer (PR+)*
abnormal uterine bleeding
puerperal sepsis
cervical or endometrial cancer
liver disease*
postpartum <4 weeks

*only for LNG-IUS

Question 19

how to manage pain of insertion of IUDs?

Answer 19

premedicate with NSAIDs like:
ketoprofen
ketorolac
naproxen

use lidocaine

Question 20

is misoprostol needed before insertion?

Answer 20

no

Question 21

if a pt has an STI, do they need to remove their IUD to tx their STI?

Answer 21

no, it can stay in

Question 22

does a IUD increase risk of ectopic pregnancy?

Answer 22

no
but if pt gets pregnant while IUD is in, then that risk actually increases

Question 23

what are the risks with an IUD?

Answer 23

expulsion
uterine perforation (rare)
PID (rare, and happens in first month)
fainting (uncommon)

Question 24

what is a good source for finding a qualified IUD expert?

Answer 24

RAICE

Question 25

what is the contraceptive implant Nexplanon

Answer 25

a 3rd gen progestin 4cm long etonogestrel 68mg placed under skin of upper arm

Question 26

how much etonogestrel does the implant release?

Answer 26

60 mcg daily for 1 month then 30 mcg daily by the end

Question 27

how long is the implant good for?

Answer 27

3 years easy to insert, hard to remove

Question 28

how does the implant work?

Answer 28

suppresses ovulation thicken cervix thins the endometrium

Question 29

when can the implant be inserted?

Answer 29

any time use condoms for 7 days after

Question 30

how long is the wait for fertility after removing implant?

Answer 30

within one month

Question 31

what are the a/e of the implant?

Answer 31

irregular bleeding amenorrhea progestin related a/e weight gain (1.9kg over 2 years)

Question 32

what can be done to combat bothersome BTB with the implant?

Answer 32

short course of NSAIDs or estrogen therapy

Question 33

what are d/I with the implant?

Answer 33

CYP3A4 inducers maybe

Question 34

what is the relationship between the implant and obese pts?

Answer 34

reduced efficacy

Question 35

what if a pt is on CHC and switched to LARC?

Answer 35

continue CHC for 7 days after starting LARC

Question 36

what if a pt is on the injection and switched to LARC?

Answer 36

insert LARC no later than 13 weeks after last injection

Question 37

if a pt is interested in getting pregnant within the next year what would you recommend?

Answer 37

SARC - CHC/injection

Question 38

what do you recommend to a trans patient

Answer 38

anything without estrogen

Question 39

what would you recommend to pts with seizure hx?

Answer 39

LNG-IUS CHC: minimum 30 mcg EE; long half life progestins backup contraception recommended or continuous dosing

Question 40

what do you recommend to a pt with migraines but no aura?

Answer 40

continuous CHC OR estrogen during HFI

Question 41

what do you recommend to a pt with migraines + aura?

Answer 41

CONTRAINDICATED migraines with aura = increase in stroke

Question 42

what are some things to keep in mind with obese pts who want to start contraception?

Answer 42

patch not rec if >90kg increase risk in VTE reduced efficacy with implant

Question 43

what considerations using contraception while breastfeeding?

Answer 43

breastfeeding = delayed ovulation <6 weeks pp = AVOID CHC; progestin-only pill

Question 44

what considerations if postpartum but not breast-feeding?

Answer 44

<3 weeks = avoid CHC if hx or risk of VTE = wait 6 weeks

Question 45

what considerations if postpartum and wanting an IUD or implant?

Answer 45

wait 4 weeks pp IUD can be put in within 48 hours, but has high expulsion rates

Question 46

can IUD and implant be used if breast-feeding?

Answer 46

yes