CONTRACEPTION CONTINUED

LONG ACTING REVERSIBLE CONTRACEPTIVES (LARC)

I will discuss, what is called long acting reversible contraceptives.

What is LARC; these are long acting   reversible contraceptives. They can last anything from 1 to 15 years or forever you do not have to worry about contraception every day or every time you have sex. Have it done or fitted and forget about it. Fertility returns when it is removed.  It is as safe as sterilization, but much better than sterilization, as it is not surgical and not permanent. LARCs are inexpensive in the long term, although upfront cost in some countries seems to be high. Other contraceptives are dependent on the couple to remember every time, they have sex therefore their failure rate is high, between 25 % to 50%particularly among the teenagers.

About 3 million unplanned pregnancies occur in America alone. Nearly 30% of pregnancies around the world are unplanned, 25% to 30% of these are aborted. It is estimated that 35 of every 1000 women have had an induced abortion in their life time. The World Health Organisation’s quoted statistics are 1.6 million unsafe abortions took place in 2008. 1 in 10 pregnancies will end in an unsafe abortion. In 2008, 47,000 women died of unsafe abortions; this is 13% of all maternal deaths. Besides these deaths many women (8.5 million) get temporary or permanent disability as a result of these botched procedures. Almost one third of these women have no access to any medical help. This is well known to many of us.

Forced sex, domestic violence, no access to   contraception, poor quality of contraceptives, incorrect use and finally no empowerment or education for women.  Globally, in the developing world 215 million women, have a need for contraception which they are unable to get. These figures show that effective contraception is an important issue for women’s health. Contraceptive methods discussed so far depend on the user compliance. As already mentioned LARC methods are independent of user compliance, they are very private (your partner or his relatives as in some cultures cannot interfere). Failure rates are low when used correctly, like in perfect use. Long term these are very cost effective from the cost of contraception itself, reduction in abortions in general, reduction of septic abortions and compromised women’s health, and maternal death.

Around the world there is a movement to promote  LARC methods  among women of all age groups and we should take this as international priority.

There are four methods;

1) Intrauterine devices (IUD)

2) Intrauterine systems (IUS)

3) Subcutaneous implants

4) Hormone injections

LARC can be used for

1) Women of any age

2) Nullpariae (meaning a woman whose has never given birth) is no

 longer an objection to these contraceptive particularly IUD OR IUS.

3) Women who cannot take hormone contraceptive particularly oestrogen

4) Have nausea, breast tenderness, and migraine headaches.

5) Who are breast feeding or recently had a baby.

6) Have or had a hormone dependent breast cancer,

7) Who have had an STI including  HIV

8) Have epilepsy

9) Have Diabetes or high BP, inflammatory bowel disease or are smokers

10) Have recently had an abortion. In fact Copper IUD is used as an emergency contraceptive and can be continued as a contraceptive.

Let us talk about these LARC Methods

The intrauterine device for contraception was first invented by a gynaecologist, Jack lippes. He started working on it in the 1950’s. Initially he was discouraged about it, however he continued to work on it and he released it in1962. It is an S or different   shaped plastic with a string attached to its tail end, so that it can be easily removed. It works by making the bizarre changes in lining of the uterus, this, also realises white blood cells and an hormone called prostaglandins. These are hostile to the fertilized eggs, preventing implantation.  After its release in the sixties, it became the most popular IUD. From memory I can remember that I used to put in a few IUD’s for women who went home after child birth. We were sure we will never see them again until they were pregnant. It was 99% safe as regards failure, expulsion, perforation of the uterus and infection .In some women the loop remained there for their life time. It’s now off the market as; no inert IUD’s are   approved in USA, UK and CHINA.  Now is the era of copper IUD’s which came in the market in 1969. Slowly different designs were made and sold globally. A new IUD called a DALKON shield came on the market in the seventies (1971-1976) it caused a lot of pelvic infections even deaths with lots of legal issues.  The company went bankrupt, and Dalkon shield was withdrawn.  Its design was   faulty. It had a multi filament at the end for withdrawal. This caused infections. This episode with  the  Dalkon  shield gave women a worrying time. Confidence in using IUD’s was very low.  The newer IUD and IUS are both safe. One of the IUD’s is a Copper IUD called  Paragard . It came on the market in 1984, and was made in the USA. It is the only copper IUCD you can get in USA.

It is a T shaped polyethylene frame wrapped with 380 mm of copper wire and it is called a T380A.
The following photograph shows Paragard with Mirena

Copper is wrapped around the arms and stem of the T shape IUD.  They have two monofilamentous strings attached to its tail end which helps to pull it out when it needs to be removed. There are only two different types of IUCD available now. These are called IUCS (intra uterine contraceptive system) .They contain hormones and not copper. The two IUCS are called MIRENA and SKYLA or JAYDEN.  Both  of the IUD and IUCS work by damaging or even killing sperm. Copper is toxic to the sperm, it makes the uterus and the fallopian tubes produce a fluid containing copper ions, white blood cells, prostaglandins(Hormones) and enzymes, that kills the sperm; this also causes a kind of inflammatory reaction in the uterine cavity . Some women have an ethical objection to it, thinking it is an abortion. This is not so. According to the latest American laws, a pregnancy is a pregnancy only after implantation.

Your care giver should be trained, as to when to and how to insert an IUD and IUCS. You will be required to attend the clinic twice, once to get your medical, social, sexual and family history, and make sure you are suitable for a particular contraceptive and second to have it fitted. All the methods are discussed with you in detail. After this you can go home and think about it.

May be if you wish or need to discuss this

with your partner. After this you can go   back  to  you care  giver  at the appropriate time. The best time is with in the first 5 days of your periods. If this clashes with your commitments it can be done at any time if pregnancy is excluded. It is easier if you have had a vaginal delivery. Any current STI’s should be excluded. If you are at risk for an STI and HIV, these tests are performed at the same time.  Many clinicians like to give a prophylactic (preventative) antibiotic as well. It is ideal if you have only one sexual partner.  It helps a woman if you explain to her how and what you are going to do. It is very useful if the woman takes a couple of Paracetamol and one Neurofen(ibuprofen 200mgms) 250 mgm half an hour before the time of insertion.    you will feel more relaxed and will not feel the pain so much. Many clinicians like to give 400 micrograms of a prostaglandin tablet either Misoprostil or Cytotec. This ideally should be taken 4 hours or the night before insertion of the IUD either orally or vaginally, to nulliparae women or in women who are expected to have a scarred cervix, (previous, caesarean section,) or cervical operation. Sometimes a local anaesthetic or mild sedation is required. It is best to go for the procedure with someone, so that you can come home easily if you feel somewhat unwell e.g.  Faint or Nauseous, or wait in the doctor’s office until you feel better.

A follow up visit is required in 4-5 weeks.  This is to make sure you are well, IUCD is in place, and you know how to feel the string.

If your partner can feel the string, it can be trimmed.

Copper IUD’s tend to cause painful and heavy periods.  They should not be used if a women already has heavy or painful periods, if she is anaemic, if she has abnormal bleeding without a diagnosis, if she has an abnormal cervical smear or cervical cancer, recent or current pelvic infection, abnormal shaped uterus or has  a uterine fibroid distorting the shape of the uterus and is suspected to be pregnant. Woman with congenital or valvular heart disease should not use IUD’s because of the risk of infection to the heart valve.

The above mentioned problems  can be diagnosed by a pregnancy test , blood tests and ultrasound . An experienced clinician can make these diagnoses by clinical examination alone.

The big benefits of IUD are fit and forget. It is very private and very effective (99%)

Long term it is not expensive.

It is immediately reversible.

An IUD can be inserted after an unprotected sex or accident at the time up to 5 days, to protect you from getting pregnant and then it can continue for future contraception.

The side effects of Copper IUD’S As already mentioned are heavy and painful periods, but they often settles down in 3-4 months. The newer IUD’s cause problems less often. For these problems women are prescribed special drugs (NSAID, e.g Nurofen, and antifibrinolytics called tranexamic acid). Both these are very   effective.

As already mentioned some situations make it more difficult to insert an IUD such as a previous caesarean section.

There is a  small chance of getting a pelvic infection (1in500). It is more likely to happen within 21 days of insertion or if you have more than one sexual partner always practice safe sex to protect yourself.

LARC’s do not protect you from STI’s. This is one very big disadvantage of LARC’s

At the time of insertion the IUD can be pushed out of the uterus. It happens in 1 in 1000 insertions. If this happens it may need to be removed laprascopically.

Sometimes it falls out spontaneously outside the uterus (5 in 100) without a woman knowing it. That is why it is important to feel the thread. Sometimes the thread withdraws in the uterine cavity. An ultrasound is the best way to look for a missing IUD. If a woman gets pregnant with an IUD (1 in 100), most often it can be easily removed; and it should be removed as soon as possible. There is a small risk of miscarriage.  In situations like this it ideal to do an ultrasound to make sure that the pregnancy is alive and it is in the uterus, because sometimes these pregnancies can be ectopic meaning outside the uterus.

Always remember to feel the thread of the IUD after a heavy period.

Report to your doctor if you do not feel well, you have pain, discharge, irregular bleeding, pain on passing urine, or you have any symptoms of pregnancy or if your period is more than a week overdue.

If you have casual sex or sex with a new partner always use condoms.

Remember the date when you need to change your IUD. It can be removed easily by pulling the string without causing too much discomfort. A new IUD can be fitted at the same time if you so desire.  Most of the IUD’s can stay 5-10 years.  Multiload, an Australian IUD needs to be changed after 3 years.

NEWER COPPER IUD

In China family planning is a big issue. It is only in the last six months that they have relaxed their one child policy, so over the years many different types of IUD were invented and used. It was always a challenge to find and remove a Chinese IUD.  Now with ultrasound it has become a game instead of a challenge. It always intrigues you what you might find. One of the most commonly used IUD was a stainless steel ring (SSR). This had a high failure rate, and higher expulsion rate which was worry some. Slowly copper IUD’s replaced SSR by 1989.

In China 60% of the female population (about 114 million women in 2007) uses IUD after first child birth, until now they were allowed only one child. One serious problem with copper IUD is heavy and painful periods. This causes anaemia and poor health. To overcome this problem  Chinese developed a copper IUD with INDOMETHACIN ( a nonsteroidal anti inflammatory drug)  in 1986.

This decreases the amount of bleeding and  cramps. It is composed of three layers. An inner layer of y shaped stainless steel the middle layer is wound with about 200 to 300 mm of copper wire, the outer layer is again stainless steel. A total of 25 mgm of indomethacin is welded to both ends of the horizontal arms and in the centre by silastic beads. Few studies compared both medicated –Y IUD VS TCU380A(a type of copper IUD).That medicated IUD’s better than other copper IUD’s , blood loss was  less , less removal rate for medical reasons, higher continuation rates, and similar low pregnancy rate. Some of these studies continued up to 5 years, more trials will be needed before we make this a standard method. It is very reassuring and comforting for women.

GYNEFIX STANDRED AND MINI

Gynefix   standard  has 6 copper rings(5MM diameter) where as gynefix mini has 4 copper rings hence it is better for nulliparous teenagers.

Due to continuing side effects of copper IUDS and a large number teen age pregnancies research for better copper IUCD continued. People measured the sizes and shapes of nulliparous uterine cavity and decided they were different.  A Belgian gynaecologist decided to make a frameless copper IUCD. He used a polypropylene string with a naught at the top to anchor it to uterine muscle in the front wall of the uterus. There were 6 or 4 copper rings on this string. The one with 4 rings was smaller and is called mini. They have 200mm square of copper on the smaller one 330mm square of copper in the larger one. The first and the last copper ring is crimped to the thread to stop it from falling out. They work the same way as any copper IUCD. Any copper IUCD which has more than300mm of copper is spermicidal.  This proved to be excellent as the egg could not be fertilized and therefore no ectopic  pregnancy has ever been reported in women using  gynefix . It needs special equipment and trained personnel to put it in. It is less painful for nulliparous teenagers. It has to be watched carefully so that the copper rings do not get uncrimped and fall out. Some authorities recommend a six monthly ultrasound. Gynefix is available in Europe only. Research continues on copper IUCD there are about about 9 already, in diffrent parts of the world.

 The above image is of GYNEFIX within the uterine cavity.

MIRENA ,SKYLA (OR JAYDEN)

Since contraception is so important in some parts of the world researchers are working on better and better methods.

Although newer, inventions in the shape and sizes of many IUCD have improved the spatial and pain problems with copper IUCDS, the main problem with menorrhagia( heavy Periods and also painful periods )remained.

This led to a new generation of hormone releasing IUCD. This is called Mirena, all over the world.  Since we emphasised using IUD for younger women a smaller version of Mirena is produced called Skyla in Australia it is called Jayden. This is also a hormone releasing IUD in a smaller size releasing smaller dose of the hormone (LNG-IUS;mirena). Mirena has a plastic T shaped frame of 32 by 32 mm, it contains a small size reservoir which stores,  52 mgm  of  Levonorgestrel  (a Progesterone hormone) Mirena is fitted inside the uterine cavity. It remain there for 5 year doing its job of contraception and preventing excessive bleeding  unless it needs to be removed for some medical reasons or woman’s wishes .It has a mechanism which helps it to release 20 micrograms of  levonorgestral per day . Skyla on the other hand is Smaller, 28 by 28 mm in size; 13.5mg of levenorgestrel is stored. It releases 12 micrograms of levonorgestral per day. Diameter of the inserter in skyla is also smaller preventing pain at the time of insertion. (Mirena 4.75   skyla3.8) Mirena works for 5 years skyla works for 3yrs .there efficiency is comparable. If the women’s uterus is small skyla is preferred as it will not cause pain.                    

Mirena was invented and released in 1976 in Finland. Like it is said while discussing copper IUD it is always best to give IUCS women two sessions, unless it is impossible for them to attend twice. The insertion is always done by a trained person. A follow up appointment is also very important.

Some Women cannot have an, IUCS these include

1)          Undiagnosed abnormal vaginal bleeding

2)          Current or recent pelvic infection

3)          Abnormal cervical cytology

4)          Present or past breast cancer

5)           Compromised immune system

6)          Abnormal uterine cavity shape  either due to congenital abnormality or fibroid uterus

7)          Serious liver disease

8)          Allergy  to levonorgestral and chemicals used to make the device, silica, silver ,barium iron oxide ,and polyethylene

9)           Make sure definitely not pregnant

10)  Not keen to get pregnant in a hurry.

11)   If  the woman suffer  from congenital heart disease , do not use IUCD or IUCS ,as these can cause infection in the heart valve

HOW DOES IUCS WORK

There is no single explanation how Mirena   works. It thickens the cervical mucus plug   so that the sperm cannot penetrate the cervical canal and enter the uterine   cavity.  The sperm becomes sluggish and cannot reach the egg to fertilize it .The lining of the uterus thins out, even if there is a fertilized egg it cannot implant itself.  Mirena works well, only 2 out of 1000 women become pregnant in the first year of use. This can often happens if, IUCS was not properly positioned to start with

or it was pushed out unnoticed often during a very  heavy  period .     

OTHER BENEFITS OF IUCS

Very heavy periods in women are   decreased almost by 90 % after few months of use. Cramps also stop, menstrual periods stop all together in almost 20% women it works like a hysterectomy. Unlike hysterectomy, the periods and fertility returns to normal after Mirena is removed in premenopausal women. It is not harmful, not to have periods when you are using the Mirena, If you are in the older age group say, 38 onwards, if you have perimenopausal symptoms you can use oestrogens. You do not need progesterone as you already have a progesterone IUD. TheyL together work like HRT. Mirena greatly helps the woman with endometriosis particularly in teenagers. High doses of progesterone for the treatment of endometriosis cause too many side effects, where as Mirena does not. Lessening of back flow  of the blood  because of the very heavy periods from the uterus via the fallopian tubes into the belly also helps to improve endometriosis, as with Mirena there is very little bleeding or no bleeding. It also prevents Endometrial thickening (HYPERPLASIA) and cancer. Reduces  the risk of Ectopic pregnancy; as the eggs do not get fertilized. It is useful to decrease bleeding in bleeders suffering from inherited bleeding disorders. Mirena can be used to decrease bleeding with fibroids.

No harmful effects have been noted in obese women on serum lipids (cholesterol and triglycerides), carbohydrates, Coagulation profile and liver enzymes. Although there are no publication on the use of IUCS with history of DVT many studies found it to be safe hence a history of DVT or  Thrombophilia , it is considered appropriate to use progesterone alone contraceptive. It should be used with caution.

IUCS, did not show any effect on High blood pressure or weight gain even in women with type 1 diabetes. It can be used in women with type 2 diabetes as long as their vascular (blood) system is normal

It can be used 4 weeks after child birth.  I preferred it to be 6-8 weeks so that the risk of expulsion, bleeding and infection is minimised. WHO and  The  American college of O and G also recommend 6 weeks. Anyway there is no need for contraception in the first 3 post natal weeks.

Levonorgestral does not have any adverse effects on breast feeding or on the growth and development of the breast fed infants.

Mirena is useful in women with heavy   bleeding with fibroids.  Before it is inserted in uterine cavity, the care giver has to make sure the fibroid is away from the Path of the IUCS. This can be done by ultrasound, and also make sure there is no other serious cause for excessive bleeding eg cancer of the uterus.

RISKS AND SIDE EFFECTS OF MIRENA

Menstrual problems;

Hormones IUCS on one hand is supposed to help with menstrual problems on the other hand this causes initial irregular bleeding. This may be due to the fact that it interferes with the normal hormone cycles, incomplete suppression of ovarian

activity and oestrogen deficiency The bleeding is treated by estrogens , oral contraceptive for few weeks, non-steroidal anti -inflammatory drugs such as Neurofen  with which most of us are familiar . Another group of drugs with which many of you may not be familiar

are very useful. They are called antifibrinolytic agents (TRANEXAMIC ACID). They are very useful in all kinds of uterine bleeding .Finally progesterone receptor modulators called  Mifepristone is also very useful as they decrease the progesterone activity and increase the oestrogen activity. This is also used if there is irregular bleeding with other progesterone only contraceptive. So please do not worry there are many ways to stop this intermittent unscheduled bleeding. Very Often some care givers give Mifepristone   (100mgm) at the time and then once a month for 3 months. It has proved to be useful and can be repeated.  Once the   uterine lining thins out this settles down, as mentioned earlier the periods usually stop for the remaining time.

Perforation of the Uterus

This is rare. It usually happens at the time of insertion, the frequency being 1 in 1000. If the uterus is perforated IUCS should be removed.

Expulsion of the IUCS

This means that the IUCS is expelled out of the uterus. It usually happens in about 5% of women in the first few months. It happens often, if it was inserted too soon after child birth or in nulliparous women.

Once it is expelled  the woman is no longer protected.

Mirena  never protects  you from STI’s. If you are at risk make sure you use a condom as well. It can be used if you are HIV positive, as it has not shown to cause viral multiplication.

 It seems to be protective against infection due to the thickened cervical mucus. The other problems Mirena can cause are headache, vaginitis

Pelvic pain, pain during bleeding, breast tenderness, hair loss, and ovarian cysts. These ovarian cysts are harmless and go away on their own.  Mirena has been reported to cause stroke like symptoms, I have seen one case amongst my own patients. I had her checked over by a neurologist, he said he cannot find anything wrong however she settled after   Mirena was removed. I have also come across intermittent anaphylactic reaction, swelling of tongue or lips, difficulty in breathing, on and off until I removed the Mirena as matter of urgency. These can be   due to Nickel allergy.                                                     

THE NEXT LARC WHICH I WILL TALK ABOUT IS A PROGESTERONE IMPLANT

Implanon, I am sure, thousands of you have heard about it. It is now used by 11 million women around the world in 60 countries. This technique uses a single rod of 4cms by 2 mm sealed on both sides.

The  possibility of subdermal(under the skin )contraceptive was discovered after Silicone was discovered in 1940 ,not only that it was found to be compatible with the human body. It was felt that these silicone rods can be filled with drugs which can then be slowly released and act as contraceptives.

Slowly different types of implants were made. They are filled with progesterone only. The implant which was first marketed was called Implanon. It was first marketed in Indonesia in 1998. It

contains 68mgm of progesterone called Etonogestrel. It is inserted into the non dominent upper arm of a woman just under the skin .This releases about 30 to 40 ug to progesterone per day. It gradually decreases in amount, in the 3rd year it releases 25 -30 ug per day, however this enough to act as a contraceptive.

The commonest implant used in the world was Implanon. However in recent times it has been modified so that it has become easier to locate it by x-ray when it is lost. Now it contains 15 mgm of barium dispersed in it, it is called

IMPLANON NXT. There are many different types of progesterone implants available in different countries sold under different names(NORPLANT, NEXPLANON SINOPLANT11).The techniques of their making  differs . They work similarly and have same problems. They can last from 3 to 5 years.

Like any contraceptive advice, your care giver will take your history, do an examination, and relevant tests ie: Pregnancy test and an Ultrasound. This has been discussed in detail earlier.

Progesterone Implants can be used in women of all ages. However there are some situations when it should not be used and in some it should be used with caution.

Contraindication to use Implanon

1) Make sure you are not pregnant. A negative pregnancy test excludes pregnancy only if it is more than 3weeks

2) You are not allergic to progesterone (Etonogestrol) or any substances contained in the applicator or used at time of application.

3) You have or had no jaundice, liver disease, liver tumours, and gall stones.

4) You have no history or presence of breast cancer, ovarian cancer, uterine cancer or cervical cancer.

5) If you want to breast feed, make sure baby is at least 6 weeks old.

6) You do not have unexplained, undiagnosed vaginal bleeding

7) Current or past history of thrombosis, heart disease and any other vascular disorders.

8) If you have diseases such as porphyria, epilepsy, tuberculosis, lupus and if you are on any drugs please inform your care giver so that he/she can make sure it does not interfere with Etonorgestero or vice versa. He/She will explain all this to you.

9) Diseases such as high blood pressure, severe diabetes, obesity, restricted mobility, high cholesterol and triglycerides other metabolic conditions require special care when you use ImplanonNXT

10) Previous history of ovarian cyst or ectopic pregnancy also requires special attention.

11) Any vascular diseases of the eye

12) There is some difference of opinion, if it is safe to use, Implanon, in women who are HIV positive or have AIDS.

HOW DOES IT WORK

Like all other hormone contraceptives it works in 3 ways

1) It inhibits ovulation, no eggs no pregnancy.

2) It increases the thickness of cervical mucus hence the Sperm cannot penetrate it.

3) It thins out the lining of the uterus (Endometrium) as a result the fertilized egg cannot stick to it (Implant).

This is why some people have a moral objection to it considering it to be an abortion.  However as we have already mentioned American law only considers it to be a pregnancy after the egg has implanted.

EFFECTIVENESS

Nexplanon , ImplanonNXT ( Implanon)and Sinoplast 11, are all long acting subcutaneous reversible contaceptives. They have been shown to be the most effective contraceptives in the current world. We wish we could spread them like sunshine on the grass; as this then could save millions of women and millions in terms of money. Their failure rate is .o5% . They are almost 10 times more effective than, tubal Sterilization. Not only that, they are reversible. The failure is often due to wrong placement, wrong timing of placement, and prexisting pregnancy.

It should be inserted  within the first 5 days of menstrual cycle, on the day when the previous one is removed, on the first day  after  Depo-Provera is due, within 5 days of first trimester abortion or miscarriage, within 21 -28 days of 2 trimester. If all these instructions are followed it is 99% safe.

INSERTION AND REMOVAL

An insertion is done only after the woman has been informed all about the implant and other contraceptives, and she wishes to use the sub dermal implant .Make sure she is not pregnant, has no STI, no absolute contraindications; it is inserted by a trained clinician on the inner side of the non dominant arm.(ie: If right handed then implant goes in the left arm) The rod comes in a pre packed container with an applicator.

It is inserted in an aseptic manner.  The clinician and the woman have to make sure that the Implanon has gone in the arm by feeling it under the skin.

Removal of the device is also done by a trained clinician. A small cut is made; the device is picked with a small forceps and gently pulled out. Sometimes the   Implanon migrates and is lost; this often requires a high resolution ultrasound or an x-ray, CT or MRI.

Most women begin to ovulate within 6 weeks of removal. Fertility levels return to pre Implanon levels within 3months.

Implants require changing every 3 years.

Sometimes they require removing for medical reasons for example, thrombosis, persistent high blood pressure, ovarian cysts, and reaction with other drugs. Like all drugs; Implanon can have side effects, some of these are serious, tell your care giver if you don’t feel well after the implant of Implanon.

SIDE EFFECTS OFSUBDERMAL IMPLANTS

1) Insertion and removal complications

They can  cause  pain , infection , bruising and scarring . Many pregnancies have been reported when the rod was not checked and it was left in the inserter. Newer applicators are much better and easier.

2) Irregular bleeding pattern is the most annoying problem .Sometimes, on and off or else prolonged. They do not hurt in any way but they are bothersome, and often one of the reasons to have it removed. The same treatment is offered as with Mirena . Generally it settles down in 3 to 6months

3) Many other side effects are similar to  Mirena ; Acne , Decreased libido , Hair loss, pigmentation of the skin and face ; Cloasma ( yellowish butterfly pigmentation of the face),Hives, Breast tenderness, Depression, nervousness, Mood  swings, Dizziness

Nausea, Vomiting, and Abdominal pain. Besides these progesterone like symptoms more serious ones are increase of Blood Pressure, poor control of diabetes, chest pain, pain in the  legs  suggesting thrombosis, swollen face or tongue , trouble swallowing, breathing problems, sudden collapse, loss  of vision and sudden feeling of weakness in your body you need urgent medical attention. These symptoms are indicative of thrombosis phenomenon in the body.
ADVANTAGES OF IMPLANTS AS CONTRACEPTIVES

1) Most women of any age group can use it

2) Most effective form of birth control and does not require women’s compliance or daily attention.

3) It can be confidential, you do not have

to involve your partner, does not require

interruption of foreplay or intercourse.

4) Fit it and forget about it for 3 years. In   some special cases you may require regular   checkups e.g. if you smoke, you have high blood pressure you have any conditions already discussed before.    

5) You can use this if you cannot use oestrogens

5) Women who want to breast feed can use it after baby is 6 weeks old. Very small quantities of progesterone are seen in the breast milk but this does not alter the quality of milk or in any way interfere with

the babies’ growth and development.

6) You can use it if you are a smoker and over 35.

7) It takes only 1- 2 minutes to insert it and remove it, if inserted at the correct time, it starts working soon after.

8) Fertility returns within months of

 Removal.

9) You cannot use it if you have an abnormal shaped uterus or if you have a fibroid distorting the uterine shape.

10) Medical benefits, it reduces menstrual bleeding and pain in women with fibroids or endometriosis

11) Helps with Premenstrual symptoms

12) Although in some women it causes acne in others it prevents it.

13) There is initial expense in some parts of the world, but long term it works out very economically.

DISADVANTAGES

1) The biggest risk is of STI, Including HIV. Anyone who feels that they are at risk for STI, they must use condoms along with Implants.

2) Other risks have already been discussed with side effect.

INJECTABLE LARC

In this paragraph I will talk about the injectable larcs. They are progesterone injections;

1) Depot medroxyprogesterone,(DMPA) it is also called Ralovera or in simple English depo-provera.It was first introduced in 1967. It has a maximum action of 12 weeks. It is best to repeat after 11 weeks, it takes one week to be active. Woman must wait for one week after the first injection. With perfect use the failure rate is .02%.

It can be used if you are breast feeding. I found it to be very popular in Indian villages, as village health care provider gave the injection every 12 weeks.

Other injectable long acting progesterone is called NET-EN. This contains only 200 mgm 0f a progesterone called Norethistirone.

 It needs to be given every 2 months and is not popular.

Advantages and Disadvantages

1) Safe in women who cannot take estrogens or the pill

2) Can be used in women who suffer from migraine.

3) Can be given any time postpartum, or soon after first or second trimester abortion.

4) Women with liver enzyme inducing medication can use it without the dose interval being reduced. Some of these drugs are, drugs for epilepsy, Tuberculosis, antibiotics and antifungal

They should be used with great care.

5) Safe in women who have HIV, AIDS,

And STI’s.

6) Useful for women with endometriosis and unexplained bleeding problems and painful period. Endomeriosis symptoms are well controlled.

7) Usually does not cause headaches depression and acne.

8)  No increased risk of DVT, pulmonary embolism   stroke and myocardial infraction

9) Decreased risk of endometrial cancer, pelvic inflammatory disease (PID), fibroids, endometriosis and functional ovarian cyst, Iron deficiency anaemia, ectopic pregnancy.

10) Minimal drug interactions compared with other hormonal contraceptives.

11) It is useful for women who are obese i.e Body mass index of 30 or more.

 12) It is good for women who suffer from bowel diseases.

Disadvantages of injectable contraceptives

1)          World health organization has reported no increased risk of breast cancer or any other cancer. In fact it decreases the risk of the cancer of the lining of the uterus (Endometrium )

2)           Irregular bleeding is the most annoying side effect. However it settles down after 2-3months. 50% women have no period after 1 year of use they are generally happy about this. The treatment for irregular bleeding can be by Oestrogens or Neurofen . There is no real dander in this bleeding, it happens because of the thinning of the uterine lining.

3)          Weight gain is another annoying side effect especially in women who were already obese. The weight gain can be as much as 5 lbs in 1 year or 8 pounds at 2 years. One of the problems is that once the injection is in it is in. 

4)          The side effects are headaches, depression, poor sex drive, breast tenderness, nervousness, dry vagina, and tiredness.

5)          The other important side effect is loss of bone density. It has been shown that some teenagers can lose as much as 2-3 % in bone density. Because of this many clinicians recommend a evaluation if  Depo- Provera is to be continued  for more than 2 years. To keeps your bones healthy, you need to take about a 1000 mg of calcium daily .  Regular exercises, sports, vitamin D, and magnesium. Your GP will be able to give you detailed information on life style, particularly in teenagers.

6)          It takes longer for a woman to get pregnant after she stopped DEPO –PROVERA. It depends on the age  weight and any other problems, a woman had before she went on DEPO- PROVERA

7)          One of the most important risk factor is exposure to STI’s, HIV. This does not protect you from any form of infections from the genital tract. If think you are at risk tell  your care giver to test for these .You should all ways use condoms when making love either ,vaginal oral or anal to protect you from STI’s.

8)          Your clinicians will always take a detailed history and examination, before you are told you are fit to have the injection.

9)          It can interfere with few Diseases. Thyroid is one such problem. It can become under active when you are on depo- provera , so if you are putting too much  weight or too tired have it checked. It is generally contraindicated in women with liver disease, severe depression.  It may have  some degree of effect on blood coagulation system

10)  You can stop It any time you like, but side effect will last for the duration of 12 weeks. Always have regular checkups. Report to your doctor if you have yellow colour urine, severe abdominal pain, prolonged painful, vaginal bleeding, headache, risk of exposure to STI, severe depression and painful legs.

 KEY POINTS ABOUT LARC

1) Larc means long acting reversible contraceptives for extended period without requiring user action. Currently a lot of attention is being paid on these methods, due to high rates of teenage pregnancies, high typical failure rate compared to perfect failure rate . This is because user is not involved, therefore compliance is not required. High failure rates of other methods leads to increased abortion rates and consequently high maternal deaths          

2) These can last anything from 2month, (There is only one such injection that has to be repeated every 2 month), 5years, 10 years and even life long.

There are 4 such methods;

A) IUD

B) IUS OR IUCS

C) Implants, It used to be called, Implanon

 now it is  ImplanonNXT , it has been modified by adding Barium to it so that it can be detected by x-ray. It is a progesterone hormone implant

 D) Progesterone injections

There are two such injections1) depo –provera, NET-NE. Depo-provera is commonly used. It starts acting after 1 week after the injection and lasts for 12 weeks. Main drawback is while using depo-provera you tend to loose, bone density. It is especially important for teenagers as this is the time for them to build their bone density. It is suggested that it should not be used for more than 2 years as a contraceptive unless there are very pressing reason to use it.

2) Larc methods are 20 times more effective than birth control pill.

There typical failure rate means the rules are not rigorously followed and every now and then the user becomes casual. Where as in perfect use all rules are strictly followed and there are no casual lapses. In larcs methods typical and perfect failure rate is the same, as you do not need to worry every time you have sex. It works on the principal, fit and forget. Failure rate of LARC methods varies between .02 % to 1 in 100 women in  one year This is even better than sterilization and it is reversible.

3) IUD and IUS are devices that live inside the uterus after being inserted. They are inserted by special tools by specially trained clinicians.  This can cause some discomfort, but it is taken care of by pre insertion pain relief, local anaesthesia or in difficult cases sedation. This settles down in a day or so. Most women do not feel anything. IUD’s are, copper IUD’s. They can last for many years, 5-10 or even forever. They used to cause heavy bleeding and pain, however newer IUD’s have been improved.  Women are given anti bleeding and anti pain medication.  The chinese have invented a new copper IUD which contains a drug called Indomethacin, it takes the pain away and decreases excessive bleeding. It is not available to the rest of world, but is becoming popular in china. This does not contain any hormones.

ICS is a hormone containing IUD. Recently it has been produced in two sizes. These have been discussed in the main text Mirena and skyla (Jayden). There contraindications and side effect are also discussed. There medical benefits are many. Decreased period pain, bleeding, less symptoms of endometriosis, less anaemia and better general health.   I frequently used Mirena in later years of my practice. I found it to be Magical. It hardly takes 5 minutes to put it in and 30 seconds to remove it . However it takes at least a one hour session to explain benefits and risk of LARCS to the clients. Mirena is permitted to be used for 5 years and skyla for three.  The biggest drawback of these IUCD and IUCS is that they cannot protect you from STI’S. Copper IUD can also be used as emergency contraceptive.

4) IUD, IUCS, both work by thickening the, cervical mucus so that the sperm cannot enter the uterine cavity, copper IUD are also spermicidal so that the sperm cannot move around and die. They both cause the failure of fertilization. Beside this copper IUD causes inflammatory reaction in the uterine cavity, IUCS thins out the uterine cavity, hence in either case even if the egg is fertilised it cannot implant. These should be considered as contraceptives not as abortificants.

The injectable contraceptives also thicken the cervical mucus, so that the sperms cannot enter the uterine cavity, stops the ovary to produce an egg, this results in a thin uterine lining so the fertilized egg cannot implant, if there is any by chance.

 5) The side effects of IUD AND IUCS, ImplanonNXT and Depo-provera are irregular bleeding, they happen more often initially and settle down in3-4 months. The treatment has already been discussed. It is generally by, nurofen, anti bleeding drugs and sometimes by oestrogens. Other side effects are headaches, depression, and a risk of weight gain with Depo-vera.  Rarely (1in 1000) IUD can perforate the uterus, it generally happens at the time of insertion. It can get expelled by itself especially with a very heavy period, and then you are not protected. This happens in, about 5% in the first year. That’s why it is important to feel for the thread after each period. There is some misconception that you get PID and STI after using IUD. If your clinician  has taken due care at the time of insertion it can happen only in the first 3 weeks . If you are at risk of STI please always use condoms, for Vaginal rectal and oral sex.

6) Rarely pregnancy can occur. There is a higher chance that his could be an ectopic pregnancy ( pregnancy outside the uterus) or you may miscarry. In this case the IUD or IUCS should be removed. If the pregnancy continues this does not cause any foetal abnormalities.

7) Over all benefits of LARC

A) Fit and forget , once it is in place you do not have to do anything to prevent pregnancy.

B) No one can guess that you are using any birth control. Does not interfere with

Sex, or any daily activities.

C) It can be inserted soon after an early abortion, 3 weeks after late abortion, 6 weeks after a baby is born and you can breast feed if you wish.

D) Any time if you wish to get pregnant or you are not happy with it. It can be easily removed.

E) Copper IUCD is an effective ,emergency contraceptive.

F) Hormone IUCS is effective with many medical problems, heavy bleeding, pain, Endometriosis, Fibroids

G) Long term works out to be cheap

H) Problems with cooper IUD’S are being resolved with newer inventions , Indomethacid, copper  IUD,and  Gynefix

I) Hormone IUCS is also improved With invention of skyla.

J) It can be used in women with HIV, History of PID, High blood pressure, Diabetes, can be used in women on liver enzyme inducing medications without changing the dose interval. These are medication used for epilepsy, tuberculosis

and other complex medical diseases. Copper IUCD can be used in women with thrombophilic disorders. In all these situations they require special care.

 K) Myths about LARC should be removed from, care givers and public by better education information and training. This is happening. This does not have an increased risk of PID, or infertility, unless your sexual habits are compromising.

It can be used in nulliparous women or after caesarean section. These can be easily inserted and removed by trained personals’ with proper equipment. I hope once this happens we can save lots of money and lots of women. At present Russians use the highest number of LARCS  33%, as compared to Australia about 10%.

Possible rare risks are with insertion and removal they occur in only 2 % of cases. You often need a clinician if there are any problems .The most important problem is you are not protected from STI’s. 

I hope this gives you a very good prospective on LARC’s methods of contraception which in most people’s opinion are one of the best methods, but unfortunately least used so far. We need a lot of education, training, publicity, and initially some government finances to start the method. Fortunately all this is being done.