A mouthful though it may be, “long-acting, reversible contraception” refers to a variety of different contraception methods, both hormonal and non-hormonal, that can be reversed at any time. Although the birth control pill remains the most widely used method in the U.S., these other options are becoming increasingly popular. I explain to women that these methods are more convenient than the birth control pill, lasting months or even years before a woman needs to take any action, and are therefore often more effective than the pill.
I discuss all of these methods with my patients, as I believe very strongly in making sure that each woman who sees me understands all of her contraceptive choices so that she can make the best decision for her. We talk about lifestyle, the pro’s and con’s of each method including potential side effects (they all have them), the timeframe in which she might be considering getting pregnant, and her willingness or comfort with having a minor procedure. These will help inform the best choice for her.
I also remind my patients that, just like the birth control pill, none of these methods protect against sexually-transmitted diseases!
Below please find an overview of each form of long-acting, reversible contraception. Harvard Vanguard has at least 1 or 2 clinicians in every OB/GYN Department who have received the specialized training necessary to perform these procedures safely and comfortably at our practice locations.
NEXPLANON
This is a subdermal (under the skin in the upper part of the arm) implant of a slow-release etonogestrel, a type of progesterone. It works by suppressing ovulation, by causing the cervical mucus to thicken and by changing the lining of the uterus, the endometrium, and inhibiting its growth. It is highly effective and good for 3 years.
The Nexplanon is inserted in the first 5 days of the menstrual cycle and is immediately effective. (Note: if you’ve just had a baby and are breastfeeding, it should be inserted in the 4th postpartum week and you should use a back-up contraceptive method for 7 days; if you are not breastfeeding, it can be inserted 21-28 days postpartum or during your menstrual cycle.) The plastic “rod” is small – 1.6 inches long – and soft and flexible. You will be given a local anesthetic in the area of the arm where it will be inserted. An applicator is then used to insert the rod underneath the skin of the arm. A pressure dressing is then applied to the arm which should remain in place for 24 hours.
Advantages: Nexplanon is highly effective, does not require a pelvic exam before inserting, and is long acting (it’s good for 3 years), easily removable and reversible, and convenient once it is inserted. I find it is a method particularly suited for young women who do not want a pelvic exam. Many women also experience lighter periods on Nexplanon.
Disadvantages: most common side effects are changes in a woman’s menstrual pattern during the first year. These changes can range from having no periods at all (about 1 in 5 women experience this) to irregular bleeding (1 in 3 women). Therefore, while more than half of all women saw a decline in the frequency of their periods, about 1 in 6 women experienced prolonged bleeding, which is defined as any bleeding or spotting episode that lasts more than 14 days in 90 days, and about 6% had frequent bleeding with more than 5 bleeding episodes in 90 days. Usually, a more predictable and “normal” menstrual cycle emerges for women after the first year.
Another important point I raise is that, as with any contraceptive method that uses hormones, there is a small percent of women who experience weight gain, mood swings, headaches or acne.
INTRAUTERINE DEVICES (IUDs)
There are 3 kinds of IUDs that are available: Paragard, Mirena, and Skyla. Like Nexplanon, the optimal time to have an IUD inserted (which is a very quick procedure) is within the first 5 days of a woman’s menstrual cycle.
Paragard IUD
This is a non-hormonal IUD that contains copper. This IUD safely introduces a foreign body “into the mix,” so to speak, and causes chemical changes that interfere with the ability of the sperm to reach the fallopian tube or decrease the sperm’s ability to fertilize an egg; it essentially impairs the sperm function to do its job. (There is a misperception about Paragard that I would like to address: some women mistakenly believe that this IUD causes a woman to have an abortion, but that is not how it works – by impairing the sperm’s ability to do its job, a pregnancy is never attained.)
Advantages: this is a highly effective form of contraception – less than 1% pregnancy rate in the first year of use. It is also non-hormonal for those who are concerned about exposure to hormones. It lasts for 10 years, so it’s very convenient, but it’s also easily reversible if a woman should wish to go off this method for any reason.
Disadvantages: One of the downsides of this method is that periods may be a little bit heavier. Like all IUDs, too, this method requires a pelvic exam for insertion and removal, and for some, the insertion is uncomfortable. We do recommend ibuprofen prior to the procedure to minimize pain. However, those women who have had a previous vaginal birth usually do fine with the insertion. Although very slight, there is also a risk of perforation at insertion and a risk of infection.
Mirena and Skyla IUDs
Both of these IUDs have the hormone progesterone (levonorgestrel) in them. They release progesterone directly into the endometrial cavity – initially, the amount is 20mcg per day which declines to about 14 mcg daily after the first year. But, the daily dose of progesterone is about 10-15% of the dose in birth control pills (which contains 150 mcg of levonorgestrel).
The IUDs work by releasing progesterone into the endometrial cavity. This causes a thinning of the endometrium; as a result, many women will have either light periods or no periods at all. It also causes a thickening of the cervical mucus and inhibits sperm motility (the ability of the sperm to move properly towards an egg in order to fertilize it) and survival. While the progesterone effect is mainly in the uterus, there may be some systemic absorption which could also prevent ovulation in some women.
There are a few differences between the Mirena and the Skyla: the Skyla is smaller and has a lower amount of progesterone in it, making it better suited for women who have never been pregnant before. The Mirena lasts for 5 years and the Skyla for 3 years. But they are both well-tolerated and easily reversible.
Advantages: like the Paragard IUD, this is a highly effective (<1% pregnancy rate in first year) but unlike the Paragard, many women experience a lighter period, and oftentimes, women do not have a monthly period. Given the low dose of progesterone, many of the associated hormonal impacts (weight gain, mood swings, etc.) do not occur at all or are very slight.
Disadvantages: The same downsides as the Paragard exist for both the Mirena and the Skyla. Also, there is a possibility of menstrual irregularity initially, but over time this should decrease.
DEPO PROVERA
Depo Provera is a long-acting, injectable progesterone. Each injection lasts 12 weeks. It prevents pregnancy by inhibiting ovulation, thickening the cervical mucus (which prevents sperm penetration) and thinning the lining of the endometrium. About 10-30% of women stop having periods altogether after the 1st injection, and 40-50% stop after the 4th injection.
Advantages: It is more effective than the birth control pill or the transdermal and ring methods if used and administered correctly and is not invasive like an IUD or Nexplanon. Over time, most women experience a decrease in menstrual flow. It provides relatively short term contraception, no estrogen (birth control pills can contain both estrogen and progesterone), and easily reversible (although there might be a delay in return to ovulation).
Disadvantages: Although more convenient than taking a daily pill, it does require return visits to your doctor’s office every 12 weeks. While most women are happy with it, a small number of women stop receiving Depo Provera is because they continue to have persistent irregular spotting or bleeding. Because it too is hormonally-based, weight gain and mood changes can also occur.