This document provides an overview of long-acting reversible contraceptives (LARCs). It discusses that LARCs include intrauterine devices, implants, and injectables that are effective for 1-5 years. While effective at preventing pregnancy, LARCs have low usage rates due to lack of access and awareness as well as misperceptions about safety. The document reviews the various LARC methods, including types like intrauterine devices, implants, and injectables. It discusses their mechanisms of action, effectiveness, benefits, and risks to provide clinicians with information to educate women about LARC options for pregnancy prevention.

1. DR AKISEKU A.K

2.  Introduction
 Long acting reversible contraceptives
 Long acting hormonal contraceptives

3.  There are about 1.2 billion women of reproductive age
world wide
 An estimated 1.5 million unplanned pregnancies
occur in Nigeria every year and about half of these
result in elective abortion.
Bankole A , Oye-Adediran. International Family Planning Perspectives
Volume 32, Number 4, December 2006

4.  Unexpected or unplanned pregnancy poses a major
public health challenge in women
of reproductive age, especially in developing
countries.
 It has been estimated that of the 210 million
pregnancies that occur annually worldwide, about 80
million(38%) are unplanned, and 46 million (22%) end
in abortion.

5.  Abortions account for 20%–40% of maternal deaths in
Nigeria.
 Many factors contribute to unwanted pregnancy in Nigeria,
and a very important factor is the low level of contraceptive
use
 Contraception a key strategy for the prevention of
unwanted pregnancy.
Open Access Journal of Contraception 2010: 19–22

6.  The current prevalence rate for contraceptive use in
Nigeria is approximately 11%–13%.
 The Nigeria’s family planning commitments is to
achieve a contraceptive prevalence rate of 36% by 2018.
National Strategy and implementation plan (2013-2015)

7.  The low prevalence of contraceptive use in Nigeria and
indeed in the Sub-Saharan region is due to interplay of
many factors:
 Socio-cultural, economic, political,
 religious, and demographic.

8.  Contraceptive prevalence=
Women of reproductive age (15-49) who are married or
in a union and who are currently using any method of
contraception
x 100
Total number of women of reproductive age (15-49)
who are married or in a union

9.  Family planning programs have yielded positive gains
over the past decade
 Like all aspects of medicine, contraception is also
witnessing advances, changes, improvements.

10.  LARC is defined as contraceptive methods that require
administration less than once per cycle or month.
Included in the category of LARC are:
 copper intrauterine devices
 progestogen-only intrauterine systems
 progestogen-only injectable contraceptives
Nice clinical guideline 30. 2014

11.  progestogen-only subdermal implants
 Progesterone Vaginal Ring (PVR)
 The uptake of LARC is low in Great Britain, at around
12% of women aged 16–49 in 2008–09, compared with
25% for the oral contraceptive pill and 25% for male
condoms

13.  Are the most effective reversible methods available
 Have high rates of user satisfaction as indicated by high
continuation rates
 Are set and forget methods that do not require daily
adherence
 Require fewer visits to health services than many other
methods
 Are cheaper than using the pill over 12 months
 Are easily reversible
 Are suitable for women of all ages
 Do not affect fertility after removal

14.  A lack of familiarity with, or misperceptions about, the methods
 High upfront costs
 Lack of access to insertion services
 Health care providers’ concerns about the safety of IUD use,
especially in nulliparous ,younger women and teenagers
 Patient barriers, including a general lack of awareness of LARC
methods and information about their safety and effectiveness

15.  progestogen-only intrauterine systems
 progestogen-only subdermal implants
 progestogen-only injectable contraceptives
 Progesterone Vaginal Ring (PVR)

16.  Synthetic progesterone preps for long
acting contraception.
 Adminstered largely as depots, implants,
and as intra-uterine systems.
 Contraceptive efficacy relies on daily
slow release of progestogen
 Mechanisms of action are largely:
Centrally inhibiting ovulation
Thickening of vaginal and cervical
mucus
Thinning of endometrium

17.  Is a levonorgestrel-releasing intrauterine device
 Is T-shaped with reservoir on the vertical arm
 Releases progestin levonorgetsrel 20ug daily
 Has 2 monfilament string attached to the vertical arm.
 Life span is 5years

19.  Thickening of cervical mucus impeding sperm acsent.
 Alteration in uterotubal fluid that interferes with sperm
migration
 Anovulation in 10-15% of cycles.
 Thinning of endometrium to reduce likelihood of
implantation.
FR: 0.1-0.7 preg/100 WYr

20. Risks
 50% of pregnancy as a result of failure are ectopic preg.
 Irregular bleeding common in the initial 3-4 months of use.
 About 25% of users become amenorrhoeic after the 2nd year
of use
Benefits
 Improvement in dysmenorrhoea.
 Used for Rx of Menorrhagia
 Reduced incidence of PID.
 Reduces risk of endomitral carcinoma

22.  Progesterone diffuses at a continuous flow of 10mg per
day through the silicone
 Prolongs lactation amenorrhoea
 Used for Postpartum contraception
 After 6 weeks of delivery and for 3 months

23.  A vaginal ring is inserted at postnatal visit (6 weeks)
 Once inserted, the Ring is worn for 3 months
 At end of 3 months, it is removed and another
replaced
 For now, use is stopped when menstruation returns, or
for a maximum of 1 year
 Meant for breastfeeding women only

24. Types: Progestin-Only
 Depo Medroxy Progesterone Acetate (DMPA) 150 mg
 Microcrystalline suspension
 3 monthly
 Norethisterone Enanthate (Net-En) 200 mg
 In oil
 2 monthly

25.  Inhibition of ovulation by suppressing
gonadotropinns.
 Thickening of cervical mucus.
 Thinning of the endometrium.

26.  During 1 year of use, the perfect use failure rate is 0.3
pregnancies per 100 woman-years, whereas the failure
rate with typical use is 3 pregnancies per 100 woman-
years.

27.  The risk of ectopic pregnancy is significantly lower
among users compared to women who do not use
contraception.
 The risk of endometrial cancer is reduced by as much
as 80%, an effect that is long term and increases with
duration of use.
 Studies have shown as much as a 70% reduction in the
frequency of sickle cell crises; the mechanism for this
effect is not known.
 Some women with endometriosis have improvement
of symptoms with use of DMPA.

28.  Decrease in bone mineral density, hence, encourage
calcium intake.
 Irregular bleeding & prolonged menstrual flow
 Amenorrhoea in prolonged users
 Mood swing & Depression.
 ?Wt gain, about 5Ib(2.2kg) in 1 yr of use.
 Delayed return to fertility when discontinued, ≥10
months.

29.  Depo-subQ Provera (DMPA-SC)
 Contains 104 mg Depo-medroxy progesterone acetate
 In micro-crystalline suspension form
 Now Subcutaneous unlike Intramuscular in DMPA
 Also every 12 weeks
 Should not be used continuously for ˃2 years

30. Upper Thigh
Abdomen

31.  Initially Six Rods, Norplant (now discarded)
 Two rod Jadelle (levonorgestrel) – 5 years
 One rod Implanon (etonogestrel) – 3 years
 Bio-degradable (Capronor) that does not require
removal (2 years) – Developed by Research Triangle
Institute

32. [Levonorgestrel Implant]
 1st generation of implants
 Consists of 6 rods, each measuring 34mm in length &
2.4mm in diameter

33.  Each rod contains 36mg levonorgestrel.
 Approximately 80mcg of levonorgestrel is released
daily during the first 6-12 months after insertion.
 Rate of release gradually declines to 30-35ug/day.
 LH surge necessary for ovulation is suppressed in
approximately 50% of cycles

34.  Are mainly irregular bleeding pattern, which
normalises over long term use.
 Headaches
 Acne, Weight gain/loss, mastalgia, mood cahnge or
depression.
 Hyperpigmentation over site of implant
 Hirsuitism.
 Galactorrhoea.
 Symptomatic functional cyst occasionally occur.

35.  Insertion is by special troca, subdermally on the inner
surface of the left upper arm under local anaesthesia.

36. JADELLE [NORPLANT-2]
 Levonorgestrel preparation
 Contains 2 non-biodegradeable silicone elastomer
capsule.
 Each capsule is 43mm in length & 2.5mm in diameter.
 Each capsule contains 75mg Levonorgestrel.
 Insertion is effective for 5yrs.

38.  Implanon: Non biodegradable
 Single rod
 Contain 68mg of etonogestrel active metabolite of
desogestrel.
 The hormone is released at an initial rate of 60mcg per
day decreasing to 30mcg per day after 2years.
 Duration of action is 3years

39.  Nexplanon identical to Implanon except for containing
15mg Barium sulphate, added to the core to make it
detectable by x-ray.

40.  Rod is 4cm in length & 2mm in diameter.
 Shld be removed after 3yrs, or earlier if preg is
desired .
 When the rod is removed, the return to fertility is
rapid, with the return of ovulation within 3 weeks
 Apart form its effect on cervical mucus, it also
inhibits ovulation.

41.  Compared with the Norplant system, Implanon is
associated with a higher frequency of amenorrhea and
oligomenorrhea, a decrease in the prevalence of
frequent and prolonged bleeding, and a decrease in
the frequency of adverse effects such as weight gain,
headache, and acne.

43. Implanon insertion kit.

45.  Uniplant is a single implant contraceptive containing
38mg nomegestrel acetate in a 4cm silastic tube with a
100ug per day release rate
 It provide contraception for 1year.

46.  CAPRONOR, NORETHINDRONE PELLETS
 CAPRONOR: is a single capsule, levonogestrel
releasing subdermal implant
 2.4mm in diameter and 40mm in length
 It provide contraception for 1year.
 Capsule remain intact for the first 12 months allowing
for easy removal then begins to disappear after
12months

47.  NORETHINDRONE PELLETS or anuelle
 Is injected subdermally and maintain circulating
contraceptive level of progestin for up to 3years.
 This pellet is compose of 10% pure cholesterol and
90% norethindrone
 This method is currently under development.

48.  Expert clinical opinion is that LARC methods may
have a wider role in contraception and their increased
uptake could help to reduce unintended pregnancy
 Enabling women to make an informed choice about
LARC and addressing women's preferences is an
important objective.

49.  SH&FPA statement on LARCs: October 2013.
 Nice clinical guideline 30. 2014.
 Long acting reversible contraception (C-Gyn 34) New statement july 2014.
 Increasing access to long acting reversible contraceptives in nigeria:
National strategy and implementation plan (2013-2015)
 Open Access Journal of Contraception 2010:1 9–22
 Kigbu J H, Daniyan A B C. UPDATES ON CONTRACEPTION. Ibom
Medical Journal.2008;3: 4-12
 Current Concepts In Contraception. Text of Presentation at the MDCAN,
OOUTH Sagamu, CPD LECTURE SERIES. By Dr. Peter O. Adefuye.
 Current Diagnosis & Treatment Obstetrics & Gynecology, Eleventh
Edition.2013

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