MARCH Long-acting reversible contraception ADDRESSING KNOWLEDGE GAPS AND MISPERCEPTIONS SUPPORTED BY:

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1 PUBLISHED AS AN EDUCATIONAL SUPPLEMENT TO Long-acting reversible contraception ADDRESSING KNOWLEDGE GAPS AND MISPERCEPTIONS SUPPORTED BY:

2 2 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception FACULTY COURSE CHAIR Paula J. Adams Hillard, MD, is professor of obstetrics and gynecology at Stanford University School of Medicine, California, where she serves as associate chair for medical student education. She also directs the program in pediatric and adolescent gynecology at the Lucile Packard Children s Hospital at Stanford. Dr. Hillard has been active on a number of national medical committees, including chair of the American College of Obstetricians and Gynecologists (ACOG) committees on patient education, adolescent health, and guidelines for women s health. She is a past member of ACOG s gynecologic practice committee and the gynecology document review committee, and is currently a member of the ethics committee. She is the author of more than 140 peer-reviewed articles and abstracts, and more than 100 book chapters on women s health. PANELISTS Katharine O Connell White, MD, MPH, FACOG, is an assistant professor of obstetrics & gynecology at the Boston University School of Medicine in Boston, Massachusetts. Dr. White s primary research interests include contraceptive decision-making, rapid repeat pregnancies, immediate postpartum intrauterine device (IUD) placement, and pain reduction with IUD placement. Melanie Ariane Gold, DO, DMQ, is a professor in the Department of Pediatrics, Division of Child and Adolescent Health, Section of Adolescent Medicine, at Columbia University Medical Center, and a professor in the Department of Population & Family Health at the Mailman School of Public Health, New York. She is also the Medical Director of New York-Presbyterian Hospital s (NYPH) 7 school-based health centers (SBHCs). Dr. Gold is an osteopathic physician, a pediatrician, and an adolescent medicine subspecialist. She was the American Academy of Pediatrics Section on Adolescent Health (SOAH) liaison to the ACOG committee on pediatric and adolescent health care from 2005 to Stephanie Teal, MD, MPH, is a professor of obstetrics and gynecology, and pediatrics at the University of Colorado School of Medicine in Aurora, Colorado. She also serves as the medical consultant for the Colorado Department of Public Health Family Planning Program, and as Medical Director of the Adolescent Family Planning Clinic at Children s Hospital Colorado. Dr. Teal s medical interests include new innovations in contraception, adolescent reproductive health and gynecology, and contraception for women with chronic medical conditions. Her research is focused on ambivalence toward pregnancy and its effect on contraception use, and adolescents and long-acting birth control methods. Learning Objectives Discuss common misconceptions and myths about long-acting reversible contraception (LARCs), as well as strategies to combat them among patients Identify appropriate information sources to share with patients regarding the efficacy and safety of LARCs Analyze recommendations from the American College of Obstetricians and Gynecologists and American Academy of Pediatrics regarding LARCs Review common transient, as well as less common but more significant, side effects of LARCs Disclosures All faculty, planning committee members, editors, managers, and other individuals who are in a position to control content are required to disclose any relevant relationships with any commercial interests related to this activity. The existence of these interests or relationships is not viewed as implying bias or decreasing the value of this publication. Disclosures are as follows: Paula J. Adams Hillard, MD, has affiliations with Merck (trainer), BioWink (consultant), and Sanofi (consultant). Katharine O Connell White, MD, MPH, FACOG, has affiliations with Bayer (consultant). Melanie Ariane Gold, DO, DMQ, has affiliations with Bayer (advisory board) and Afaxys, Inc. (advisory board) Stephanie Teal, MD, MPH, has affiliations with Actavis (advisory board), Bayer (advisory board), and Merck (consultant). Scott Kober, MBA (medical writer), has disclosed that he has no relevant financial relationships specific to the subject matter within the last 12 months. Commercial Support This educational supplement was developed by Contemporary OB/GYN with support from Bayer. A supplement supported by Bayer Healthcare. Copyright 2017 and published by UBM Inc. No portion of this program may be reproduced or transmitted in any form, by any means, without the prior written permission of UBM Inc. The views and opinions expressed in this material do not necessarily reflect the views and opinions of Bayer Healthcare, UBM Inc., or Contemporary OB/GYN. Published as an Educational Supplement to Contemporary Ob/Gyn

3 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception 3 Long-acting reversible contraception ADDRESSING KNOWLEDGE GAPS AND MISPERCEPTIONS Introduction Readers of Contemporary OB/GYN are undoubtedly aware of the important role that long-acting reversible contraception (LARC) methods play in our contraceptive toolbox. We have seen our patients enjoy their benefits in terms of efficacy that is comparable to sterilization as well as ease of use, particularly compared to options with daily or weekly requirements. In the United States, we are seeing significant reductions in the rate of adolescent pregnancy, due in part to increasing use of LARC methods. Nonetheless, many patients and providers remain somewhat skeptical of their use, and may not understand or appreciate the truth about these methods. In this supplement, 3 of my esteemed colleagues all well-known clinicians, teachers, researchers, and patient advocates address some of the myths and misconceptions about LARC methods. They provide helpful tips and strategies for communicating with our patients. Although many, if not most, of our patients get their information about contraception online, the sources of information can be of variable quality. Asking patients to consider, for example, who might post a video, tweet, or blog online about a LARC method may help a teen to realize that a happy, satisfied LARC user who is moving on with her life is much less likely to post about her choice than someone who is upset, angry, or irritable. I recommend a careful read of this supplement as you work to engage your patients in a constructive dialogue and help them find appropriate and effective options for preventing unintended pregnancies. Paula J. Adams Hillard, MD photo: Image Point Fr/shutterstock.com The Initial Conversation about LARCs Contemporary OB/GYN: When patients come to you expressing interest in potential placement of a LARC, what are the important initial pieces of information to discuss with them? Dr. Teal: Once I determine that a patient is not actively planning a pregnancy, I ask, So what are you looking for in birth control? With that kind of open-ended question, you can get so much information about what s worked for the patient in the past, what are potential deal breakers, and misconceptions the patient has about birth control. While it can sometimes be scary for doctors to ask open-ended questions because we fear the patient who won t stop talking, in fact, the reality is that doctors are more likely to talk too much. Contemporary OB/GYN: What are some common clinician reservations about the use of LARCs, particularly in adolescents and nulliparous women, and what does the evidence say about their use? Dr. White: One concern that s been around for many years is the fear related to the risk of pelvic infl ammatory disease (PID). There are many clinicians in practice who have direct memory of, or have read about, some of the issues with older intrauterine devices (IUDs), and they still associate IUDs with those complications. Happily, the current evidence is clear that the greatest risk of PID with IUD use is in the 3 weeks following insertion. After that period, the risk disappears. IUD strings are not an escalator for bacteria to the upper genital tract. 1 There are also some reservations around future fertility, particularly in adolescents and nulliparous women, although there is good evidence that IUDs do not harm fertility. 2,3 Published as an Educational Supplement to Contemporary Ob/Gyn

4 4 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception Some providers feel their patients simply aren t interested in LARCs, which decreases their enthusiasm about supplying them. This is the ultimate Catch-22, since we know that women are more likely to consider a LARC if they have heard about it from their provider. 4,5 Another common issue involves providers worrying about the cost-effectiveness of the LARC if it is removed early or before its expiration. In reality, though, if a LARC device is used for a year or more, it is cost effective. 6 A woman doesn t have to commit to 3 or 5 or 10 years of use for the financial benefit to become apparent. Dr. Teal: There are many clinicians who still have the concern that, I won t be able to get the IUD in. It will cause the patient a lot of pain that she won t be able to tolerate, so we ll need to abort the procedure, and she ll never want to consider an IUD ever again. This is especially a concern with adolescent and nulliparous women. The data, though, do not support that belief. We published a paper in 2015 that looked at nearly 1200 women between the ages of 13 and 24 years who d had at least 1 attempt at IUD placement at our facility. 7 We found that the rate of successful placement was approximately 96% both for parous and nulliparous women. The majority of the placements (86%) were performed by advanced practice clinicians, without using dilation, paracervical blocks, or other ancillary measures. Contemporary OB/GYN: How do you specifi cally counsel adolescents about the potential use of LARCs? What sorts of communication strategies do you use? Dr. Gold: I use a lot of motivational interviewing with my adolescent patients, incorporating open-ended questions, reflections, affirmations, and summary statements to assess patient history and determine what they do and don t know about LARCs. I let them do most of the talking. With permission, I fi ll in wherever there are gaps or inaccuracies. Once we cover the initial bases, I always bring the conversation back to their goals, values, and beliefs, and how any birth control method would fi t into their lives. One thing I find to be extremely useful is the teach back technique, where I ask patients to teach back to me what they heard me tell them. You need to make sure that patients are both listening to and understanding what you are telling them, and hearing them express your thoughts in their own words can be a great way to clear up any lingering misinterpretations. I ll usually say to a patient, If I was your girlfriend or sister or someone else close to you that you were going to tell about LARCs, what would you tell me? If they tell me, I don t know what I d say I try to prompt them along: What is it? How long does it last? What are the side effects? How well does it work? How does it work? Kids today are very savvy. They ve read a lot, they ve learned a lot. Often, by the time they get to me, they ve been counseled by a health educator or another clinician. I m there to make sure the information they have is accurate before I provide them with their chosen method. Dr. White: It s important to start the discussion with openended questions that get into the patient s values around contraception, their relationship status and frequency of sexual activity, and their life goals after high school or college. This strategy allows me to help my patients identify any inconsistencies between their goals and their current behavior. For example, I may point out that their avoidance of using contraception when they re sexually active is going to pose a dilemma for them if they get pregnant. I think it s also important to avoid direct confrontation with a patient who is resistant to what you are talking about. While it s vital to provide patients with accurate information and to dispel myths about LARCs, it isn t helpful to try to talk any patient into something they may not want or be ready for. Contemporary OB/GYN: What do you tell your patients about potential menstrual changes after insertion of a LARC? Dr. Gold: What I usually do is to sit down with my patients and say, Let s discuss your period. Let s talk about how each LARC method may change your period, and let s talk about how you could tolerate that. Then we talk about how all LARCs at least the hormonal ones might stop periods or cause irregular bleeding. With the copper IUD, patients might have more cramps, as well as heavier or more prolonged bleeding. The truth is that I have patients with dysmenorrhea and menorrhagia, and they do great on the copper IUD. And then I have patients who had no prior abnormalities to their menses, and they hated it. I feel like I look at the literature, and that tells me one thing, but when I talk to patients, their individual experience is, well, individual. Consequently, I don t use dysmenorrhea or menorrhagia or even anemia as an absolute contraindication to the copper IUD. It s an individual discussion with each patient. Contemporary OB/GYN: Do you find that patients know about LARCs before seeing you, and if so, what sort of information or misinformation do they come with? What is their typical source of information? Dr. Teal: There was a major grant-funded program in Colorado called the Colorado Family Planning Initiative that was administered by the state s Department of Public Health. Through this initiative, free or very low-cost contraception was offered to women who wanted it, and it was a huge success in helping to familiarize the public about birth control options. 8 As more women chose LARCs, they told their friends and family, and we found that word of mouth ultimately became the main source of information. We fi nd that approximately 75% to 80% of our patients are familiar with LARCs before they come to see us. That s not all due to the statewide initiative, but it certainly helped. Dr. Gold: In my setting, many of my patients are adolescents who have been referred to me, though there are some for whom I am the first provider they are talking to about LARCs. I spend a lot of time with new patients talking about the source of their information about LARCs: What did you think about that YouTube video you watched? How reliable do you think that is? High schools today talk a lot about the reliability and unreliability of what people learn online, which is great because there is obviously a ton of misinformation. Published as an Educational Supplement to Contemporary Ob/Gyn

5 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception 5 My favorite quote is, Who do you think posts those YouTube videos and blogs and tweets? Are they from happy people who are doing well, enjoying their lives, and moving on with their lives after LARCs? Probably not. It s kind of a bias a bias from people who are upset, angry, irritable, sad, and depressed. Those are the people who are putting their stories online. Most of my patients feel like everything they see online about LARCs is bad. We spend a lot of time debriefing about the source of the information: Who was that person? How reliable is that information? Younger patients aren t reading studies or medical information. It s too dense. They re drawn to those sensationalist, personal stories, as we all are. of LARCs? Do you commonly share components of those recommendations with your patients? Dr. White: ACOG and AAP both updated their policies around LARCs in the last several years. 4,9 ACOG encourages more access to LARC devices for women of all ages, including adolescents, and supports members in encouraging their patients to consider implants and IUDs, to educate patients on LARC options, and to advocate for insurance coverage and appropriate payment reimbursement for every type of contraceptive method (Table 2). 4 The AAP notes that given their efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. 9 Contemporary OB/GYN: How do you steer patients toward appropriate sources of information? Dr. White: I like to lead with the line that, Dr. Google is not board certified, and that information on the Internet really ranges from material that is very complete and accurate to information that is just trying to scare you or give you the wrong sense of LARCs. I tell my patients that looking at blogs or Facebook or Instagram is just like looking at product reviews on Amazon. Most often, the comments are coming from people who are incredibly happy or completely miserable with their LARC. Relying solely on social media, you get a very skewed perspective of what it s like to have a LARC. I will also tell patients that, You are not your friend and you are not your sister, and their experience does not predict your own. Just like taste in food or music or boyfriends, methods are going to work differently for different people, and that while you want to gather a lot of information from everyone in your universe, you eventually need to pick a method and see how it works for you. Another thing I tell my patients is that, You date your birth control. You don t marry it. You are committed to it the day you get it, but you can always change a method if it s not working for you. A list of my favorite online resources is included in Table 1. LARC Practice Guidelines Contemporary OB/GYN: What do the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) say about the appropriate use Dr. Teal: It s really important to emphasize that LARCs are considered as fi rst-line options by ACOG and AAP. Traditionally, first-line contraceptives were condoms and pills, and it was almost like those were considered gateway drugs that you would use before you hit the hard stuff like LARCs. Now, we can emphasize that you don t have to fail at another method first before you get offered a LARC. When you think about what failing at a contraceptive method really means, that has lifelong consequences for our patients. We really do not want to set young people up to fail. We want to set them up to succeed in meeting their goal. If their goal is to delay childbearing until they re out of college, the data tell us that using condoms or birth control pills alone is going to cause more failures than LARCs as a first-line option (Figure 1). 10 Dr. Gold: Teenagers don t care much about what AAP or ACOG thinks, but it s critical for medical providers who may otherwise be skeptical. It s also important for parents. I have been challenged by many angry parents who tell me, Why did you give my daughter this IUD? I didn t give permission for that. How dare you do this to my daughter? Of course, I first talk to them about the law, but I also talk about how an IUD is not only a personal recommendation of mine for some of my adolescent patients but that it is also recommended by ACOG and AAP for adolescent women as a first-line option. 4,9 Some parents will then sit back and say, Hmm, I m still angry you did this to my daughter without my permission, but the professional recommendation adds a level of validity, and that s important. The legitimacy for parents is critical. Table 1 Online resources about benefits and risks of LARCs WEB URL DESCRIPTION Online birth control support network for women age years operated by The National Campaign to Prevent Teen and Unplanned Pregnancy CDC website on contraception Planned Parenthood s guide on birth control Q&A site run out of Columbia University that includes information about sex and contraception Sex education site geared specifically toward adolescents published by Answer, an organization based at Rutgers University Abbreviations: CDC, Centers for Disease Control and Prevention; LARCs, long-acting reversible contraception. Published as an Educational Supplement to Contemporary Ob/Gyn

6 CS Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception Contemporary OB/GYN: Are patients with specific medical problems candidates for LARCs? If so, how do you counsel them on their use? Dr. White: There are several categories of women who are excellent candidates for LARCs. The first is women who have heavy menstrual bleeding, particularly bleeding that s not due to large fibroids. There is strong evidence of the positive effects of hormonal IUDs on decreasing menstrual blood flow. 11 Hormonal IUDs have also been shown to help patients who are suffering from heavy menstrual bleeding avoid hysterectomy or other invasive procedures. 12 For patients with severe dysmenorrhea or severe menstrual cramps, there is good evidence that hormonal LARC devices can reduce cyclic and pelvic pain. 13 Hormonal IUDs are also effective for women with chronic pelvic pain due to endometriosis or adenomyosis. 14 There are many women who have a medical problem for which estrogen is contraindicated, such as hypertension, heart disease, longstanding or complicated diabetes mellitus, migraine headaches with aura, women who are on particular seizure medications, and especially women who are newly postpartum. All of these women are excellent candidates for LARC devices. I have also found that LARC devices are excellent for women older than age 35 who are regular smokers. Contemporary OB/GYN: How do you make the determination regarding the type of LARC that will be best for an individual patient? Table 2 Best practices for LARC insertion Provide long-acting reversible contraception (LARC) methods the same day as requested, whenever possible, if pregnancy can reasonably be excluded. Offer LARC methods at the time of delivery, abortion, or dilation and curettage for miscarriage. Screen for sexually transmitted infections at the time of intrauterine device (IUD) insertion; if the screening test result is positive, treat the infection without removal of the IUD. Offer the copper IUD as the most effective method of emergency contraception. Source: Ref 4 Figure 1 Effectiveness of family planning methods MOST EFFECTIVE Less than 1 pregnancy per 100 women in a year 6-12 pregnancies per 100 women in a year 18 or more pregnancies per 100 women in a year LEAST EFFECTIVE REVERSIBLE REVERSIBLE REVERSIBLE EFFECTIVENESS OF FAMILY PLANNING METHODS * *The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method. Once in place, little or nothing to do or remember. Implant Injectable 0.05% Get repeat injections on time. Male Condom 6% 18% Condoms should always be used to reduce the risk of sexually transmitted infections. Intrauterine Device (IUD) Take a pill each day. Pill SUN MON TUES WED THUR FRI SAT Female Condom 0.2% LNG 0.8% Copper T 9% 21% PERMANENT STERILIZATION After procedure, little or nothing to do or remember. Use another method for first 3 months (Hysteroscopic, Vasectomy). Female Male (Vasectomy) (Abdominal, Laparoscopic, and Hysteroscopic) Keep in place, change on time. Patch Ring 9% Use correctly every time you have sex. Withdrawal 22% Fertility Awareness-Based Methods JANUARY Abstain or use condoms on % fertile days % 9% 0.15% Use correctly every time you have sex. Diaphragm 12% Sponge 12% Nulliparous Women 24% Parous Women Spermicide Spermicide Other Methods of Contraception: (1) Lactational Amenorrhea Method (LAM): is a highly effective, temporary method of contraception; and (2) Emergency Contraception: emergency contraceptive pills or a copper IUD after unprotected intercourse substantially reduces risk of pregnancy. Adapted from World Health Organization (WHO) Department of Reproductive Health and Research, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Knowledge for health project. Family planning: a global handbook for providers (2011 update). Baltimore, MD; Geneva, Switzerland: CCP and WHO; 2011; and Trussell J. Contraceptive failure in the United States. Contraception 2011;83: % Source: Ref 10 Published as an Educational Supplement to Contemporary Ob/Gyn

7 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception 7 Dr. Teal: Ultimately, I m just trying to get relevant, factual information in front of the patient so she can decide on something she feels confident about. I ll go through almost an algorithm. I ll begin by telling the patient that there are 3 effective methods that are all easily reversible and then I ll ask, What are you looking for in terms of your bleeding pattern? If they say, It s really important to me to have a period every month, I ll say, OK, the one long-acting, effective method we have in which your period will still come with whatever frequency is normal for you would be the copper IUD. The other 2 LARC methods are going to change the frequency of your bleeding, and you may not bleed at all. But if they say, I want my periods to be lighter and maybe go away and not have much bleeding, then I look at whether they would benefit from ovulating or not ovulating. For example, if they get horrible menstrual headaches every month, then maybe they would do better with the etonogestrel implant where they stop ovulating. If they have a seizure disorder where they are more likely to have seizures in the week before their period, same thing. If they say, You know what I hate about being on the pill? I just feel like my hormones have flattened out, and my libido is really low. When I have my period, I feel more alive. In that case, maybe that patient would do better with a levonorgestrel IUD. If someone feels strongly about hormone exposure and they say, I want the lowest hormone dose possible, but I really don t like the sound of possibly having heavier crampier periods with the copper IUD, then I would again lean toward a levonorgestrel IUD. There are also some patients with a personal or cultural preference of not having something in their uterus or, on the fl ip side, not wanting to see or feel the implant rod under their skin. Dispelling Misconceptions/ Myths Around LARCs Contemporary OB/GYN: What kinds of common misconceptions and myths do your patients have about LARCs? How do you specifically address each of these? Dr. White: Here are several myths about LARCs and some insight into how I address each one: Myth: My partner will be able to feel the IUD during sex. The IUD resides where the baby is when you re pregnant, so if your partner would not be able to feel the fetus, he cannot feel the IUD. If you are worried that you or your partner will feel the IUD strings, we can manage them to keep them out of the way for both of you. Myth: The IUD will get lost. You can check the positioning of the string immediately after IUD placement, but after that time, the only place the string might go is out, meaning expulsion through the cervix and out of your body. It is not going to travel and take a vacation somewhere else in your pelvis or abdomen. Myth: I am more likely to get an infection. IUD strings are not magnets for STIs [sexually transmitted infections], but if your partner has an STI, you re likely to get it with or without an IUD if you are not using condoms. IUDs have no effect on your vagina because they are placed high up in the uterus, so there is no increased risk of vaginosis or yeast infections. Myth: I won t be able to get pregnant after the IUD comes out. If your fertility status is normal before the IUD, it will be normal after the IUD. Myth: I can still get pregnant even with the IUD. No method of birth control is perfect. Even sterilization has a failure rate. But IUDs have very low failure rates, so even if you hear or read about 1 or 2 stories of IUD failure, that does not mean that it won t work for you. Myth: It s too long of a time commitment. An IUD only has to stay in until you want to get pregnant. Don t think of it as a 3- or 5- or 10-year commitment, but as a I won t get pregnant till I m ready to try commitment. Dr. Teal: One myth I would add is, I will gain a lot of weight. There is a lot of concern that hormone use equals weight gain. I tell patients that in adolescence, you are gaining weight just because you are still growing and getting your adult size and form. So yes, it is likely that you will gain a little weight over the course of 3 or 5 years, but that is due to natural growth and not to the hormone released by your IUD. Contemporary OB/GYN: What are some common misperceptions that physicians and providers have about LARCs that actually get passed on to patients? Dr. Teal: There are some providers who believe that there is an age restriction to LARCs. I had one patient who had a baby at 15 and was told after giving birth she couldn t get an IUD because she was too young. She went on to have another baby at 17, but was told again that she was too young for an IUD even though she already had 2 children. Her provider seemed to have it stuck in her mind that 18 was the absolute age cutoff for a LARC. There are also some physicians and providers who tell patients that the IUD insertion is going to be very painful. While that may sometimes be true, most of the time, it is not a painful process. I have also spoken to patients who have been told by their provider that they need to have their LARC in for at least 6 months before they would even consider its removal. That is counterproductive. To threaten a patient like that can be destructive to the doctor patient relationship and often discourages patients from considering use of a LARC. Acknowledging LARC-Related Adverse Events Contemporary OB/GYN: Are there issues or errors related to LARC insertion that you commonly see being made by clinicians who are in training or new to the procedure? Dr. White: One of the most difficult parts of placing IUDs is getting through the internal os of the cervix, especially in women who are nulliparous or adolescent. The packaging instructions for all of the currently available IUDs call for use of a tenaculum Published as an Educational Supplement to Contemporary Ob/Gyn

8 8 Addressing Knowledge Gaps and Misperceptions of Long-Acting Reversible Contraception on the cervix. Providers who routinely perform endometrial biopsies without a tenaculum may not always want to use one during IUD insertion, knowing that it causes more pain. But a tenaculum definitely makes IUD insertion easier and safer. Perforations are more common when IUDs are inserted by clinicians who have not placed a lot of IUDs, and so some of the tips to reduce the risk of perforation are as follows: Perform a good pelvic exam beforehand to ensure that you are aware of which direction the uterus is pointing in Be sure of your sound placement before you place the IUD Follow the directions precisely for insertion for the particular IUD. Each device has a slightly different insertion method, and it can be helpful to refresh your memory with the pictures of the insertion process for each IUD before you put it in. The last difficulty I see often with new providers is placing the etonogestrel implant too deeply in the arm. Doctors should not rely on just the design of the implant inserter to save them from an insertion that is too deep. It s still important to be aware that you are only going to the dermal layer and placing the implant in a very shallow fashion where it is very easily palpable after insertion. Contemporary OB/GYN: What are some of the common but perhaps transient effects of LARCs that you typically warn your patients to be mindful of? Dr. Gold: It depends on the method. With the etonogestrel implant, for example, the skin at the insertion site may bruise and turn purple, then green, and then yellow. It may also feel tender for a week, so we make sure to discuss that in advance. With the IUDs, pelvic discomfort is always on the list of conversation topics. I will tell my patients that I don t know what it s going to feel like when we insert your IUD. I ve had patients who get their IUD and it doesn t hurt one bit when we put it in, but then it s really uncomfortable while they re lying on a table. For others, it s uncomfortable putting it in, but then immediately afterward, it s fine. Other patients are crampy for days or weeks. We just can t know, but I emphasize to every patient that if they are ever unsure if something is wrong, let us know. There is another transient effect I have seen a few times with the copper IUD, change in discharge odor. My patients tell me that it smells metallic. I have had enough patients mention it to me that I include it in my upfront conversation with patients. It s not an infection, just a different smell. Contemporary OB/GYN: What are some of the less common but more serious potential side effects of LARCs? Dr. White: With IUDs, there are 3. The fi rst is perforation related to the insertion that typically requires surgery to remove it from the abdomen. The second is an embedded IUD, which can be difficult to remove even if the strings are present but rarely requires an overnight hospital stay following surgery to remove the device. The last, which is very uncommon, is anemia from blood loss with the copper IUD. When it comes to the implant, infections at the insertion site are rare, but can require antibiotics. The most serious complication is migration of the implant up the arm into the chest or the abdomen. This is a very rare complication, but it is not unheard of. If the implant is placed too deeply, it may require referral to a specialized center for removal. With both the IUD and the implant, there is a higher risk of an ectopic pregnancy should a pregnancy occur. 15,16 REFERENCES 1. Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol. 2012;120(6): Stoddard AM, Xu H, Madden T, et al. Fertility after intrauterine device removal: a pilot study. Eur J Contracept Reprod Health Care. 2015;20(3): Mansour D, Gemzell-Danielsson K, Inki P, Jensen JT. Fertility after discontinuation of contraception: a comprehensive review of the literature. Contraception. 2011;84(5): Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015;126(4):e44 e Fleming KL, Sokoloff A, Raine TR. Attitudes and beliefs about the intrauterine device among teenagers and young women. Contraception. 2010;82(2): Foster DG, Biggs MA, Malvin J, et al. Cost-savings from the provision of specific contraceptive methods in Womens Health Issues. 2013;23(4):e265 e Teal SB, Romer SE, Goldthwaite LM, et al. Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications. 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