Long-acting reversible contraception

This guideline covers long-acting reversible contraception. It aims to increase the use of long-action reversible contraception by improving the information given to women about their contraceptive choices.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
This guideline offers the best-practice advice on the provision of information and care for women who are considering or using LARC. Treatment and care should take into account women's individual needs and preferences.

# Contraception and principles of care

## Contraceptive provision
Women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods.
Women should be provided with the method of contraception that is most acceptable to them, provided it is not contraindicated.

## Provision of information and informed choice
Women considering LARC methods should receive detailed information  both verbal and written  that will enable them to choose a method and use it effectively. This information should take into consideration their individual needs and should include:
contraceptive efficacy
duration of use
risks and possible side effects
non-contraceptive benefits
the procedure for initiation and removal/discontinuation
when to seek help while using the method. See the implementation resource for this guideline, which provides links to up to date, relevant and valid information about LARC methods.
Counselling about contraception should be sensitive to cultural differences and religious beliefs.
Healthcare professionals should have access to trained interpreters for women who are not English speaking, and to advocates for women with sensory impairments or learning disabilities.

## Contraceptive prescribing
A medical history  including relevant family, menstrual, contraceptive and sexual history  should be taken as part of the routine assessment of medical eligibility for individual contraceptive methods.
Healthcare professionals helping women to make contraceptive choices should be familiar with nationally agreed guidance on medical eligibility and recommendations for contraceptive use.
When considering choice of LARC methods for specific groups of women and women with medical conditions, healthcare professionals should be aware of and discuss with each woman any issues that might affect her choice (see the implementation resource for this guideline, which provides links to up to date, relevant and valid information about LARC methods).
Healthcare professionals should exclude pregnancy by taking menstrual and sexual history before initiating any contraceptive methods.
Healthcare professionals should supply an interim method of contraception at first appointment if required.
Healthcare professionals should ensure that informed consent is obtained from the woman whenever any method of LARC is being used outside the terms of the UK Marketing Authorisation. This should be discussed and documented in the notes.
Women who have a current venous thromboembolism (VTE) and need hormonal contraception while having treatment for the VTE should be referred to a specialist in contraceptive care.

## Contraception and sexually transmitted infection
Healthcare professionals providing contraceptive advice should promote safer sex.
Healthcare professionals providing contraceptive advice should be able to assess risk for sexually transmitted infections (STIs) and advise testing when appropriate.
Healthcare professionals should be able to provide information about local services for STI screening, investigation and treatment.

## Contraception for special groups
Healthcare professionals should be aware of the law relating to the provision of advice and contraception for young people and for people with learning disabilities. Child protection issues and the Fraser guidelines should be considered when providing contraception for women younger than 16 years. (See the Department of Health's best practice guidance for doctors and other healthcare professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health).
Women with learning and/or physical disabilities should be supported in making their own decisions about contraception.
Contraception should be seen in terms of the needs of the individual rather than in terms of relieving the anxieties of carers or relatives.
When a woman with a learning disability is unable to understand and take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman's contraceptive need and to establish a care plan.

## Training of healthcare professionals in contraceptive care
Healthcare professionals advising women about contraceptive choices should be competent to:
help women to consider and compare the risks and benefits of all methods relevant to their individual needs
manage common side effects and problems.
Contraceptive service providers who do not provide LARC in their practice or service should have an agreed mechanism in place for referring women for LARC.
Healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide these methods.
IUDs and the IUS should only be fitted by trained personnel with continuing experience of inserting at least one IUD or one IUS a month.
Contraceptive implants should be inserted and removed only by healthcare professionals trained in the procedure.# Recommendations for research
The scarcity of robust evidence to answer important clinical questions on the use of LARC methods by women in the UK posed great challenges to the developers of the original guideline (October, 2005). In the majority of cases, the guideline recommendations were based on extrapolated evidence that is indirect or of poor methodological quality. In 2005, the Guideline Development Group made the following recommendations for research on the basis of its review of the evidence.
In making these recommendations for research, the guideline developers consider it important and relevant that the research should be specific to the UK population because there are cultural differences in the response to side effects and noncontraceptive effects of hormonal contraceptives. In addition, freedom to choose any contraceptive method and the provision of a free contraceptive health service in the UK can influence important outcomes such as continuation rates and patterns of method switching.

# Typical use of contraception
Few women use contraception perfectly (that is, exactly in accordance with the product instructions) and consistently. Pregnancy rates during typical use reflect effectiveness of a method among women who use the method incorrectly or inconsistently. Few data are available on typical use of any contraceptive method among women in the UK. Much of the data on contraceptive effectiveness used in the guideline come from clinical trials or surveys undertaken in other countries such as the USA. Large prospective cohort studies are needed to compare the contraceptive effectiveness of LARC methods with nonLARC methods during typical use in the UK.

# Patterns of LARC use
Most women will need to use contraception for more than 30 years. Patterns of contraceptive use vary with age, ethnicity, marital status, fertility intention, education and lifestyle. Large prospective cohort studies are needed to identify:
patterns of use (initiation, continuation and switching between methods) of LARC methods compared with nonLARC methods
factors that influence the patterns of use of LARC.

# Uptake and acceptance of LARC
In addition to individual circumstances and needs, a woman's choice and acceptance of LARC may be influenced by potential health disbenefits (side effects and risks) as well as noncontraceptive benefits of LARC (such as alleviation of menorrhagia). Large population studies of appropriate design are needed to determine the effect of these factors on the uptake of LARC methods and the implications for NHS resources.

# Bone mineral density in women using DMPA
The effect of injectable contraceptives on bone mineral density in women who have used DMPA for longer than 2 years is uncertain. Adequately powered surveys or crosssectional studies are needed to examine the recovery of bone mineral density after discontinuation of DMPA after longterm and very longterm use. Studies are also needed to examine the risk of bone fractures in older women.# Context
It is estimated that about 30% of pregnancies are unplanned. The effectiveness of the barrier method and oral contraceptive pills depends on their correct and consistent use. By contrast, the effectiveness of long-acting reversible contraceptive (LARC) methods does not depend on daily concordance. The uptake of LARC is low in Great Britain, at around 12% of women aged 16 to 49 in 2008 to 2009, compared with 25% for the oral contraceptive pill and 25% for male condoms.
Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy. The current limited use of LARC suggests that healthcare professionals need better guidance and training so that they can help women make an informed choice. Health providers and commissioners also need a clear understanding of the relative cost effectiveness of LARC compared with other methods of fertility control. Enabling women to make an informed choice about LARC and addressing women's preferences is an important objective of this guideline.
LARC is defined in this guideline 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
progestogen-only subdermal implants
The guideline offers the best-practice advice for all women of reproductive age who may wish to regulate their fertility by using LARC methods. It covers specific issues for the use of these methods during the menarche and before the menopause, and by particular groups, including women who have HIV, learning disabilities or physical disabilities, or are younger than 16 years.
Drug recommendations
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.