New guidance should ensure women are able to make an informed choice about contraception, say Dr Chris Wilkinson (left), Irene Kwan and Dr Martin Dougherty


   

A new guideline from NICE on long-acting reversible contraception (LARC),published in October 2005, promotes greater contraceptive choice for women. It demonstrates that LARC methods are a cost-effective alternative to conventional contraception and can reduce unintended pregnancies.1

LARC is defined as contraceptive methods that require administration less than once per cycle or month. The LARC methods described in this guideline are:

  • Non-hormonal methods
    • Copper intrauterine devices (IUDs)
  • Progestogen-only methods
    • Intrauterine system (IUS)
    • Injectables (POIs)
    • Subdermal implants (SDIs).

It has been estimated that as many as 30% of pregnancies are unintended.2 In England and Wales the abortion rate for the 3 months January-March 2004 was 18.6 per 1000 women of reproductive age. The abortion rates were 33.6 per 1000 for women in the 20-24 years age group, 28.1 per 1000 for women in the 16-19 years age group and 3.9 per 1000 in women under 16 years of age.3

Contraceptive use

The effectiveness of some contraceptive methods, including condoms and combined oral contraceptive pills (COCs), depends on their correct and consistent use. By contrast, the effectiveness of LARC methods is independent of daily concordance.

The uptake of LARC is low in Britain, at around 8% of women aged 16-49 years in 2003-2004, compared with 25% for the COC and 23% for condoms. 4 Access to and knowledge of LARC varied.5 The high initial costs and, up until now, lack of costeffectiveness data for LARC may play a part in its limited availability in England and Wales.

Clinical evidence and expert opinion are that LARC may have a wider role and an increase in its use could help reduce unintended pregnancies.

There may be several reasons for the current low uptake of LARC:

  • Lack of awareness of the positive risk:benefit ratio for LARC among healthcare providers and women needing contraception
  • Pressure from consumer preferences
  • Lack of awareness of the relative cost-effectiveness of LARC compared with other contraceptive methods.

There are no current NHS guidelines covering this topic that are widely used or tailored to UK practice.

The LARC guideline, commissioned by NICE, intends to complement other existing and proposed guidance, including A strategic framework for sexual health in Wales,6 and the National strategy for sexual health and HIV.7

Box 1 The key recommendations

Contraceptive provision

  • Women requiring contraception should be given information about and offered a choice of all methods, including long-acting reversible contraception (LARC) methods [D(GPP)]
  • Contraceptive service providers should be aware that:
  • All currently available LARC methods (IUDs, IUS, injectable contraceptives and implants) are more cost effective than the combined oral contraceptive even at 1 year of use [C]
  • IUDs, the IUS and implants are more cost effective than the injectable contraceptives [C]
  • Increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies [C]

Counselling and provision of information

  • 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 the user's individual needs and should include:
  • Contraceptive efficacy [D(GPP)]
  • Duration of use [D(GPP)]
  • Risks and possible side-effects [D(GPP)]
  • Non-contraceptive benefits [D(GPP)]
  • Procedure for initiation and removal/discontinuation [D(GPP)]
  • When to seek help while using the method [D(GPP)]

Training and care pathways

  • 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 [D(GPP)]
  • Manage common side-effects and problems [D(GPP)]
  • Contraceptive service providers who do not provide LARC within their own practice or service should have an agreed mechanism in place for referring women for LARC [D(GPP)]
  • Healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide these methods [D(GPP)]

Improving access to all methods of contraception, including LARC, is an integral part of broader sexual health services.

Development of the LARC guideline

The guideline was developed by an independent advisory group, the guideline development group (GDG).

It comprised three specialists in sexual and reproductive healthcare (including contraception), one genitourinary medicine physician, two general practitioners, two family planning nurses (one working in primary care) and two consumer representatives. The GDG was supported by a technical team from the National Collaborating Centre for Women’s and Children’s Health.

The guideline development process included a rigorous systematic approach to searching the literature, appraising the clinical evidence, synthesising evidence statements and then forming recommendations.8-14

Figure 1, below, shows the classification scheme for recommendations.

Figure 1: Classification of recommendations

The evidence

The lack of robust evidence to answer clinical questions about LARC methods posed the greatest challenge to the guideline developers.The true efficacy of LARC cannot be established with randomised controlled trials because of ethical concerns about withholding contraception.15,16

The majority of evidence in the guideline is based on populations outside the UK, which have different healthcare systems and side-effect profiles.

The key recommendations

The key recommendations reflect the importance and relevance of choice, safety and cost-effectiveness (Box 1, above).

While the key recommendations are central to the guidance, there are 145 recommendations in total covering wider clinical and training issues, such as which IUD to use first line. (The most effective IUDs contain at least 380 mm2 of copper and have banded copper on the arms. This, along with the licensed duration of use, should be taken into account when deciding which IUD to use.)

Healthcare professionals should offer women a choice of all methods and must address each woman’s individual needs.Women considering using LARC should be provided with detailed information on topics such as contraceptive efficacy, risks and side-effects, duration of use and noncontraceptive benefits.

Those who advise or provide intrauterine or subdermal contraceptives should receive training to maintain the relevant skills to provide these methods and manage common problems.

Features of LARC methods to discuss with women

Information about the use of different LARC methods should be provided to women requesting LARC and they are summarised in a table in the guideline’s quick reference guide.

It is important to inform women about the differences between copper IUDs, the IUS, progestogen-only injections and implants as this will enable them to make an educated decision about contraception.

The medical eligibility of the women should be assessed to identify any contraindications and these are summarised in Box 2, below.

Box 2 Choice of method for different groups of women

All LARC methods are suitable for:

  • Nulliparous women
  • Women who are breastfeeding
  • Women who have had an abortion — at time of abortion or later
  • Women with BMI > 30
  • Women with HIV — encourage safer sex
  • Women with diabetes
  • Women with migraine with or without aura — all progestogen-only methods may be used
  • Women with contraindication to oestrogen

Choices for adolescents:

  • IUD, IUS, implants: no specific restrictions to use
  • DMPA: care needed; only use if other methods unacceptable or not suitablea

Choices for women more than 40 years old:

  • IUD, IUS, implants: no specific restrictions to use
  • DMPA: care needed, but generally benefits outweigh risksa

Choices for women post-partum, including breastfeeding:

  • IUD, IUS: can be inserted from 4 weeks after childbirth
  • DMPA, implants: any time after childbirth

Choices for women taking other medication:

  • IUS, DMPA: no evidence that effectiveness of other medication reduced
  • Implants: not recommended for women taking enzyme-inducing drugs

Choices for women with epilepsy:

  • IUD, IUS, DMPA: no specific contraindications; DMPA use may be associated with reduced seizure frequency
  • Implants: not recommended for women taking enzyme-inducing drugs

Choices for women at risk of sexually transmitted infection (STI):

  • IUD, IUS: tests may be needed before insertion
  • DMPA, implants: no specific contraindications
  • Provide advice on safer sex
aRefer to CSM advice issued in November 2004. See www.mhra.gov.uk and search for Depo Provera
Reproduced by kind permission of the National Institute for Health and Care Excellence

The care pathway

The guideline recommends that a planned pathway is important to ensure choice and comprehensive management of women seeking contraceptive advice, including LARC (Figure 2, below).

Figure 2: The care pathway
For further information on the different methods of LARC, refer to the quick reference guide (www.nice.org.uk)
Reproduced by kind permission of the National Institute for Health and Care Excellence

Cost-effectiveness of LARC

This guideline incorporated an economic analysis to determine the costeffectiveness of LARC compared with other contraceptive methods.

Among the four LARC methods, the injectable is less cost-effective than the IUD, IUS and the implant. The IUD, IUS and the implant become more cost-effective with longer duration of use. This means the relatively high initiation costs should not be a barrier to their use, as LARC use results in the greatest cost savings compared with other reversible methods.

In the clinical context the cost-effectiveness of LARC is just one consideration when offering women contraception. Consumer preferences, lifestyle and individual circumstances must also be taken into account when helping women make an informed choice about contraception.

Conclusion

This guideline recommends the use of LARC because of its contraceptive efficacy and cost-effectiveness. To offer women choice, access to all methods of contraception, including LARC, needs to be available uniformly across contraceptive services.This guideline has gone some way to clarify the clinical position of LARC and dispel the myth that this method is not cost-effective.

Implementation tools
NICE is developing the following tools to support implementation of its guideline on long-acting reversible contraception.They should be available to download from the NICE website: www.nice.org.uk from mid-December.

Slide set

The slides are aimed at supporting organisations to help implement the guideline recommendations at a local level.They do not try to cover all the recommendations from the guideline but contain key messages and should be used in conjunction with the quick reference guide.

Costing tools

National cost reports and local cost templates for the guideline are also being produced. Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice and predictions of how it might change following implementation of the guideline. Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates and quickly assess the impact the guideline may have on local budgets.

Copies of the full guideline and the quick reference guide can be downloaded from the NICE website: www.nice.org.uk

Acknowledgements

We wish to thank the technical team at the National Collaborating Centre for Women’s and Children’s Health for their work in the development of this guideline; in particular Ifigeneia Mavranezouli for her work on the economic analysis of LARC.

 

Guidelines in Practice, December 2005, Volume 8(12)
© 2005 MGP Ltd
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