02.Long-acting reversible contraception
Aside from abstinence and sterilisation, the most effective forms of contraception are long-acting reversible contraception (LARC).
Professor of general practice at Monash University Danielle Mazza says that according to one national survey, 50% of women in Australia experience an unplanned pregnancy, despite the fact that 70% of women use contraception. The solution, she says, is more women using LARCs. “I’d like to see a move towards the LARCs so that we can start to address the quite high rates of unplanned pregnancy in this country.”
Unlike other forms of contraception, human error has little impact on LARCs. Dr Philip Goldstone, medical director of Marie Stopes International Australia, a global sexual and reproductive health service provider, says: “There is no chance of user failure… [aside from interaction with certain medication] there’s nothing the person can do to make that contraception less reliable.”
Name: Etonogestrel implant (implant), marketed as Implanon NXT in Australia.
Method: A 4cm-long, flexible plastic rod is inserted directly under the skin of a woman’s arm. The implant contains a synthetic hormone resembling progesterone, which is released continuously into the bloodstream for three years. Fertility returns very quickly upon removal.
Price: Subsidised by the government on the Pharmaceutical Benefits Scheme (PBS), it costs about $35 for one implant.
Use: Lasts three years, must be prescribed, inserted and removed by a doctor.
Efficacy (with both perfect use, where all instructions are followed exactly, and typical use, which is how most women tend to use it): 99.95%.
The implant is the most effective contraceptive option available. In fact, it is even more effective than permanent contraception such as vasectomies, female tubal occlusions and ligations. Each implant lasts up to three years.
Although implants came onto the Australian market in 2001, the old Implanon was replaced by Implanon NXT in 2011. “The difference lies in the applicator, which is designed to minimise deep insertions leading to difficult and potentially risky removals,” says Bateson.
“On insertion there is no incision. You just need a little local anaesthetic in the arm, there’s a slight sting, and some women have a bit of bruising. When we remove it we need to make a two-millimetre incision. There’s a very small risk of scarring, but more so in people who have a tendency to scar.”
Some women with the implant will experience an unacceptable change to their menstrual cycle, but Bateson says women should trial the implant for three months and discuss issues with a doctor before considering removal.
Name: Levonorgestrel IUD (hormonal IUD), known in Australia as Mirena.
Method: A small piece of T-shaped plastic is inserted into the uterus. Fine threads attached to it protrude through the cervix, making removal easier. It slowly releases the progestogen-like hormone levonorgestrel for up to five years. Fertility returns very quickly upon removal.
Price: Available on the PBS, it costs about $35 for one IUD.
Use: It lasts for up to five years, and must be prescribed, inserted and removed by a doctor.
Efficacy (perfect and typical use): 99.8%
IUDs suffer from being tarred with the same brush as their earlier counterparts, according to Goldstone. “I think there’s a lack of information among women and among GPs. Historically IUDs have a bad reputation, which is completely out of date thinking with today’s IUDs.”
Bateson agrees. “The latest devices are a far cry from earlier prototypes. There is a very low risk of pelvic infection which is mainly confined to the first 20 days after insertion. There's no evidence of an increased risk of subsequent infertility for women using an IUD.”
The insertion procedure is generally done by a GP or gynaecologist with experience in insertion, and is relatively brief and painless.
“We get women to take painkiller beforehand, and most find it’s OK,” says Bateson. “There can be cramping pain when the IUD goes in, and women who haven’t had children, or those who have had C-sections, may have more cramping discomfort. While more commonly used by women who've completed their family or are spacing pregnancies, they are also useful for younger, [childless] women. They’re useful for women with heavy menstrual bleeding.”
Like the contraceptive pill and the implant, Mirena can be used to treat excessive menstrual bleeding or protect against endometrial hyperplasia (excessive growth of the lining of the womb). As with the implant, the menstrual cycle is altered by Mirena, but women usually end up with lighter periods.
And a randomised trial of 571 women showed that Mirena is more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on quality of life. The trial, conducted by the University of Birmingham in the UK, also found that there were no significant differences in serious adverse events between groups using the IUD and those receiving conventional treatment.
There are some downsides to Mirena. In five per cent of cases, women may experience an unexpected expulsion of the device. However, women can check whether the device is still in place by feeling for the threads high up in their vagina, something the doctor who inserts the IUD should teach them to do.
Interestingly, a new, mini Mirena may soon be available in Australia, according to our experts. “We have been trialling it,” says Bateson. “It’s smaller, lasts up to three years and should be available around 2014. It might be useful for younger women with smaller uteruses, or women who’ve experienced side effects from other IUDs.”