When “the Longer, the Better” Is Best: Extended Use of LARCs
Long-acting reversible contraceptive (LARC) methods appeal to many women because they are highly effective, discreet, and forgettable—once in place, no regular action is required on the part of the user. Because of their long duration of effectiveness, they can also be more cost-effective for individuals, family planning programs, and donors compared with short-acting methods such as oral contraceptive pills or condoms.
The contraceptive implant Implanon® and its successor product, Implanon NXT®, and levonorgestrel-releasing intrauterine systems (LNG-IUS) such as Mirena® are two LARC methods gaining in popularity around the world. While Implanon® is currently labeled for three years of use and Mirena® for five years, clinical data from long-term studies show that both of these methods are highly effective for longer than their labels indicate.
Beginning in 2012, Washington University in St. Louis launched the Effectiveness of Prolonged Use of the IUD/Implant for Contraception (EPIC) study with the aim of measuring effectiveness of Mirena® and Implanon® for three years beyond their FDA-approved durations of use. The most recent data available from this study show that among 123 women using Implanon® for four years, and 34 using it for five years, no pregnancies occurred. In the Mirena® cohort, one pregnancy occurred among 108 women using the method for six years. This pregnancy occurred in a woman with a partially-expelled IUD. Additional results from this study are expected to be published later this year.
In addition to the EPIC study, forthcoming results from a World Health Organization (WHO)-sponsored study comparing Implanon® and the two-rod implant system Jadelle® over five years show that the methods are of comparable effectiveness over the period. A recently-published literature review has also concluded that evidence exists to support use of the LNG-IUS through seven years.
The implications of extended use of Implanon® and the LNG-IUS are especially important for low- and middle-income countries where access to family planning services is often limited. Having LARC products that are effective for longer durations offers the opportunity for less frequent provider visits, which may be cumbersome and costly, especially for women in remote areas. Longer duration of effectiveness also means potential for fewer removal and reinsertion procedures in which women must assume risk of rare complications. Additionally, if Implanon® is shown to be effective for five years, provider training and counseling messages for the product can be streamlined to match those of the other widely used implant system, Jadelle®, which is labeled for five years of use. Extending duration of use of these LARCs also has appreciable financial implications since the products become more cost effective the longer they are used. These financial benefits extend throughout the health system from the costs of commodity procurement and provision to individual costs of resupply and transportation.
It is our hope that existing and new data on these important LARC methods will be considered by international normative bodies to amend service delivery guidelines such as those put forth in the WHO Selected Practice Recommendations for Contraceptive Use to increase the recommended duration of use of the Implanon® implant and the LNG-IUS. Such amendments will be important steps in the research-to-practice continuum and another important strategy for expanding access to highly effective contraception.