Providing long-term contraception
As the popularity of long-acting reversible contraceptives continues to increase, so does the need for incorporation of placement procedures and contraceptive counseling into primary care and resident education.
More and more patients are interested in using long-acting reversible contraceptives (LARCs), such as contraceptive implants and intrauterine devices (IUDs). But most of the time, they aren't getting them from their internists.
“Patients need access to contraception—it's an important part of primary care, and for us to not offer it in our primary care clinics is really unfortunate,” said ACP Member Vidya V. Gopinath, MD, an assistant professor of medicine at the Warren Alpert Medical School of Brown University in Providence, R.I.
However, some clinics are starting to offer LARCs in primary care, including a procedure clinic at Brown, and Dr. Gopinath and colleagues found that patients are interested. At the clinic, usage was 19% among 1,182 female patients ages 20 to 39 years—nearly twice the national average, according to results published in April by the Rhode Island Medical Journal.
“One of the big takeaways from our study was if you build it, they will come. … Patients would love for them to not have to go somewhere else—to not have to meet a new doctor, to go to a new clinic, to navigate another aspect of our health system,” said Dr. Gopinath, who performs LARC procedures at the Brown clinic.
LARCs became first-line contraceptive options in 2009, when the American College of Obstetricians and Gynecologists recommended them for most women. Since then, they have increased in popularity, with more than one in 10 reproductive-age women in the U.S. now using a LARC, according to an October 2020 National Center for Health Statistics (NCHS) data brief.
As the popularity of these devices continues to increase, there is more impetus to incorporate LARC placement procedures—or, at the very least, contraceptive counseling—into primary care and resident education, experts said.
Safe and effective
Currently available LARCs include the etonogestrel implant (Nexplanon), the levonorgestrel IUDs (e.g., Liletta, Mirena, Kyleena, and Skyla), and the copper IUD (ParaGard).
In a 2017-2019 survey, 10.4% of women ages 15 to 49 years reported using one of these devices—more than the male condom (8.4%) but less than tubal ligation (18.1%) and the oral contraceptive pill (14.0%), according to the NCHS data brief. Use of LARCs was highest among those in their 20s (13.7%) and 30s (12.7%).
While tubal ligation remains common in the U.S., this permanent birth control method is no more effective at preventing pregnancy than IUDs, according to a study published in February by the Journal of General Internal Medicine. Compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUD and similar following placement of a copper IUD, with lower rates of infection and pelvic pain with either IUD type.
“These reversible contraceptives are a really important part of internal medicine practice, as they are the safest and most effective way to protect our patients from undesired pregnancy,” said Eleanor Bimla Schwarz, MD, MS, FACP, lead author of the study.
LARCs are more than 99% effective at preventing pregnancy, according to the CDC, and, once placed, require little to no effort from the patient. They also carry none of the risks of estrogen, which is in most commonly used oral contraceptive pills, she noted.
“This is important because so many of the patients we internists care for have vascular risks that can be provoked by use of estrogen,” said Dr. Schwarz, who is chief of the division of general internal medicine at Zuckerberg San Francisco General Hospital and a professor of medicine at the University of California, San Francisco.
In addition to these benefits, LARCs are of particular relevance to the health and well-being of an internist's typical patient population, she said. Internists care for many patients with chronic conditions that can exacerbate risks of maternal morbidity and mortality, as well as those who require treatment with medications that can cause birth defects if used during pregnancy, underscoring the need for effective, long-term contraception, Dr. Schwarz noted.
That said, she tries to avoid the term LARC due to the important differences between IUDs, which are placed in the uterus, and the implant, which is placed just under the skin of the upper arm. Although these contraceptives can be easily removed whenever desired, arm implants offer five years of protection, while levonorgestrel and copper IUDs offer up to seven and 12 years of pregnancy protection, respectively.
For internists who counsel patients on these methods, the main key is explaining potential differences in menstrual patterns that are associated with each method, said Mindy Sobota, MD, MS, MPhil, FACP, an associate professor of medicine and clinician educator at Brown who started the procedure clinic in 2015.
While there are subtle differences between each of the IUDs and the implant, an internist doesn't need to know all of them unless they are actually placing the device, she said. However, the biggest difference all internists should be aware of is how each method will likely affect a patient's menstrual cycle, said Dr. Sobota.
With the nonhormonal copper IUD, patients will have their usual menstrual pattern but with, on average, 50% heavier bleeding, she said. “So that can become an issue, and it's the No. 1 reason why people may have it removed.”
On the other hand, the subdermal implant and levonorgestrel IUDs lead to less bleeding overall, on average, but no regular menstrual pattern, said Dr. Sobota, adding that patients may need reassurance that spotting or skipping periods with these methods is normal.
“I think a lot of patients culturally feel like if you don't have a regular, predictable period, there must be something wrong with you, and some patients even imagine that the blood is building up inside their body,” she said. “So it takes some counseling to let people know that people, on average, have less endometrial cancer with a progestin-containing method and that it's not that it's building up inside.”
For this reason, the hormone-containing IUDs are useful for more than contraception, added ACP Member Heather Hirsch, MD, MS, who is the clinical program director of the Menopause and Midlife Clinic at Brigham and Women's Hospital and an instructor at Harvard Medical School in Boston.
“The progestin-releasing IUDs are much more effective in reducing bothersome, heavy bleeding in the perimenopausal years … [which] could lead to more demand for this type of procedure,” she said.
LARCs in primary care
ACP supports efforts to encourage LARC uptake in primary care, according to a June 2018 position paper published in Annals of Internal Medicine.
“Promoting the safety of these methods and training in LARC insertion among primary care physicians and patients and addressing issues about same-day availability of LARC in primary care settings can enhance access and potentially increase use of this highly effective contraception,” wrote authors representing the College's Health and Public Policy Committee.
LARC placement and counseling are important in primary care because contraception is something that people often feel most comfortable discussing with somebody they know, as opposed to someone they've never met before, said Dr. Sobota.
“Especially when it comes to IUDs, just because it's a potentially scary procedure, a lot of patients, in my experience—even though I have wonderful OBs who work down the road from me—would much prefer to have their IUD placed by me,” she said. “And I think implants also, because there's a privacy factor and there's a trust factor.”
Contraception is also a common issue of concern for patients, Dr. Sobota said. “But I think that there's a misperception amongst internists because they don't ask and so don't realize that patients either may be really trying to get pregnant or may be really trying not to get pregnant.”
Despite the importance of contraceptive counseling, a survey of program directors found limited inclusion of this and other women's health topics in internal medicine residency training. However, most program directors agreed that residents should master the skills of providing preconception counseling (74%) and prescribing contraceptives (83%), according to results published in February 2017 by the Journal of Women's Health.
Although some internal medicine programs train their residents in LARC placement and removal, it's certainly not a routine part of internal medicine training as of yet, Dr. Gopinath noted. But Brown and other programs are starting to change that.
“By the time I graduated, I was fairly confident but also got to do a couple of months of procedure clinic by myself, essentially, just to increase my numbers … and then I started to have residents with me,” said Dr. Gopinath.
She said the level of experience needed to be competent in LARC removal and insertion depends on the method. “IUD removals and Nexplanon insertions are both incredibly easy, and then a little bit more experience for a Nexplanon removal, and a little bit more than that for an IUD insertion.”
Placing a subdermal implant is easier and safer than placing an IV, noted Dr. Schwarz. “Unfortunately, the FDA-mandated training continues to be a barrier to widespread use of this method,” she said. Interested primary care clinicians can sign up for the training.
“But it can be hard to find time to attend one of these trainings, and currently relatively few clinicians have made the commitment to do so,” said Dr. Schwarz. “As a result, the main challenge in making these procedures a routine part of primary care training and practice remains the ongoing need for faculty development—to ‘train our trainers.’”
Dr. Sobota agreed, adding that a growing number of internists are taking the lead on this work. “One thing that's really exciting is that the number of mentors 15 years ago, you could count on one hand. … But now, we keep a list of people we've heard about in internal medicine, and that list is now 20 or 30 people,” she said.
The first step for internists in improving contraceptive counseling is asking premenopausal patients with a uterus whether they are thinking about getting pregnant in the next year, said Dr. Sobota.
“It's the easiest question to ask, and the CDC recommends that. You may be really surprised to find out the patient is trying to become pregnant or is already pregnant, and it might be really helpful to know that before you prescribe your atorvastatin, [angiotensin-converting enzyme] inhibitor, or Bactrim,” she said. “Conversely, you may find out that the patient really doesn't want to get pregnant, and you can help them with that.”
Of course, a LARC will not be the contraceptive method of choice for every patient, and clinicians need to respect that, Dr. Sobota added. “In particular, given the legacy of reproductive coercion, a lot of patients don't want to have something placed in their body that they can't take out on their own, so [we should be] really trying to develop our skills in patient-centered counseling and trying to identify what's important,” she said.
To get this information quickly, Dr. Sobota asks patients what's important to them about their birth control. “If someone says, ‘I really want to make sure it works,’ then I go down that IUD and implant pathway … but it's really important to have those conversations and not make our patients feel like we're pushing them towards IUDs and implants,” she said.
Looking to the future
There are several challenges to incorporating LARC training into internal medicine clinics and residency education. In one study, 15 internal medicine faculty who had implemented or tried to implement LARC training reported several barriers, such as a lack of trained clinic preceptors, an unclear definition of procedural proficiency, and low numbers of referrals, according to results published online in May 2021 by the Journal of General Internal Medicine.
For lead author Rachel Casas, MD, one of the biggest hurdles to becoming proficient in LARC placement was finding the opportunity to perform enough of the procedures. As a Brown resident before Dr. Sobota started the procedure clinic, she wasn't able to get LARC experience until she sought help from colleagues in OB-GYN and family medicine during her medical education fellowship at Boston University.
Now, as a general internist and an assistant professor of medicine at Penn State Health Milton S. Hershey Medical Center in Hershey, Pa., she does Nexplanon insertions and removals and IUD removals.
One internist who had a unique ability to provide contraception training to her fellow residents was Dr. Hirsch, who had spent her first year in residency doing OB-GYN (and learning LARC procedures) before switching residency paths.
“What I was seeing was that residents sort of knew there was long-acting contraception but would skirt away from discussing it with patients because they didn't know how to counsel on some of the more nuanced questions about intrauterine devices,” she said.
To assess whether an intervention could help residents feel more competent in counseling about IUDs, Dr. Hirsch conducted a randomized controlled trial. Residents in the control group received a traditional one-hour didactic lecture on contraceptive care, whereas those in the intervention arm received a novel curriculum that included a one-hour video module on contraceptive care basics, a seven-minute mock patient video that simulated a patient-clinician interaction about IUD counseling, and a hands-on simulation workshop where residents learned to place IUDs on plastic pelvic models.
Of 58 residents who completed the study, more in the intervention group than in the control group reported feeling somewhat or very comfortable counseling about IUDs (46.7% vs. 27.2%); however, the difference was not statistically significant, according to results published in May 2020 by the Journal of General Internal Medicine.
While the perfect intervention for LARC training has yet to be determined, Dr. Hirsch said it is up to knowledgeable internal medicine attendings to continue to train interested residents, who will someday teach others. Eventually, this cycle will create more access to care for patients, she said.
“It's definitely something that we should own, that we can do, and that actually really helps the gynecologists who can focus on the really complex surgeries, delivering babies, etc.,” said Dr. Hirsch.
But despite the advantages of LARCs, it's important for internists to remember that the most appropriate method of contraception is the one the patient wants to use, said ACP Member Meghan Geary, MD, an assistant professor of medicine at Brown and coauthor of a letter to the editor, published in the July 2017 JAMA Internal Medicine, that advocated for LARCs in primary care.
Counseling about reproductive life goals is key for any patient of childbearing age who has a uterus, Dr. Geary said.
“I think my practice has probably evolved to be more patient-centric,” she said. “I can imagine a younger version of myself being so pro-IUDs—they are so effective and so easy—but now I think the method someone wants is the best method, if that's something else.”
