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Long-acting reversible contraception

About

What is covered

This pathway covers the effective and appropriate use of long-acting reversible contraception.

Update of the recommendations on progestogen-only subdermal implants

NICE has reviewed the evidence and updated the section of this pathway that makes recommendations on progestogen-only subdermal implants.

Long-acting reversible contraception

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 LARC methods does not depend on daily concordance.
Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy. Healthcare professionals need 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 pathway.
LARC is defined in this pathway as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:
  • copper IUDs
  • progestogen-only IUSs
  • progestogen-only injectable contraceptives
  • progestogen-only subdermal implants
The pathway 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.

Updates

Updates to this pathway

7 September 2016 Contraception (NICE quality standard 129) added.
2 September 2014 Paths on offering information about contraception and follow-up and managing problems with long-acting reversible contraception updated in line with the NICE clinical guideline on progestogen-only subdermal implants.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Short Text

The effective and appropriate use of long-acting reversible contraception

What is covered

This pathway covers the effective and appropriate use of long-acting reversible contraception.

Update of the recommendations on progestogen-only subdermal implants

NICE has reviewed the evidence and updated the section of this pathway that makes recommendations on progestogen-only subdermal implants.

Long-acting reversible contraception

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 LARC methods does not depend on daily concordance.
Expert clinical opinion is that LARC methods may have a wider role in contraception and their increased uptake could help to reduce unintended pregnancy. Healthcare professionals need 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 pathway.
LARC is defined in this pathway as contraceptive methods that require administration less than once per cycle or month. Included in the category of LARC are:
  • copper IUDs
  • progestogen-only IUSs
  • progestogen-only injectable contraceptives
  • progestogen-only subdermal implants
The pathway 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.

Updates

Updates to this pathway

7 September 2016 Contraception (NICE quality standard 129) added.
2 September 2014 Paths on offering information about contraception and follow-up and managing problems with long-acting reversible contraception updated in line with the NICE clinical guideline on progestogen-only subdermal implants.

Sources

NICE guidance and other sources used to create this pathway.
Long-acting reversible contraception (2005 updated 2014) NICE guideline CG30
Contraception (2016) NICE quality standard 129

Quality standards

Contraception

These quality statements are taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statements

Contraceptive information and methods

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.

Rationale

Offering information about the full range of contraceptives available, including long-acting reversible contraception, will ensure women asking for routine or emergency contraception can make an informed choice. Helping women choose the method of contraception that suits them best, and increasing their awareness of how to use contraceptives effectively, will help to reduce unplanned pregnancies.

Quality measures

Structure
a) Evidence that accessible information is available about the full range of contraceptive methods, including long-acting reversible contraception, and the local services that provide them.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.
Data source: Local data collection.
Process
a) Proportion of women who ask for contraception from contraceptive services who are given information about all methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are given information about all methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
b) Proportion of women who ask for contraception from contraceptive services who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
Outcome
a) Contraceptive use in women.
Data source: Local data collection.
b) Uptake of long-acting reversible contraception.
Data source: Local data collection.
c) Women’s satisfaction with their choice of contraceptive method.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that processes are in place to offer women information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. Service providers work together so that they can refer women to a suitable alternative service if they cannot provide the preferred method of contraception.
Healthcare practitioners (including GPs, community pharmacists, sexual and reproductive health consultants and nurses) ensure that they give women who ask for contraception information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. If they cannot provide the woman’s preferred method of contraception they refer them to a suitable alternative service.
Commissioners (clinical commissioning groups, local authorities and NHS England) commission contraceptive services that provide information on all contraceptive methods, including long-acting reversible contraception, and offer all contraceptive methods to all women. Commissioners ensure providers work together to ensure women are provided with their preferred method of contraception.

What the quality statement means for women attending contraceptive services

Women attending a contraceptive service are offered a choice of all contraceptive methods, including long-acting reversible contraception, and the information they need to decide which method is suitable for them. If the service cannot provide their preferred method of contraception they tell them where they can get it from.

Source guidance

Definitions of terms used in this quality statement

Contraceptive services
Contraceptive services include those offered in education, GP services, pharmacies, maternity and postnatal care services, walk-in centres, acute and emergency care, and the voluntary and private sectors. This includes open access contraceptive services that are available to everyone and provide walk in and appointment clinics.
[NICE’s guideline on contraceptive services for under 25s, recommendation 3 and expert opinion]
Information about contraceptive methods
This information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guideline on long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Contraceptive options may be limited for women with a learning disability or cognitive impairment. Contraceptive services should make it clear to women why specific methods cannot be offered to them.
Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner‘s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Emergency contraception

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.

Rationale

An intrauterine device (IUD) has a lower failure rate than oral methods of emergency contraception. Also, once in place, it can be used on an ongoing basis. If women use an IUD this will reduce the risk of unplanned pregnancies and avoid the need for emergency contraception. If a woman chooses to have an IUD as a form of emergency contraception, but the healthcare practitioner cannot fit it there and then, they should direct the woman to a suitable service and give her an oral method in the interim.

Quality measures

Structure
Evidence of local processes to ensure that women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.
Data source: Local data collection.
Process
Proportion of requests for emergency contraception where the woman is told that an intrauterine device is more effective than an oral method.
Numerator – the number in the denominator where the woman is told that an intrauterine device is more effective than an oral method.
Denominator – the number of requests for emergency contraception.
Data source: Local data collection. Quality and Outcomes Framework indicator CON003 captures data on the provision of information about long-acting reversible methods of contraception to women who are prescribed emergency hormonal contraception by their GP.
Outcome
a) Intrauterine device use as an emergency contraceptive.
Data source: Local data collection. The Health and Social Care Information Centre’s Sexual and Reproductive Health Activity Dataset includes information on methods of contraception for people using dedicated sexual and reproductive health services.
b) Abortion rate.
Data source: Local data collection. The Department of Health’s Abortion statistics can be analysed geographically.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that protocols and procedures are in place to tell women asking for emergency contraception that an IUD is more effective than an oral method. Service providers ensure that rapid referral pathways are in place for women who choose an emergency IUD if they are not able to fit one immediately. Service providers also ensure that protocols are in place to offer them an oral emergency method in the interim.
Healthcare practitioners (including GPs, community pharmacists, sexual health consultants and nurses) tell women who ask for emergency contraception that an IUD is more effective than an oral method. Practitioners unable to fit IUDs at presentation refer women to a service that can and offer them an oral emergency method in the interim.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that services providing emergency contraception tell women that an IUD is more effective than an oral method. Commissioners ensure that referral pathways are in place for women who choose to have an emergency IUD fitted if the service cannot provide this on presentation, and that the service offers an oral emergency method in the interim.

What the quality statement means for women

Women asking for emergency contraception are told that an intrauterine device (IUD, also known as the coil) is more effective than an oral method (an emergency pill) and can also be used as a long-term method of contraception.

Source guidance

Definitions of terms used in this quality statement

Emergency contraception
If a woman has had sex without using contraception, or thinks that her contraception did not work, an emergency contraceptive can be used. There are 3 different types:
  • emergency contraceptive pill, levonorgestrel 1.5 mg
  • emergency contraceptive pill, ulipristal acetate 30 mg
  • emergency intrauterine device.
Both emergency contraceptive pills are also referred to as the ‘morning after pill’.
[Adapted from Emergency contraception (Faculty of Sexual & Reproductive Healthcare)]
Intrauterine device
Also referred to as an IUD or coil, this is a small, T-shaped copper device that is inserted in the uterus. It has 1 or 2 threads on the end that hang through the entrance of the uterus (the cervix).
[Adapted from Intrauterine contraception (Faculty of Sexual & Reproductive Healthcare)]

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information and allow the woman to choose the one that suits her best.
If a healthcare practitioner‘s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after an abortion

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who request an abortion discuss contraception with a healthcare practitioner and are offered a choice of all methods when they are assessed for abortion and before discharge.

Rationale

Ensuring women can make an informed choice about contraception following an abortion will reduce the risk of future unplanned pregnancies. Having the opportunity to discuss contraception when they are being assessed for an abortion will give them time to consider all the options. Further discussion before discharge from the abortion service can help ensure timely access to contraception.

Quality measures

Structure
a) Evidence of local processes to ensure that women discuss contraception and all contraceptive methods with a healthcare practitioner when being assessed for an abortion.
Data source: Local data collection.
b) Evidence of local processes to ensure that a healthcare practitioner offers women a choice of all contraceptive methods before discharge from an abortion service.
Data source: Local data collection.
Process
a) Proportion of women who discuss contraception and all contraceptive methods with a healthcare practitioner at an assessment for abortion.
Numerator – the number in the denominator who discuss contraception and all contraceptive methods with a healthcare practitioner.
Denominator – the number of women having an assessment for abortion.
Data source: Local data collection.
b) Proportion of women who are offered a choice of all contraceptive methods before discharge from an abortion service.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods before discharge.
Denominator – the number of women discharged from an abortion service.
Data source: Local data collection.
Outcome
a) Uptake of long-acting reversible contraception at the time of abortion.
Data source: Local data collection.
b) Contraception uptake rate after abortion.
Data source: Local data collection.
c) Women who have more than 1 abortion.
Data source: Local data collection. The Department of Health’s Abortion statistics include data on repeat abortions.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (including secondary care, community genitourinary medical and private sector services) establish protocols to ensure that healthcare practitioners discuss contraception and all contraceptive methods with women at their assessment for abortion and before discharge. Service providers offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, service providers ensure that referral pathways to a contraceptive service are in place.
Healthcare practitioners (including GPs, hospital doctors and nurses) discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Healthcare practitioners offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, they offer to refer women to a contraceptive service.
Commissioners (clinical commissioning groups) ensure that abortion services discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Commissioners ensure that abortion services offer women a choice of all contraceptive methods before discharge, or offer a referral to a contraceptive service if contraceptives are not provided. Commissioners could consider a local performance indicator for abortion services to improve uptake of contraception at discharge.

What the quality statement means for women

Women who plan to have an abortion are offered the chance to discuss contraception with a healthcare practitioner during assessment for their abortion and again before they are discharged. They are offered a choice of all contraceptive methods before they are discharged or referral to a contraceptive service if contraception is not provided.

Source guidance

Definitions of terms used in this quality statement

Discussion about contraception
When discussing contraception, emphasise that women are fertile immediately after an abortion and give details of all contraceptive methods including:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and IUDs)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guidelines on contraceptive services for under 25s and long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception ]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.
[Adapted from the Faculty of Sexual & Reproductive Healthcare guidelines on barrier methods for contraception and STI prevention, fertility awareness methods, progestogen-only pills and combined hormonal contraception]

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after childbirth

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who give birth are given information about, and offered a choice of, all contraceptive methods by their midwife within 7 days of delivery.

Rationale

Supporting women to make an informed choice about contraception after childbirth will reduce the risk of future unplanned pregnancies. Advice and information should be given as soon as possible after delivery because fertility may return quickly, including in women who are breastfeeding. Providing advice about contraception after childbirth also helps avoid the risk of complications associated with an interpregnancy interval of less than 12 months.

Quality measures

Structure
a) Evidence of local processes to ensure that women who give birth are given information about all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women who give birth are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
Process
a) Proportion of women who give birth who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
b) Proportion of women who give birth who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
Outcome
a) Satisfaction with advice about contraceptive methods after childbirth.
Data source: Local data collection.
b) Contraception uptake rates in women who have given birth.
Data source: Local data collection.
c) Women who have a short interpregnancy interval.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers (secondary care and community maternity services) establish protocols to ensure that midwives give women information about all contraceptive methods, and offer them a choice of all methods, within 7 days of delivery. Service providers ensure women are referred to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Healthcare practitioners (midwives) give women information about, and offer them a choice of all contraceptive methods within 7 days of delivery. Midwives refer women to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Commissioners (clinical commissioning groups) ensure that maternity services give women information about, and offer them a choice of all contraceptive methods within 7 days of delivery, and refer them to a contraceptive service if contraception cannot be provided immediately.

What the quality statement means for women

Women who give birth are offered a choice of all contraceptive methods and given the information they need to decide which method is suitable for them by their midwife. This happens within a week of delivery. The midwife tells them how to get their chosen contraceptive.

Source guidance

Definitions of terms used in this quality statement

Information about contraceptive methods
Information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
[Adapted from NICE’s guideline on long-acting reversible contraception and expert opinion]
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
[Adapted from NICE’s guideline on long-acting reversible contraception]
Methods that depend on the person remembering to take or use them. These include:
  • contraceptive vaginal ring
  • contraceptive patch
  • combined oral contraceptive pill
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • natural family planning.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception healthcare practitioners should give information about all methods and allow the woman to choose the method that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
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These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
NICE has written information for the public explaining its guidance on long-acting reversible contraception.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in 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.

Supporting information

Glossary

Body mass index
Depo medroxyprogesterone acetate
Intrauterine device
Intrauterine system
Long-acting reversible contraception
Norethisterone enantate
Sexually transmitted infection
Venous thromboembolism
The progestogen-only subdermal implant (Implanon) recommended in 'Long-acting reversible contraception' (NICE guideline CG30) is no longer available. Healthcare professionals considering offering the replacement device, Nexplanon, should refer to the summary of product characteristics.

Paths in this pathway

Pathway created: April 2013 Last updated: September 2016

© NICE 2016

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