Female Reproductive & Breast

Long-acting reversible contraception: IUDs and implants

Clinical Overview and When to Suspect LARC Candidacy

— Levonorgestrel IUDs: 52 mg (Mirena 8 yr, Liletta 8 yr), 19.5 mg (Kyleena 5 yr), 13.5 mg (Skyla 3 yr)

— Copper T380A IUD (ParaGard): hormone-free, FDA-approved 10 yr (effective ≥12 yr)

— Etonogestrel implant (Nexplanon): single subdermal rod, inner upper arm, 3 yr (effective ≥5 yr per evidence)

— Any reproductive-age patient desiring contraception, including nulliparous women and adolescents (ACOG/AAP first-line)

— Postpartum (immediate post-placental IUD or implant before discharge)

— Post-abortion (immediate placement reduces repeat unintended pregnancy)

— Patients with contraindications to estrogen (migraine with aura, VTE history, HTN, smokers ≥35, SLE with APLA, breast cancer survivors → non-hormonal copper preferred for last)

— Patients struggling with adherence to pills/patch/ring

Board pearl: LARC is first-line for adolescents per ACOG and AAP—nulliparity and young age are not contraindications. A 16-year-old requesting contraception in a confidential visit should be offered LARC alongside other methods, not steered toward condoms alone.

Step 3 management: When a patient presents requesting "the most effective birth control," your first move is contraceptive counseling using US MEC categories—not reflex prescription of OCPs.

Long-acting reversible contraception (LARC) = intrauterine devices (IUDs) and the etonogestrel subdermal implant; top-tier efficacy (<1% failure/year), comparable to tubal sterilization but reversible.

Available methods in the US:

When to actively offer LARC (Step 3 ambulatory thinking):

Copper IUD second use: most effective emergency contraception (>99%) within 5 days of unprotected intercourse; also provides ongoing contraception. LNG 52 mg IUD is now also evidence-supported for EC.

Counseling frame: use shared decision-making and tiered effectiveness charts; avoid coercion, especially in marginalized populations (history of reproductive coercion in US medicine).

Presentation Patterns and Key History

— 22-yo nullipara wants "set it and forget it" contraception → implant or IUD

— Postpartum day 1 wanting long-term spacing → immediate implant or post-placental IUD

— 17-yo with heavy menstrual bleeding (HMB) and dysmenorrhea wants contraception → LNG 52 mg IUD (dual benefit)

— 30-yo with migraine with aura on COCs → switch to LARC (estrogen contraindicated)

— Breastfeeding mother at 6-wk visit → any LARC acceptable (progestin-only or copper)

— LMP and pregnancy risk (rule out current pregnancy before insertion)

— Obstetric history: parity, prior cesarean, recent delivery/abortion

— Gynecologic: menstrual pattern, dysmenorrhea, fibroids, distorted uterine cavity, prior ectopic, PID

— Medical: VTE, breast cancer, liver disease, SLE, Wilson disease (copper IUD contraindicated), pelvic TB

— STI risk factors: new/multiple partners, age <25, prior STI

— Medications: enzyme inducers (rifampin, certain antiepileptics) reduce implant efficacy—IUDs unaffected

— No intercourse since LMP

— Consistently using reliable contraception

— <7 days since LMP start

— <4 wk postpartum (non-lactating)

— Fully/nearly fully breastfeeding, amenorrheic, <6 mo postpartum

— <7 days post-abortion

— Negative high-sensitivity urine pregnancy test (with caveat re: early pregnancy)

Key distinction: Copper IUD worsens menstrual bleeding/cramping (counsel explicitly); LNG 52 mg IUD typically reduces bleeding by ~90% at 1 yr and is FDA-approved for HMB. Choose by symptom profile, not just patient age.

Board pearl: Enzyme-inducing antiepileptics (phenytoin, carbamazepine, topiramate >200 mg, phenobarbital) and rifampin reduce implant levels—IUDs and DMPA are unaffected and preferred. Lamotrigine is the opposite concern: estrogen lowers lamotrigine levels.

Typical Step 3 vignettes:

Essential history elements (US MEC screening):

Pregnancy exclusion before placement (CDC criteria, any one):

Physical Exam Findings and Pre-Insertion Assessment

— Identify insertion site: non-dominant inner upper arm, ~8–10 cm proximal to medial epicondyle, in the sulcus between biceps and triceps (overlying triceps to avoid neurovascular bundle in the bicipital groove)

— Inspect for skin infection, scarring, prior implant; palpate to confirm subcutaneous tissue depth

— Bimanual to determine uterine size, position (ante- vs retroverted), and mobility—critical to avoid perforation

— Speculum: assess cervix, screen for active cervicitis/mucopurulent discharge

— Sound the uterus: depth should be 6–10 cm; <6 cm or >10 cm increases expulsion/perforation risk

— Same-day NAAT for gonorrhea/chlamydia in patients at risk (age <25, new partner, etc.)

— Insert the IUD the same day; treat if positive without removing the IUD

— Active purulent cervicitis or known untreated GC/CT → defer until treated

— Pelvic mass or unexplained vaginal bleeding → workup first

— Distorted cavity (large submucosal fibroid, bicornuate uterus) → IUD often unsuitable; implant fine

CCS pearl: Order "urine pregnancy test, NAAT GC/CT, bimanual exam, speculum exam" on the same visit as IUD placement—do not split into multiple appointments. Step 3 rewards efficient single-visit ambulatory workflows.

Board pearl: A non-palpable implant after insertion is an emergency—stop, do not discharge. Use high-frequency ultrasound (≥15 MHz) or MRI to localize before removal. Failure to confirm placement is a classic malpractice scenario.

Implant pre-insertion exam:

IUD pre-insertion exam:

STI screening at time of insertion (not before; do not delay placement):

Findings that change management:

Post-insertion check: trim IUD strings to ~3 cm visible at cervix; document length; palpate implant to confirm placement before patient leaves the room.

Diagnostic Workup — Pre-Placement Screening

— Pregnancy exclusion (criteria in chunk 2; urine hCG if uncertain)

— Blood pressure (baseline; implant/IUD don't require monitoring but document)

— STI risk assessment ± same-day NAAT

— Routine pelvic ultrasound before IUD

— Pap smear before placement (do cervical cancer screening on its own schedule)

— HIV/syphilis testing as a placement prerequisite

— Antibiotic prophylaxis (no benefit shown, even with positive GC/CT—treat the infection, leave IUD in place)

— Misoprostol cervical priming (does not ease insertion, increases side effects; not recommended routinely)

— NSAIDs (ibuprofen 600–800 mg) 30–60 min pre-procedure

— Paracervical block with 1% lidocaine has the strongest evidence for IUD insertion pain

— Topical lidocaine gel/spray—limited efficacy

— Anxiolysis for select patients

— IUD: visualize strings; if not seen, transvaginal ultrasound to confirm intrauterine position; if not in uterus → abdominal/pelvic X-ray to find a perforated/expelled device

— Implant: palpate the rod; if impalpable → high-frequency ultrasound first, MRI if still not localized

Step 3 management: A patient comes in 4 weeks post-IUD-insertion and cannot feel the strings. Sequence: (1) urine pregnancy test, (2) TVUS to confirm IUD in uterus, (3) if not seen, plain abdominal/pelvic X-ray to locate (intra-abdominal vs expelled), (4) backup contraception in the meantime.

Board pearl: Routine ultrasound is not required after every IUD insertion if strings are visualized and placement felt straightforward. Reserve imaging for difficult insertions, missing strings, suspected perforation, or pain.

Required before LARC placement:

NOT required (common Step 3 distractors):

Pain management options (evidence is modest; offer choice):

Post-placement confirmation:

US Medical Eligibility Criteria — Confirmatory Decision-Making

— Current breast cancer → LNG IUD and implant Category 4 (copper Category 1—safe choice)

— Pregnancy (any LARC)

— Unexplained vaginal bleeding before evaluation (initiation)

— Distorted uterine cavity (IUDs)

— Current PID, purulent cervicitis, current GC/CT (IUD initiation; Category 2 for continuation)

— Postpartum sepsis, immediate post-septic abortion (IUDs)

— Pelvic TB (IUDs)

— Wilson disease (copper IUD only)

— Cervical or endometrial cancer awaiting treatment (IUD initiation)

— Ovarian cancer (IUD initiation)

— SLE with positive/unknown antiphospholipid antibodies (LNG/implant Category 3)

— Severe decompensated cirrhosis, hepatocellular adenoma (hormonal LARC)

— Ischemic heart disease or stroke (continuation of LNG IUD/implant Category 3)

— Nulliparity, adolescence

— History of ectopic pregnancy (LARC is protective in absolute terms vs no contraception)

— Immediately postpartum or post-abortion

— HIV infection (any stage)

— Migraine with aura (estrogen is the problem, not progestin or copper)

— VTE history, smoking, HTN, diabetes

Key distinction: Current breast cancer is the classic LARC Category 4 for hormonal methods—pivot to the copper IUD, which is Category 1. Remote (≥5 yr disease-free) breast cancer is Category 3 for hormonal methods.

Board pearl: Past ectopic is not a contraindication to IUDs. Absolute ectopic risk is lower on an IUD than off contraception entirely; the proportion of pregnancies that are ectopic is higher because total pregnancies are so rare.

CDC US MEC categories (1–4): 1 = no restriction, 2 = benefits>risks, 3 = risks>benefits (avoid unless no alternative), 4 = unacceptable risk.

High-yield Category 4 (do NOT use):

Category 3 (generally avoid):

Conditions that are SAFE (Category 1–2) and often misidentified as contraindications:

First-Line Management Logic — Choosing the Right LARC

— Wants amenorrhea or less bleeding → LNG 52 mg IUD

— Wants no hormones → copper IUD

— Wants to avoid pelvic procedure or has uterine distortion → etonogestrel implant

— Needs emergency contraception + ongoing → copper IUD (or LNG 52 mg IUD) within 5 days

— Has HMB, dysmenorrhea, endometriosis pain, adenomyosis, or simple endometrial hyperplasia without atypia → LNG 52 mg IUD (therapeutic)

— On enzyme-inducing meds (rifampin, certain AEDs) → IUD (any) preferred over implant

— Postpartum, breastfeeding → all LARC acceptable; immediate placement OK

— Any time in cycle if pregnancy reasonably excluded

— Immediate postpartum IUD: within 10 min of placental delivery (higher expulsion but high continuation)

— Delayed postpartum: at 4–6 wk visit

— Post-abortion: immediately after uterine evacuation

— Implant placed >5 days after LMP start

— LNG IUD placed >7 days after LMP start

— Copper IUD: immediately effective, no backup needed

— LNG 52 mg IUD: FDA 8 yr; evidence supports up to 8 yr for contraception

— Copper T380A: FDA 10 yr; evidence ≥12 yr

— Implant: FDA 3 yr; evidence ≥5 yr (counsel re: off-label extension)

Step 3 management: A 28-yo with HMB, BMI 38, migraine with aura, and desire for contraception → LNG 52 mg IUD. It addresses bleeding, avoids estrogen (aura/BMI), and is the most effective option. Don't pick COCs.

Board pearl: Copper IUD = only LARC that is immediately contraceptive regardless of cycle timing—because the mechanism (spermicidal copper ions, sterile inflammation) is non-hormonal and instant.

Algorithm by patient priorities:

Timing of placement:

Backup contraception (7 days) needed if:

Duration in practice (extended use evidence):

Pharmacology and Mechanisms — How LARC Actually Works

— Local progestin release: thickens cervical mucus (primary), thins/decidualizes endometrium, partial ovulation suppression (dose-dependent—~50% with 52 mg in year 1)

— Systemic LNG levels low; side effects (acne, mood, breast tenderness) less than oral progestins but possible

— Bleeding pattern: irregular spotting first 3–6 months → progressive lightening; 20% amenorrhea at 1 yr with 52 mg (less with lower-dose devices)

— Copper ions create sterile inflammatory reaction toxic to sperm and ova; impairs fertilization

— No hormonal effects; ovulation continues

— Bleeding pattern: heavier, longer menses and more dysmenorrhea (especially first 6 months); counsel and offer NSAIDs

— Releases ENG (active metabolite of desogestrel); suppresses ovulation (primary mechanism—differs from IUDs), thickens mucus, thins endometrium

— Serum levels higher than IUDs; systemic progestin side effects more common

— Bleeding: unpredictable—~20% amenorrhea, ~20% frequent/prolonged bleeding (leading cause of discontinuation)

— Enzyme inducers ↓ ENG: rifampin, rifabutin, phenytoin, carbamazepine, phenobarbital, primidone, topiramate (high-dose), oxcarbazepine, St. John's wort, efavirenz

— IUDs act locally—efficacy preserved with enzyme inducers

— NSAIDs 5–7 days

— Short course COCs or estrogen if no contraindication

— Counsel that bleeding usually improves; do not remove for bleeding before 3-month trial

Board pearl: The implant works primarily by ovulation suppression; LNG IUDs work primarily by cervical mucus and endometrial effects with variable ovulation suppression. This explains why ovarian cysts are more common with the implant.

Levonorgestrel IUDs:

Copper IUD:

Etonogestrel implant:

Drug interactions (implant most affected):

Bleeding management on hormonal LARC (first 3–6 months expected):

Insertion and Removal Procedures

— Patient supine, non-dominant arm externally rotated, hand behind head

— Mark insertion site 8–10 cm proximal to medial epicondyle, 3–5 cm posterior to the sulcus (avoid neurovascular bundle)

— Lidocaine wheal → insert applicator at ~30° angle, then flatten parallel to skin and slide subdermally

— Confirm by palpation before patient leaves; document both ends palpable

— Palpate distal end → 2 mm incision at distal tip → push proximal end down → grasp with hemostat → remove

— Deep/impalpable implants: refer to specialist; use ultrasound guidance; never blind-dissect (risk of brachial artery, median/ulnar nerve injury)

— Bimanual → speculum → cleanse cervix → tenaculum on anterior lip (cough technique to reduce pain) → sound uterus → load device → insert to fundus → deploy per device-specific technique → trim strings to 3 cm

— Vasovagal reactions common; have atropine and recovery time available

— Grasp strings with ring forceps, gentle steady traction

— Missing strings: cytobrush in canal → if unsuccessful, TVUS → IUD hook or alligator forceps under ultrasound or hysteroscopy

— Uterine perforation ~1/1000 (higher postpartum, lactating): suspect with sudden loss of resistance, pain, or vasovagal—stop, ultrasound; if perforated, laparoscopic retrieval

— Vasovagal syncope: legs up, IV fluids, atropine if persistent bradycardia

— Expulsion: 2–10% in first year, highest in first 3 months; counsel string checks

CCS pearl: After IUD insertion, advance simulated time, then check strings at the 4–6 week follow-up visit. If perforation is suspected intraoperatively, order pelvic ultrasound STAT, consult gyn, NPO—do not discharge.

Board pearl: Never attempt to remove a non-palpable implant in primary care—refer to a trained specialist with ultrasound guidance. Brachial artery and median nerve injuries are catastrophic and litigated.

Implant insertion (Nexplanon):

Implant removal:

IUD insertion:

IUD removal:

Complications during placement:

Special Populations — Older Reproductive-Age and Medical Comorbidities

— LARC excellent: avoids estrogen risks (VTE, stroke, MI) that increase with age

— LNG 52 mg IUD doubles as endometrial protection if systemic estrogen used for vasomotor symptoms—off-label but guideline-supported (replaces oral progestin in HRT)

— Contraception can be discontinued at age 55 (universal menopause assumption) or after 1 yr amenorrhea off hormones if >50, 2 yr if <50

— Severe decompensated cirrhosis, hepatocellular adenoma, malignant hepatoma → hormonal LARC Category 3

— Copper IUD Category 1 in all liver disease—the go-to

— All LARC methods safe; no dose adjustment

— Pregnancy in advanced CKD is high-risk—LARC strongly preferred

— Uncomplicated: all LARC Category 2

— Complicated (graft failure, rejection): IUD Category 3 for initiation due to theoretical infection concern (rarely clinically significant in modern practice)

— Malabsorptive procedures (Roux-en-Y) reduce oral contraceptive efficacy → LARC preferred

— Implant and IUDs unaffected by GI absorption

— All LARC Category 1–2 regardless of CD4 count or ART

— No interaction with most ART; efavirenz reduces implant efficacy modestly—still acceptable

— All Category 1–2 for LARC—LARC is the safe pivot when estrogen is contraindicated

Board pearl: Woman age 52 with hot flashes, HMB, and HTN needs both contraception and endometrial protection if estrogen therapy is started → LNG 52 mg IUD covers all three indications in one device.

Key distinction: Copper IUD is the universal "medical contraindication" answer—safe in breast cancer, liver disease, migraine with aura, VTE, and lupus with APLA.

Perimenopausal patients (40s to early 50s):

Hepatic impairment:

Renal impairment / dialysis:

Solid organ transplant:

Bariatric surgery:

HIV:

Diabetes, HTN, prior VTE, smoking ≥35:

Special Populations — Postpartum, Breastfeeding, Adolescents

— Placed within 10 min of placental delivery (vaginal or cesarean)

— Higher expulsion (10–25%) vs interval placement (~5%), but high continuation rates make it net beneficial

— Use long-placement instruments; document fundal placement

— All LARC fine; rule out interim pregnancy

— Ovulation can return as early as 25 days postpartum in non-lactating women

— Progestin-only methods (implant, LNG IUD) Category 2 from immediately postpartum; no clinically significant effect on milk supply or infant outcomes

— Copper IUD Category 1

— Historical concern about LNG and lactation establishment is not supported by current evidence

— Immediate placement (after uterine evacuation, either medical or surgical) is preferred—reduces repeat unintended pregnancy

— Category 1 for first-trimester; Category 2 for second-trimester (slightly higher expulsion); Category 4 if septic

— Nulliparity is not a contraindication

— Confidential care laws vary by state—know your state's minor consent rules

— Counsel that LARC does not protect against STIs—dual method with condoms

— Insertion pain anxiety is real—offer paracervical block, music, support person, anxiolysis

— Rule out ectopic

— If intrauterine and strings visible/accessible → remove the device (lowers risk of miscarriage, preterm birth, infection)

— If strings not accessible → counsel about increased risks; do not blindly probe

Step 3 management: Adolescent at postpartum day 1 → offer immediate postpartum implant or IUD before hospital discharge. The 6-week visit is the highest-risk window for repeat pregnancy; don't wait.

Board pearl: If a patient becomes pregnant with an IUD in place and strings are visible, remove the IUD—retained IUD increases miscarriage, chorioamnionitis, preterm delivery, and septic abortion risk.

Immediate postpartum IUD:

Delayed postpartum (4–6 wk):

Breastfeeding:

Post-abortion / post-miscarriage:

Adolescents (AAP/ACOG first-line):

Pregnancy with LARC in place:

Complications and Adverse Outcomes

— Presents as missing strings, cramping, increased bleeding, or palpable device at cervix

— Confirm with ultrasound; replace if desired (recurrence rate not high)

— Acute: pain, vasovagal, loss of resistance; chronic: missing strings, pelvic pain, pregnancy

— Risk factors: lactation, <6 mo postpartum, inexperienced inserter, retroverted uterus

— Management: TVUS → if not intrauterine, plain X-ray to localize → laparoscopic retrieval (especially copper—intense adhesion formation)

— Risk elevated only in first 20 days post-insertion (insertion-related contamination)

— After 20 days, IUD users have same/lower PID risk than population

— Treat PID without removing the IUD unless no improvement at 48–72 h

— Absolute risk reduced (IUD prevents pregnancy)

— Of pregnancies that occur with IUD in place, ~50% are ectopic → always rule out

— Insertion-site bruising, neurovascular injury (rare, deep insertion), migration (usually <2 cm; deep migration to pulmonary artery extremely rare but reported)

— Irregular bleeding (most common reason for discontinuation, especially implant)

— Acne, mood changes, breast tenderness, headache, ovarian cysts (functional, usually resolve—do not remove for asymptomatic cysts)

— Menorrhagia and dysmenorrhea—counsel and treat with NSAIDs; persistent severe symptoms after 6 months → consider removal

— Asymptomatic → no treatment, leave IUD

— Symptomatic (pelvic pain, mass) → remove + antibiotics

Board pearl: A pregnant patient with an IUD must be evaluated for ectopic pregnancy before assuming intrauterine—threshold should be very low for early TVUS and serial hCG.

Expulsion (2–10% first year, higher postpartum/post-abortion):

Perforation (~1/1000 insertions):

Pelvic inflammatory disease:

Ectopic pregnancy:

Implant-specific:

Hormonal side effects:

Copper IUD-specific:

Actinomyces on Pap:

When to Escalate — Urgent Care, Specialist Referral, Inpatient

— Suspected uterine perforation with peritoneal signs, hemodynamic instability

— Suspected ectopic pregnancy with hCG positive and unstable vitals

— Severe pelvic pain + fever + IUD in place → rule out severe PID, tubo-ovarian abscess

— Implant insertion with suspected vascular injury (expanding hematoma, distal ischemia)

— Missing IUD strings with negative office maneuvers, particularly if pregnancy ruled out and TVUS doesn't show device

— Non-palpable implant

— Pregnancy with IUD in place where strings are not visible

— IUD expulsion partial (device at cervix)

— Severe PID with sepsis, tubo-ovarian abscess, pregnancy or immunocompromise → IV antibiotics

— Septic abortion with IUD in place → emergent uterine evacuation + IV antibiotics + IUD removal

— Postpartum septic IUD placement complications

— Deep/impalpable implant for ultrasound-guided removal

— Translocated IUD (intra-abdominal) for laparoscopic retrieval

— Refractory abnormal uterine bleeding on LARC after 6-month trial

— Pre-procedure imaging for fibroid uterus considering IUD

CCS pearl: Septic abortion with IUD in place: order CBC, blood cultures, lactate, type and screen, broad-spectrum IV antibiotics (clindamycin + gentamicin or pip-tazo), uterine evacuation, IUD removal, OB/Gyn consult, ICU monitoring if hypotensive. Do not "watch and wait."

Board pearl: PID + IUD does not require IUD removal upfront. Start antibiotics; remove only if no clinical improvement in 48–72 h or if patient prefers removal after counseling.

Emergency department referral:

Same-day gynecology referral:

Inpatient admission:

Specialist consultation (non-urgent):

Key Differentials — Same-Category Contraceptive Choices

— DMPA is highly effective but requires q3-month injection (adherence), causes weight gain, reversible bone density loss, delayed return to fertility (up to 10 mo)

— LARC has higher continuation and lower failure with typical use

— CHC failure rates ~7% typical use vs <1% LARC

— CHC contraindicated with: migraine with aura, smoker ≥35, HTN, VTE history, breast cancer, <21 days postpartum, decompensated liver disease

— LARC sidesteps most of these

— POP requires strict daily timing (3-hour window for traditional POP; 24-hour for drospirenone POP)

— LARC adherence-independent

— Comparable efficacy; LARC is reversible and reaches similar low failure rates without surgery

— Vasectomy is the safest, least expensive permanent option for couples

— Counsel that regret rates after tubal ligation are 20% in women <30—offer LARC as equivalent-efficacy reversible option

— Implant vs IUD: implant avoids pelvic exam, no menstrual cramping changes from device, but more unpredictable bleeding

— LNG IUD vs copper IUD: LNG reduces bleeding, copper preserves hormone-free cycles

— LNG 52 mg vs lower-dose LNG IUDs: higher dose = more amenorrhea, FDA-approved for HMB, longer duration

Step 3 management: 26-yo requesting tubal ligation "because the pill failed her twice." Before scheduling surgery, explain LARC has equivalent typical-use efficacy and is reversible. Many patients regretting tubal ligation were never offered LARC.

Key distinction: "Most effective reversible contraception" = LARC; "most effective method overall" = vasectomy/tubal/LARC are all top-tier (<1% failure).

LARC vs DMPA (depot medroxyprogesterone):

LARC vs combined hormonal contraceptives (OCP/patch/ring):

LARC vs progestin-only pill:

LARC vs permanent contraception (tubal ligation, Essure withdrawn, vasectomy):

Within LARC:

Key Differentials — Other-Category Causes of Presenting Symptoms

— Pregnancy (always test first)

— STI/cervicitis—NAAT

— Cervical or endometrial pathology—exam, Pap if due, endometrial biopsy if age ≥45 or risk factors

— Fibroids, polyps—pelvic ultrasound

— Coagulopathy in adolescents with HMB

— Thyroid dysfunction—TSH

— Ectopic pregnancy (always)

— PID, tubo-ovarian abscess

— Ovarian cyst (functional cysts more common with implant)

— IUD malposition or partial expulsion—TVUS

— Endometriosis, adenomyosis (LNG IUD may treat but not always)

— Non-gynecologic: appendicitis, UTI, nephrolithiasis, IBS

— Expected with LNG 52 mg IUD (~20% at 1 yr) and implant (~20%)

— Still rule out pregnancy if any concern

— No workup needed if amenorrhea develops gradually on LARC

— Often unrelated; assess timing and pattern

— Trial removal if persistent and temporally linked

— Implant: small mean weight gain, individual variability

— LNG IUD: minimal systemic effect

— Copper IUD: no hormonal weight effect—useful "control" answer

Board pearl: New pelvic pain in a patient with an IUD = pregnancy test + TVUS before anything else. Ectopic pregnancy with an IUD in place is a classic missed diagnosis.

Key distinction: Don't blame all symptoms on the LARC. A 47-yo with new heavy bleeding on a 4-year-old LNG IUD needs endometrial evaluation, not device replacement.

Abnormal bleeding on LARC—rule out non-LARC causes:

Pelvic pain on LARC—differential:

Amenorrhea on LARC:

Headaches, mood symptoms on hormonal LARC:

Weight gain:

Long-Term Plan and Continuation Strategy

— LNG 52 mg IUD (Mirena, Liletta): 8 yr FDA, 8 yr evidence

— LNG 19.5 mg (Kyleena): 5 yr

— LNG 13.5 mg (Skyla): 3 yr

— Copper T380A: 10 yr FDA, evidence ≥12 yr; if placed at ≥age 40, can leave until menopause

— Etonogestrel implant: 3 yr FDA, evidence supports ≥5 yr

— At end of duration: remove and replace at same visit if continued contraception desired

— Transitioning to pregnancy: fertility returns immediately after removal of any LARC; counsel preconception (folic acid 400 mcg, optimize chronic conditions, immunizations)

— Transitioning to menopause: see chunk 9; LNG IUD can stay as endometrial protection for HRT

— LARC does not prevent STIs; counsel dual-method use with condoms for at-risk patients

— Continue cervical cancer screening per USPSTF (every 3 yr cytology age 21–29; every 5 yr co-test or primary HPV age 30–65)

— Unlike DMPA, LARC does not affect BMD—no DXA monitoring needed

— Covered under ACA preventive services with no cost-sharing for most insured patients

— 340B and Title X clinics for uninsured

— Same-day insertion is the equity standard—avoid "come back another day" workflows

Step 3 management: When a LARC user wants to conceive, remove the device at any time; recommend prenatal vitamins with 400 mcg folic acid for ≥1 month preconception, update rubella/varicella status, and address chronic conditions (HbA1c, BP, medication teratogenicity review).

Board pearl: Fertility returns to baseline within one cycle of LARC removal—no "washout" needed, in contrast to DMPA where return to fertility may take up to 10 months.

Duration and replacement schedule:

Transition planning:

STI prevention reminder:

Bone health:

Cost and access:

Follow-Up, Monitoring, and Counseling

— Optional 4–6 week post-insertion visit (string check for IUDs, palpation for implant, address bleeding concerns)

— Routine annual visits otherwise—no special monitoring labs required

— No need for routine pelvic ultrasound, hormonal labs, or BMD

— IUD: teach monthly string check after menses; return if strings absent, longer, or device palpable

— Implant: confirm palpability periodically

— LNG IUD: irregular spotting 3–6 months → progressive lightening

— Copper IUD: heavier/longer menses, especially first 6 months

— Implant: unpredictable—amenorrhea, spotting, or frequent bleeding all possible; ~20% discontinue for this reason

— Reassure that bleeding does not mean device failure

— NSAIDs (ibuprofen, mefenamic acid) for 5–7 days

— Short course of estrogen or COCs (if no contraindication) for implant/LNG IUD breakthrough bleeding

— Tranexamic acid for heavy episodes

— If persistent >6 months and intolerable → consider removal and alternative method

— Annually for sexually active women <25 and ongoing risk factors—leave LARC in place

CCS pearl: Advance simulated time 6 weeks; order "follow-up office visit, string check, address side effects." This is the Step 3 ambulatory cadence pattern.

Board pearl: Lot number and expiration documentation are not bureaucratic busywork—they are legally required for device traceability if a recall occurs.

Standard follow-up cadence:

Self-care between visits:

Bleeding counseling (set expectations upfront—prevents discontinuation):

Management of bothersome bleeding (after pregnancy excluded):

STI re-screening:

Cervical cancer screening: continue per guidelines independent of LARC

Documentation: device type, lot number, expiration date, insertion date in problem list (medical-legal essential)

Ethics, Legal, and Patient Safety Considerations

— LARC has a documented history of coercive use in marginalized populations (incarcerated women, low-income, racial minorities, intellectual disability)

— Counsel using a tiered-effectiveness approach without steering; equally support method choice, continuation, and removal on request

— A patient requesting removal must have it removed at the same or next available visit—no requirement to "try longer"

— Most US states allow minors to consent to contraception without parental involvement; know your state's law

— Billing/EOB can inadvertently disclose to parents—offer cash-pay or Title X options if confidentiality is critical

— Patients with intellectual disability: assess decisional capacity; surrogate decision-making for contraception is fraught—involve ethics committee for non-emergent decisions

— Avoid LARC placement under coercion (court-ordered, employment-conditioned)

— Adolescent disclosing sexual activity with significantly older partner → assess for statutory rape/abuse per state law

— Suspected reproductive coercion (partner controlling contraception) → safety planning, IPV resources

— Patient changing PCPs or insurance: document LARC type, placement date, replacement date in portable summary

— ED visits for unrelated complaints: ensure presence of LARC is recorded so imaging isn't misread as "foreign body" needing removal

— Time-out before insertion (correct device, expiration, patient ID)

— Universal precautions; sharps safety; biohazard disposal

— Never remove a non-palpable implant blindly—brachial neurovascular injury is a sentinel event

— Document counseling about miscarriage risk if strings inaccessible

— Offer options counseling neutrally

Step 3 management: Patient requests LARC removal after 3 months because of irregular bleeding. Correct response: counsel on bleeding course, offer adjuncts, and remove if she still wants it removed. Patient autonomy supersedes clinician preference for continuation.

Reproductive autonomy and informed consent:

Adolescent confidentiality:

Capacity and consent:

Mandatory reporting:

Transition-of-care risks:

Procedural safety:

Pregnancy with LARC:

High-Yield Associations and Rapid-Fire Facts

Board pearl: The single phrase that unlocks many LARC vignettes: "no hormones and bleeding worsens" = copper IUD; "less bleeding and amenorrhea OK" = LNG 52 mg IUD.

Most effective EC = copper IUD (>99%, up to 5 days post-coitus); LNG 52 mg IUD also evidence-supported.

LNG 52 mg IUD FDA-approved for heavy menstrual bleeding in contracepting women.

First-line for adolescents per ACOG/AAP = LARC.

Ectopic risk: absolute risk lower on IUD vs no contraception; proportion of pregnancies that are ectopic is higher.

PID risk elevated only in first 20 days post-IUD insertion.

Implant primary mechanism = ovulation suppression; LNG IUD primary mechanism = cervical mucus/endometrial.

Copper IUD = immediately effective; LNG IUD/implant need 7-day backup if placed outside cycle days 1–5/1–7.

Wilson disease = only specific contraindication unique to copper IUD.

Current breast cancer = Category 4 for hormonal LARC; copper IUD is Category 1.

Enzyme inducers reduce implant efficacy; IUDs unaffected.

Migraine with aura = no estrogen, but all LARC fine.

Lactation does not preclude any LARC; immediate postpartum placement is supported.

Functional ovarian cysts more common with implant; usually resolve—don't remove device.

Actinomyces on Pap asymptomatic → leave IUD, no treatment.

Pregnancy with IUD + visible strings → remove the IUD.

Continue IUD during PID treatment unless no improvement at 72 h.

Fertility returns immediately after LARC removal.

Strings missing workup: pregnancy test → TVUS → X-ray if needed.

Non-palpable implant → ultrasound (≥15 MHz) or MRI; refer to specialist.

No labs required for routine LARC monitoring.

STI testing at insertion is fine—do not delay placement awaiting results.

Board Question Stem Patterns

— Stem: woman wants highly effective birth control without daily adherence → answer is LARC (specific device depends on co-features)

— Migraine with aura, smoker ≥35, HTN, VTE history, postpartum <21 days → LARC (any), or copper IUD if hormones also avoided (breast cancer)

— Heavy menses, anemia, wants contraception → LNG 52 mg IUD

— Sexually active teen wanting effective method → offer LARC first-line; do NOT pick "condoms alone" or "abstinence counseling"

— Unprotected intercourse 3 days ago, wants ongoing contraception → copper IUD

— UPA (ulipristal) if pills preferred and within 5 days

— Stepwise: urine hCG → TVUS → X-ray if not seen on TVUS

— Strings visible → remove; rule out ectopic first

— Treat with antibiotics, leave IUD in place unless no improvement

— Breastfeeding mother at delivery → immediate postpartum IUD or implant; "wait 6 weeks" is the wrong answer in 2024 guidelines

— Patient on rifampin/AED → IUD over implant

— Do not attempt blind removal → ultrasound/MRI + specialist referral

— Respect autonomy → remove the device; don't talk her out of it

Step 3 management: When the stem includes both a contraception need and a medical comorbidity (cancer, migraine, VTE, liver, lactation), the answer is almost always a specific LARC tailored to the comorbidity—not OCPs, not condoms alone, not "wait."

Board pearl: If two LARC options seem reasonable, choose by secondary benefit (HMB → LNG 52; hormone avoidance → copper; ease of removal/no pelvic exam → implant).

Pattern 1 — "Most effective reversible contraception":

Pattern 2 — Estrogen-contraindicated patient wanting contraception:

Pattern 3 — HMB + contraception needed:

Pattern 4 — Adolescent contraception:

Pattern 5 — Emergency contraception:

Pattern 6 — Missing IUD strings:

Pattern 7 — Pregnancy with IUD:

Pattern 8 — PID with IUD:

Pattern 9 — Postpartum contraception:

Pattern 10 — Drug interaction:

Pattern 11 — Non-palpable implant:

Pattern 12 — Patient requests removal:

One-Line Recap

LARC (IUDs and the etonogestrel implant) is first-line, first-tier reversible contraception for nearly every reproductive-age patient including adolescents and the immediately postpartum—chosen by matching device mechanism to comorbidities (copper for hormone-free or breast cancer, LNG 52 mg for heavy bleeding, implant when pelvic procedures are undesirable) and placed in a single same-day visit without unnecessary pre-screening.

Board pearl: When a Step 3 stem combines a contraception request with virtually any medical complexity—migraine with aura, postpartum, lactation, HMB, breast cancer, liver disease, VTE, enzyme-inducing medications, adolescence, or obesity—the high-yield answer is a specific LARC matched to that comorbidity, not COCs, not DMPA, not condoms alone, and not "return in six weeks."

Step 3 management: Counsel using shared decision-making and tiered effectiveness, place same-day whenever feasible, respect immediate removal requests, document device type/lot/expiration, and continue STI prevention counseling and routine cervical cancer screening independently of the LARC.

Efficacy frame: <1% failure with typical use—equal to or better than tubal sterilization, fully reversible, no adherence required.

Eligibility frame: nearly all patients qualify under US MEC; key Category 4 exceptions are current breast cancer (hormonal LARC), Wilson disease (copper), distorted cavity/active pelvic infection (IUDs), and pregnancy.

Workflow frame: same-day placement is the standard—test pregnancy, screen for STIs at insertion (don't delay), counsel on bleeding expectations, schedule a 4–6 week optional follow-up.

Safety frame: ectopic must be ruled out for any pregnancy with an IUD in place; PID is treated with antibiotics while leaving the device in place; non-palpable implants demand specialist removal under imaging guidance.