ABSTRACT
INCREASING ACCESS to long-acting reversible contraceptives (LARCs) is key to reducing rates of unintended pregnancy and abortion.1'2 LARCs, including hormonal and copper-bearing intrauterine devices (IUDs) and the contraceptive implant, provide highly effective 'set-andforget' contraception, which are suitable for provision in general practice.3 They have very few contraindications and can be recommended as first-line contraceptive options across the reproductive lifespan, from adolescence to perimenopause.4 The Family Planning Alliance Australia contraceptive efficacy card is a useful tool to support informed decision making when discussing contraceptive options with patients (Figure 1).5 In Australia, uptake of LARCs has been increasing, with Pharmaceutical Benefits Scheme (PBS) claims for hormonal IUDs and implants almost doubling between 2006 and 2018, and Medicare Benefits Schedule data indicating a more than three-fold increase in IUD insertion procedures for people aged 15-24 years in the past 10 years.6'7 A recent survey also estimated that 10.8% of women aged 15-44 years were using a LARC.8 The recently completed Australian Contraceptive Choice pRoject showed that a combination of training doctors in providing LARC information and rapid access to LARC insertion clinics increases LARC uptake.9 The UK Faculty of Sexual and Reproductive Healthcare (FSRH) recommends extended use of LARC methods during the COVID-19 pandemic, as access to clinical services for removal/ replacement were limited in the UK.10 In Australia, where access has generally been maintained, removal/replacement according to current eTG guidelines is recommended, with case-by-case shared decision making with the patient when access to LARC insertion is limited.4,11 This article summarises the most recent updates to guidelines and practical recommendations concerning LARC use. The insertion technique is identical for both devices, and both are licensed for up to five years of use.16'17 Kyleena insertion might be easier and associated with less discomfort than Mirena, given the smaller insertion tube and device dimensions.18 As a result, Kyleena could be a suitable option for people with a relatively small cervical canal and/or uterine cavity, including nulliparous and younger people.19 While both devices can be associated with initial irregular bleeding, trial data suggest that Kyleena could be associated with a slightly higher average number of bleeding/spotting days and lower rates of amenorrhoea compared with Mirena.18 Most other hormonally related side effects appear similar between Mirena and Kyleena, including acne, breast discomfort and weight gain, although Kyleena is associated with a reduced risk of benign functional ovarian cysts compared with Mirena.18 As a result of its lower hormone dose, Kyleena, unlike Mirena, is not licensed either for the management of heavy menstrual bleeding or for endometrial protection with menopause hormone therapy (MHT) and is not recommended for extended use from the age of 45 years.16'17'20 A recent randomised trial indicated that Mirena could provide effective emergency contraception;however, due to data limitations, it cannot be recommended in this situation.21'22 As patients approach menopause, expert opinion supports extended off-label contraceptive use of the Mirena and copper IUDs. For patients using an LNG IUD, contraceptive implant or progestogen-only pills who have been amenorrhoeic for at least 12 months since turning 50, updated guidance recommends that a singleserum follicle stimulating hormone (FSH) level can be used to determine the need for ongoing contraception. Alternatively, patients can continue their progestogen-only method of contraception, provided they remain medically eligible, until the age of 55 years, after which the risk of conception is negligible.20 Further information and a flowchart for contraception use from 50 years of age is available from Sexual Health Victoria (formerly Family Planning Victoria;https://shvic. org.au/assets/img/content/SHV_ ContraceptionWomenOver40.pdf).