February 2016 Bulletin

Long-Acting Reversible Contraceptives for Adolescents and Young Adults: A Q&A With Dr. Anne-Marie Amies Oelschlager

Amies Oelschlager BulletinSeattle Children’s offers a Long-Acting Reversible Contraceptive (LARC) Clinic to place intrauterine devices (IUDs) and birth control implants for adolescents and young adults.

Dr. Anne-Marie Amies Oelschlager, chief of pediatric and adolescent gynecology at Seattle Children’s, addresses questions related to the clinic and its services.

What types of LARCs are approved by the Food and Drug Administration (FDA)?

There are currently four FDA-approved IUDs on the market: Mirena, Skyla, Liletta and ParaGard. The Mirena and Liletta IUDs release the hormone progestin to not only protect against pregnancy, but also reduce menstrual heaviness and pain. The ParaGard IUD, which releases a small amount of copper, does not have hormones and is for contraception only.

Mirena is the most common IUD placed at Seattle Children’s because it has higher levels of progestin than Skyla, resulting in better menstrual suppression.

Mirena can be implanted for five years, Skyla is approved for three years and ParaGard is approved for 10 years. Liletta recently received FDA approval for three years and has the same levels of progestin as Mirena.

Another LARC is the birth control implant Nexplanon, which is a small rod placed under the skin in the upper arm. The device is only used for contraception and is approved for three years.

What are the benefits of LARCs?

LARCs are 20 times more effective at preventing pregnancy in adolescent girls than birth control pills, because teenagers often forget to take their pills.

Mirena has nice medical benefits in addition to contraception. While using the device, periods are about 90% lighter and last for two days, on average. Liletta may have the same benefits as Mirena, but there have not been enough studies yet to know the impact.

LARCs are great options for females with developmental delay who are unable to perform self-care during their periods, and for patients with complex medical issues who may be unable to use other birth control options but need to avoid unplanned pregnancies, like patients with diabetes, epilepsy or who have had a transplant.

Are there some instances when a LARC device is not recommended for a patient?

Patients who have had a pelvic inflammatory disease within the last three months should not have an IUD placed at that time. After the three-month period, they may be able to have the procedure. LARCs are also not approved for women who are already pregnant, and may not be beneficial for patients with certain uterine anomalies.

What are the patient privacy laws related to LARC placement?

Teenagers in Washington can receive a LARC without parental consent or notification at age 14. Most insurance companies cover LARC placements and are legally required to protect patient privacy by not issuing a bill for the visit. Although we protect patient privacy in the clinic and throughout Seattle Children’s, we cannot guarantee the insurance company won’t bill for the visit.

What advice do you have for primary care providers about discussing IUDs and birth control implants with patients?

I encourage providers to ask patients when they ideally see themselves having children and what goals they’d like to achieve before that time. Even though primary care providers can provide patients with the birth control pill, they should talk to their patients about the most effective and longest-acting methods first, which include IUDs and the birth control implant.

It is also important that providers not scare patients but remain honest with them. For example, IUDs do hurt when inserted, and patients will likely cramp for days or even weeks. We always tell patients that if they can make a three-to-six-month commitment to their bodies adjusting to the device, they will get years of benefits.

What are some of the myths about these devices?

There are a lot of myths about IUDs, especially after the class action lawsuit related to the Dalkon Shield IUD, which was very dangerous and went off the market in the 1970s. Since then, new devices have become available that have long track records of being incredibly safe.

Besides the safety of the device itself, some people mistakenly believe IUDs cause abortions and infertility, and can damage the uterus. There is no evidence to support those claims.

Some parents may also be worried that using one of these devices may promote more sexual activity, but there’s no data to support that contraception is an aphrodisiac. What we do know is that when teens get really good information about contraception and the prevention of sexually transmitted infections, it delays sexual intercourse and decreases the rate of unplanned pregnancies.

Is a referral required for patients seeking a LARC at Seattle Children’s?

No. Providers can submit a referral to the clinic, or patients can call 206-987-3005 directly to set up an appointment. When they call, it is important they tell us if they want an IUD or birth control implant placed at the same time as the appointment. We offer the designated LARC Clinic on Wednesdays, but providers also place LARCs during their regular clinic times throughout the week at several locations in the Seattle area.

What are some good online resources about LARCs?

Bedsider.org is a great site to learn more about LARCs. Providers can also check out the Guttmacher Institute for the most recent research on contraceptives.

On Seattle Children’s website, we offer some great information on sex, sexually transmitted diseases (STDs) and birth control through our Teenology 101 blog, including this informative post on LARCs by Dr. Yolanda Evans.

I also recommend the World Health Organization’s contraceptive effectiveness chart (PDF). For teens and young adults, you need to add an extra 50% failure rate to every method in the chart except the IUD and birth control implant because of noncompliance.

Upcoming CME: Pediatric Advanced Life Support (PALS) Courses at Seattle Children’s

2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care, published in the journal Circulation, are being integrated into Seattle Children’s Pediatric Advanced Life Support (PALS) courses.

  • Providers new to PALS can register for the Saturday, March 5, PALS course for physicians and advanced practitioners.
  • Renewing PALS providers can register for Thursday or Saturday HeartCode part 1 (online) and part 2 (classroom) PALS courses in March, April and June.

Visit our PALS page for details on course profile, dates, category 1 CME hours and registration. Questions? Email Outreach Education.

Grand Rounds for March 2016 (CME Credit Available)

Upcoming Grand Rounds

  • March 3: Real Time Dashboards for Clinicians: Is This Our Future?
  • March 10: Antibiotic Use in the 21st Century: How Long Can We Go?
  • March 17: Tobacco and Children in 2016: Who Is Winning?
  • March 24: Primary Immunodeficiency Diseases – Approaching the Paradigm of Precision Medicine
  • March 31: Pediatric Lymphedema: Managing a Difficult Problem
  • See all upcoming grand rounds.

Watch Past Grand Rounds Online

  • Inequities in the Healthcare System
  • G-Tubes and You: Implementing Standard Work and Improving Outcomes
  • Rotavirus: Preventing Another Enteritis
  • Mental Health Across the Medical Education Continuum: Challenges and Opportunities
  • See all online grand rounds.

For Provider Grand Rounds information, visit our website.

New Medical Staff and Allied Health Professionals for February 2016

Medical Staff

  • Amanda Blair, MD, Seattle Children's, Hematology-Oncology
  • Bradford Stephens, MD, Olympia Pediatrics, PLLC, Pediatrics
  • KwiYun (Cassie) Yu, MD, Seattle Children's, Psychiatry and Behavioral Medicine

Allied Health Professionals

  • Annette Anderson, ARNP, Seattle Children's, Anesthesiology and Pain Medicine
  • Katherine Berndt, ARNP, Olympia Pediatrics, PLLC, Pediatrics
  • Elena Bosque, ARNP, Seattle Children's, Neonatology
  • Anna McIntyre, DNP, ARNP, Seattle Children's, Hospital Medicine
  • Jessica Zadorozny, PA-C, Seattle Children's, Emergency Medicine