LARC

Updates

Please note ‘52mg LNG-IUD’ refers to hormone containing intrauterine devices (coils) with 52mg levonorgestrel. Devices currently available include Mirena®, Benilexa®, Levosert®.

Other types of LNG-IUD containing smaller amounts of progestogen eg Kyleena®: 19.5mg , Jaydess® 13.5mg

CU-IUD refers to copper intrauterine devices (non-hormonal coils)

Gynefix (16/07/24)

Please be aware Gynefix® is not currently available in the UK and there is NO expectation that the product will become available in UK for the foreseeable future.

Unity will not be able to accept referrals for Gynefix insertion but continue to accept referrals for other copper and LNG (hormonal) IUDs. If you require further information please contact Unity.

CONTRACEPTION

Update May 2024

FSRH CEU Statement: Extended use of all 52mg LNG-IUDs for up to eight years for contraception (May 2024) - Faculty of Sexual and Reproductive Healthcare

As of January 2024, Mirena® users can now be advised that the device can be kept for 8 years for contraception. This also applies to individuals who already have a device in-situ.

In May 2024 the FSRH CEU (Faculty of Sexual and Reproductive Health Clinical Effectiveness Unit) convened an expert group who have reviewed the evidence and support extended use of any 52mg LNG-IUD for up to eight years for contraception if the user is under 45 years old at the time of insertion (Mirena, Levosert, Benilexa). It should be noted that use of Benilexa® and Levosert® for eight years is off-label and prescribers should follow recommendations as set out in MHRA3/GMC4 guidance and the recently updated FSRH Service Standards for Medicines Management.

FSRH CEU advice regarding use of the 52mg LNG-IUD and Cu-IUD after age 45 and 40 respectively remains unchanged:

Individuals who have any 52 mg LNG-IUD inserted when they are ≥45 years old can use the device for contraception until age 55 years, after which time contraception is no longer required.

Individuals who have any CU-IUD containing more than 300mm2 of copper inserted when they are ≥40 years old can use the device for contraception until 1 year after their final menstrual period ( 2 years if under the age of 50), after which time contraception is no longer required.

ENDOMETRIAL PROTECTION/ HEAVY MENSTRUAL BLEEDING

There are no changes to the established FSRH and British Menopause Society recommended duration of use when a Mirena® 52mg LNG-IUD is being used for endometrial protection as part of HRT (5 years from time of insertion) or to existing guidance about duration of use of Mirena® for heavy menstrual bleeding.

As per the FSRH Intra uterine contraception guideline April 2023 any 52 mg LNG-IUD (eg.Mirena®, Levosert®, Benilexa®) can be used for 5 years as endometrial protection as part of hormone replacement therapy (HRT).

Further information can be found at:

https://www.fsrh.org/news/fsrh-ceu-statement-mirena-52mg-lng-iud-extension-of-licence/

https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/

Overview

Long Acting Reversible Contraception (LARC) is recommended for all contraceptive users and are recommended by NICE. Advantages include:

• They are the most effective forms of contraceptive available
• LARC methods contain progesterone only, and therefore have a good safety profile (UKMEC)
• They contain lower daily doses of hormones compared to pills
• They are the most cost effective contraceptives
• Fertility returns to baseline quickly when stopped.
  • The exception is MDPA (injectables) which may result in 6-12 months delayed return of ovulation
• Patients can compare different methods ‘side by side’ on the Family Planning Association/Sexwise website

Types of LARC and duration

• Intrauterine contraception (IUC)
  • Hormone-containing coils (3-8 years)
  • Non-hormone coils (5-10 years)
• Subdermal implant (SDI, Nexplanon®) (3 years)
• Medroxyprogesterone acetate (MDPA) Injectables (12 weeks)
• Intramuscular injection (depo provera®)
• Subcutaneous injection for patient self-administration (sayana press®)

Emergency contraception/IUD

Please see Emergency Contraception page.

Who to refer

Please use the flow diagram to guide referral decisions. More details about steps to take for referral are below.

There is a separate pathway for emergency intrauterine contraceptive devices (emIUD)

Does your patient need referral to secondary care?

• IUCs should be inserted in primary care (including sexual health) unless:
• There are specific medical issues preventing primary care fit
• It is fitted as part of an operative procedure or TOP
•  Please note Unity Sexual health cannot fit coils for purely non-contraceptive purposes
  • (e.g. for hormone replacement therapy (HRT) or menorrhagia management alone)
• Referral to secondary care for Intrauterine Coil Insertion and Removal is subject to the Intrauterine Coil Insertion and Removal in Secondary Care Policy - Criteria Based Access.
• If a coil cannot be fitted in Primary Care for non-contraceptive reasons, please refer to the relevant Gynae clinic for the condition to be treated e.g menorrhagia.

Does your patient need referral to sexual health?

• Any patient in BNSSG requesting IUD/IUS or implant fitting who is aged 20 or over will need to be referred by their GP
• Patients aged <20 can self-refer and or attend Unity Young People’s clinics
• Vulnerable patients aged>20 can be discussed on a case-by-case basis
•  Where patients are eligible to self-refer, but have presented to their GP first, a referral letter is still helpful for our triage process
  • MDPA Injectables do not require referral

Please note that Unity and the WISH clinic in Weston do not offer a walk in service 

What to do before referral for IUD or SDI

Referral for fitting

1. Prevent pregnancy whilst the patient awaits LARC
   • Consider bridging with another form of contraception e.g. POP
2. IUC fit considerations
   • An IUC can only be fitted if there is no risk of pregnancy. This is assessed using the criteria in Box 1, page 5 of the Intrauterine contraception guideline
   • Further information for patients about IUC fit is found here and a self-assessment form is here
3. SDI fit considerations
   • The SDI can be quick-started even if there is a pregnancy risk

Referral for removal/ refit

1. There is patient advice about stopping contraception here
2. IUC removal considerations
   • There is a risk of pregnancy if an IUC is removed within 7d of having UPSI. Therefore unless planning to conceive, An IUC cannot be removed, or removed and replaced with another IUC if unprotected sex has taken place in the last 7 days

Complex referrals / problems with IUC / SDI 

If the referral is for a complex removal or refit or there are problems with an ICU/SDI see LARC Complex referrals and problem management

Referral

Note: Unity is not commissioned to provide LARC for reasons other than contraception and will not be able to accept referrals for removal replacement of LNG-IUDs earlier than their recommended duration for contraception. They are also not able to accept referrals for LNG-IUD insertion in individuals over the age of 55 as contraception is no longer required after this time.

LARC waiting times can be up to 10-12 weeks for both routine and complex referrals.

Please use the flow diagram to guide referral decisions.

Referrals to Unity (Bristol and South Glos)

Use the Unity Sexual Health LARC referral form (available as a template in EMIS).

From 02/07/24 all referrals should be sent via eRS. The service is found under Genito-urinary medicine.

LARC advice is also available via eRS (also under Genito-urinary medicine)

Referrals to WISH Clinic (North Somerset)

North Somerset Practices can refer to the WISH clinic at Weston General Hospital.

Use the WISH LARC referral form. (available as a template in EMIS).

Email completed forms to: WishCentre@UHBW.nhs.uk Do not post referrals.

Main phone number: 01934 881234.

Where patients are eligible to self-refer, but have presented in primary care first, please provide a referral to improve referral triage

If you need to refer a complex or vulnerable patient please complete the LARC form with details.

If urgent please contact 0117 342 6913 during working hours for the professional advice line.

Resources

Contraceptive safety (UKMEC)  

FSRH method guides https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/

LARC decision making aid for patients Family Planning Association/Sexwise website

IUC fitting advice for patients here

IUC post fitting advice for patients here

IUC removal advice for patients here

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.