FSRH CEU recommendation on extended use of the etonogestrel implant and 52mg levonorgestrel-releasing intrauterine system during COVID restrictions

20 March 2020

At present, to reduce risk of coronavirus transmission, non-essential face-to-face contact with healthcare providers is being minimised where possible. Replacement procedures for long-acting reversible contraceptive (LARC) devices that have recently expired are non-essential. The available evidence suggests that the risk of pregnancy in the 4th year of use of the etonogestrel implant (ENG-IMP) and the 6th year of use of a 52mg levonorgestrel-releasing intrauterine system (LNG-IUS) is likely to be very low. Unfortunately studies are too small to allow an accurate evidence-based estimate of contraceptive effectiveness to be made.

The evidence – etonogestrel implant (ENG-IMP) A total of 783 women across 5 observational studies used the ENG-IMP for 4 years and 306 for 5 years – no pregnancies were observed, but numbers are small.1

The evidence – 52mg levonorgestrel-releasing intrauterine system (LNG-IUS) McNicholas et al. reported pregnancy rates for the 52mg LNG-IUS of 0.25 and 0.43 per 100 woman years for the 6th and 7th years of use respectively (347 subjects completed 6 years and 160 completed 7 years of use).2 Rowe et al. reported a 7 year cumulative pregnancy rate for the 52mg LNG-IUS of 0.5% (681 women completed 6 years and 398 completed 7 years of use).3 Wu et al. reported on much smaller, earlier studies of under 100 women in which no pregnancies were observed in years 6 and 7 of 52mg LNG-IUS use).4 It is noted that all numbers are small.

FSRH CEU conclusion FSRH CEU suggests that, in the current circumstances, individuals requesting replacement of their ENG-IMP at 3 years or 52mg LNG-IUS at 5 years can be advised that their risk of pregnancy is likely to be very small during the first year of extended use (up to 4 years for the ENG-IMP and up to 6 years for the 52mg LNG-IUS). Replacement can be delayed for up to a year after expiry to avoid unnecessary risk of coronavirus transmission due to contact with healthcare professionals. (Note that individuals using Mirena® for endometrial protection as part of HRT must have the IUS changed at 5 years, or switch to a combined HRT preparation.) Extended use of lower dose LNG-IUS devices is not recommended.

Users should be made aware that contraceptive effectiveness cannot be guaranteed. Individuals may wish to use condoms in addition, or to add in a progestogen-only contraceptive pill (POP). After 4 completed years of use of the ENG-IMP and 6 completed years of use of the 52mg LNG-IUS, all women should be advised to use condoms in addition or to add a POP (note that the contraceptive effectiveness of a POP is reduced by concomitant use of an enzyme inducing medication).

Women aged over 45 years at the time of 52mg LNG-IUS insertion should continue to be advised that contraceptive effectiveness is maintained until age 55 at which time contraception is no longer required.

References
1. Thaxton L, Lavelanet A. Systematic review of efficacy with extending contraceptive implant duration. International Journal of Gynecology & Obstetrics 2019;144(1):2-8.
2. McNicholas C, Maddipati R, Zhao Q, Swor E, Peipert JF. Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the US Food and Drug Administration–approved duration. Obstetrics and gynecology 2015;125(3):599.
3. Rowe P, Farley T, Peregoudov A, Piaggio G, Boccard S, Landoulsi S, Meirik O. Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: a 7-year randomized comparative study with the TCu380A. Contraception. 2016;93(6):498-506.
4. Wu JP, Pickle S. Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception. 2014;89(6):495-503.

The Clinical Effectiveness Unit (CEU) was formed to support the Clinical Effectiveness Committee of the Faculty of Sexual and Reproductive Healthcare (FSRH), the largest UK professional membership organisation working at the heart of sexual and reproductive healthcare. The CEU promotes evidence based clinical practice and it is fully funded by the FSRH through membership fees. It is based in Edinburgh and it provides a member’s enquiry service, evidence based guidance, new SRH product reviews and clinical audit/research. Find out more here.