ACOG Guidance on Clinical Challenges in Contraception

Practice Watch |
October 3, 2016

ACOG Guidance on Clinical Challenges in Contraception

  1. Eleanor Bimla Schwarz, MD, MS

New recommendations help troubleshoot use of subdermal and intrauterine contraception.

  1. Eleanor Bimla Schwarz, MD, MS

In recent years, use of highly effective reversible contraceptives has risen — and subdermal contraceptive implants as well as intrauterine contraceptives (IUCs) both have excellent safety records. To aid in the management of clinical challenges with these contraceptives, the American College of Obstetricians and Gynecologists (ACOG) has published new algorithms. Key points include the following:

  • For nulliparous women, routine use of misoprostol before IUC placement is generally not recommended.

  • When IUC strings cannot be located, pregnancy must be excluded and alternative contraception recommended until the proper location of the IUC in the endometrial cavity is confirmed.

  • An IUC located within the cervix should be removed (and replaced with a new IUC if the woman desires).

  • Should a woman with an IUC become pregnant, the IUC should be removed immediately if strings are visible.

  • When a subdermal contraceptive implant is not palpable, the possibility of pregnancy should be excluded and the women should be counselled to use other contraception.

  • If the contraceptive implant is not palpable, removal should not be attempted until the location has been determined.

Comment

Given that the challenges addressed by these algorithms occur so rarely, it's helpful to have a quick reference to guide management when such clinical situations do arise. More-common challenges faced by women are learning that these contraceptive options exist and finding a clinician able to place subdermal or intrauterine contraception. The other challenge clinicians must guard against is the possibility that women feel coerced into using long-acting methods. To this end, we must promptly remove such contraceptives whenever help is requested.

Editor Disclosures at Time of Publication

  • Disclosures for Eleanor Bimla Schwarz, MD, MS at time of publication Grant / Research support Office of Adolescent Health Editorial boards Contraception; Journal of General Internal Medicine

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