Long-Acting Reversible Contraception (LARC) in Adolescents
Dr Steven R. Goldstein a leading Gynecologist in NYC , writes about long acting reversible contraception (LARC).
Unfortunately, in this country approximately one half of pregnancies are unintended. A majority of unintended pregnancies will result in an unintended baby, at least on a national level (not necessarily in my practice). Thus, from a public health point of view, preventing unintended pregnancy is extremely important. This is one reason why the American College of Obstetricians and Gynecologists and even the American Academy of Pediatricians have now advocated various forms of long-acting reversible contraception (implanted pellets, and intrauterine devices), also known as LARC, in adolescents (in fact, even in some who are not yet sexually active).
I have great difficulty with these recommendations. When I trained, I was taught that the two most important requirements for placing an IUD were:
1) stable monogamous sexual relationship and
2) having had a child because the uterus grows some with child bearing.
Most of my young patients practice serial monogamy. It is very unlikely that the college student who has a boyfriend will end up marrying that young man (although, not impossible).
If one were to contact a sexually transmitted infection with an IUD in place, it can serve somewhat like a wick and help spread it up through the uterus to the fallopian tubes. A small percent of women with this device will, therefore, become infertile due to tubal damage. However, if one is the Secretary of Health and Human Services, if you prevent a large number of unintended pregnancies with a very small number of now infertile women, that is a victory for the healthcare system. However, it is not a victory for the women who now becomes infertile. I have been a backup for Student Health Service at NYU Washington Square. In the past, I had two college students sent to me who had expelled two IUDs each. They were sent to me for sonohysterography to evaluate their uterine cavity to see if there was some structural abnormality causing them to expel the intrauterine device. On 3-D ultrasound, both of these young women had a distance across the top of the uterus that measured 2.9 cm. The device, when fully opened, measures 3.2 cm. Their uteri were just not large enough and developed enough as adolescents to accommodate the intrauterine device.
I have written previously about the extent of non-contraceptive benefits of birth control pills. Malcolm Gladwell published an article in the New Yorker magazine almost two decades ago entitled, “John Rock’s error.” John Rock was one of the inventors of birth control pills.
The feeling was that they should have brought these out as cancer reducing agents rather than contraceptives.
When there are no contraindications to hormonal cycle control (i.e. birth control pills or the intravaginal birth control ring), I believe suppressing ovulation with pills in such women is a far superior choice than the IUD or subcutaneous pellets.
Dr Steven R. Goldstein is a leading Gynecologist in NYC, in private practice for over 25 years. He is a Professor of Obstetrics and Gynecology at New York University School of Medicine, the author of several books on Gynecologic Ultrasound, Perimenopause and “The Estrogen Alternative”. If you are interested in birth control or in discussing the use of birth control pills for cancer prevention in the Perimenopause or Menopause stage of life, then contact Dr Goldstein, a NYC Gyn