News item: access to levonorgestrel intrauterine devices/systems widened

From 1 November, 2019, levonorgestrel intrauterine devices (IUDs; also known as levonorgestrel intrauterine systems or LIUS), can now be prescribed fully funded for appropriate indications without Special Authority restrictions.¹ PHARMAC estimates that an additional 21,000 women per year will access funded levonorgestrel IUDs nationally as a result of this decision.¹

Two funded levonorgestrel IUDs will be available in primary care:^{1, 2}

• 13.5 mg (brand name Jaydess®): Indicated for contraception only (lasts three years)
• 52 mg (brand name Mirena®): Indicated for contraception (lasts five years), management of heavy menstrual bleeding, endometriosis^* and prevention of endometrial hyperplasia during oestrogen replacement treatment

^* Unapproved indication.

Why are these changes being made?

The decision to widen funded access to levonorgestrel IUDs will offer women more long-acting reversible contraceptive choices, which are increasingly recommended as the first-line option for people of all ages, including adolescents. Use of a long-acting reversible contraceptive (LARC – including levonorgestrel and copper IUDs and levonorgestrel implants such as Jadelle) is associated with a much lower rate of unintended pregnancy, compared to shorter-acting methods such as oral contraceptives or depot medroxyprogesterone acetate (DMPA) injections.³ In New Zealand, rates of abortion have been declining since the mid-2000s and research suggests that this is due in part to an increased use of LARC.^{4, 5} Reductions have been particularly pronounced in females aged 15–19 years, however, rates of abortion are still highest amongst people of Māori ethnicity and females aged 20–29 years.⁵ Widening access to levonorgestrel IUDs may help to address these inequities.

Prior to this change in access criteria, only the 52 mg levonorgestrel IUD (Mirena) was funded with Special Authority approval; patients were required to have a clinical diagnosis of heavy menstrual bleeding and did not respond to, or could not tolerate, other recommended pharmacological treatments, in addition to low serum ferritin or haemoglobin levels.² Use of levonorgestrel IUDs for any other indication, e.g. contraception, needed to be self-funded by the patient. A 2015 Wellington-based study of women accessing levonorgestrel IUDs via Family Planning clinics showed that there was inequitable access to these devices for Māori, Pacific Peoples and women who lived in Quintile 5 areas (most deprived).⁶

Additional considerations

The upcoming funding changes for levonorgestrel IUDs do not cover costs for insertion or removal of the devices or the appointment fees associated with these procedures. Patients will therefore still need to cover these costs unless they are eligible for a subsidised or no-cost insertion.^* A standard prescription fee for the device will usually apply at the pharmacy.

^* Funding for insertions may be available for some women through their local DHB or PHO. Information will be updated as more details emerge or check the Ministry of Health website.

Two appointments are generally required if a woman is considering a levonorgestrel IUD; one for a discussion to check if it is an appropriate option and another for the insertion procedure. Given that there is likely to be an increase in demand for levonorgestrel IUDs, primary care should anticipate an increased need for staff training^* to perform insertions.

^* Bayer-supported IUD insertion training is available from Family Planning: www.familyplanning.org.nz/courses/course?id=12

As is currently the case, levonorgestrel IUDs will not be available on a Practitioner’s Supply Order (PSO). It is felt that availability of levonorgestrel IUDs on a PSO would not decrease the number of consultations required when women are considering this choice and would also not allow for prescribing data to be collected.¹ Bayer – who is the supplier of both Mirena and Jaydess – will continue to supply a free levonorgestrel IUD replacement directly to clinics in the case of device expulsion.¹

For further information on the use of levonorgestrel IUDs, see: "Long-acting contraceptives: implants and IUDs".