From the Guidelines
For a 31-year-old woman with Nexplanon experiencing prolonged vaginal bleeding for 3 months, I would recommend obtaining a complete blood count (CBC) to assess for anemia, pregnancy test to rule out pregnancy complications, cervical cytology if due, and STI testing if risk factors are present. If all labs return normal, the initial treatment would be a short course of NSAIDs, such as ibuprofen 600-800 mg three times daily for 5-7 days, as this is a recommended treatment option for implant users with heavy or prolonged bleeding, according to the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1. Other treatment options, such as hormonal treatment (e.g., low dose COCs or estrogen) or antifibrinolytic agents (e.g., tranexamic acid), may also be considered, but NSAIDs are a reasonable first-line choice given their efficacy and safety profile 1. It's essential to explore the patient's goals and preferences, including continued method use or method discontinuation, and to advise the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects 1. Key considerations in the management of bleeding irregularities while using contraception include:
- Exploring patient goals and preferences
- Providing reassurance and advising the patient to contact their provider as needed
- Considering treatment options, such as NSAIDs, hormonal treatment, or antifibrinolytic agents
- Evaluating for underlying health conditions, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions 1.
From the Research
Initial Evaluation
To evaluate a 31-year-old woman with Nexplanon (etonogestrel implant) for 2 years who is experiencing prolonged vaginal bleeding for 3 months, the following initial steps should be considered:
- Perform a thorough medical history and physical examination to rule out any underlying conditions that may be contributing to the bleeding.
- Consider laboratory tests to evaluate for any potential causes of the bleeding, such as:
- Complete blood count (CBC) to rule out anemia or thrombocytopenia
- Pregnancy test to rule out pregnancy
- Thyroid function tests to evaluate for thyroid dysfunction
- Coagulation studies to evaluate for any bleeding disorders
Treatment Options
If all laboratory tests are normal, treatment options for the prolonged vaginal bleeding can be considered:
- According to a study published in 2020 2, combined oral contraceptive pills (COCP) may be an effective treatment option for managing bleeding irregularities in etonogestrel implant users.
- The study found that COCP was more efficient than nonsteroidal anti-inflammatory drugs (NSAID) in managing bleeding irregularities, with 76.2% of women in the COCP group stopping bleeding within 7 days of treatment initiation, compared to 35.7% in the NSAID group.
- Another study published in 2008 3 found that ethinyl estradiol (EE) decreased spotting but had no effect on bleeding in women using the levonorgestrel subcutaneous implant.
- A study published in 2009 4 compared the bleeding patterns of women using extended regimens of the vaginal ring or oral contraceptives, and found that both methods decreased the total number of scheduled and unscheduled bleeding and spotting days, but the decrease was significantly higher for oral contraceptive users.
Considerations
When considering treatment options, it is essential to take into account the individual patient's medical history, preferences, and potential risks and benefits of each treatment option.
- A study published in 2011 5 highlighted the benefits of extended-cycle levonorgestrel-ethinyl estradiol oral contraceptives, which may be of particular benefit in women with medical comorbidities who would benefit from less withdrawal bleeds.
- However, it is crucial to carefully counsel women regarding the initial increased breakthrough bleeding associated with extended-cycle OCPs.