What are the management options for irregular bleeding with Implanon (etonogestrel implant) after cessation of breastfeeding?

From the Guidelines

Irregular bleeding with Implanon after breastfeeding cessation can be managed with short-term hormonal treatments and reassurance, with first-line treatment typically being a 5-7 day course of NSAIDs like ibuprofen (400-800mg three times daily) to reduce prostaglandin production and decrease bleeding. The management of irregular bleeding with Implanon involves considering an underlying gynecological problem, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids) 1. If an underlying gynecologic problem is found, treatment of the condition or referral for care is necessary.

If no underlying gynecologic problem is found and the woman wants treatment, the following options can be considered:

• NSAIDs for short-term treatment (5–7 days)
• Hormonal treatment (if medically eligible) with low-dose COCs or estrogen for short-term treatment (10–20 days) 1. Alternatively, estradiol (1-2mg daily for 14-21 days) may help regulate bleeding patterns. For persistent heavy bleeding, tranexamic acid (500-1000mg three times daily for 5 days) can reduce blood loss. These interventions are temporary, as bleeding patterns often improve naturally within 3-6 months as the body adjusts to the implant's hormone levels. The irregular bleeding occurs because etonogestrel causes endometrial atrophy and changes in endometrial vasculature, which is often exacerbated when estrogen levels rise after breastfeeding ends. If bleeding remains problematic despite interventions, implant removal and alternative contraception should be discussed. It is also important to note that unscheduled bleeding can be a sign of an STI, and adolescents should be tested accordingly 1.

Some key points to consider in the management of irregular bleeding with Implanon include:

• Evaluation for underlying conditions
• Treatment of underlying conditions if found
• Use of NSAIDs or hormonal treatments for short-term management
• Consideration of implant removal and alternative contraception if bleeding persists
• Importance of testing for STIs in adolescents with unscheduled bleeding.

Overall, the management of irregular bleeding with Implanon after breastfeeding cessation requires a comprehensive approach that considers the woman's individual needs and medical history.

From the Research

Management Options for Irregular Bleeding with Implanon

After cessation of breastfeeding, women using Implanon (etonogestrel implant) may experience irregular bleeding patterns. The following management options are available:

• Combined Oral Contraceptive Pills (COCP): Studies have shown that COCP can be effective in managing bleeding irregularities among etonogestrel implant users 2. A prospective randomized study found that COCP was more efficient than nonsteroidal anti-inflammatory drugs (NSAID) in stopping bleeding within 7 days after initiation of treatment.
• Nonsteroidal Anti-Inflammatory Drugs (NSAID): NSAID, such as mefenamic acid, can also be used to manage irregular bleeding associated with Implanon use 3. A double-blind, placebo-controlled study found that mefenamic acid was more effective than placebo in short-term treatment of irregular bleeding and spotting.
• Pharmacological Treatments: The management of unacceptable vaginal bleeding patterns in etonogestrel-releasing contraceptive implant users can be approached through pharmacological treatments, including COCP and NSAID 4.
• Relationship Between Etonogestrel Concentrations and Bleeding Patterns: Research has shown that higher levels of progestin from the contraceptive implant may be associated with bleeding side effects experienced by women 5. This suggests that pharmacologic variation may influence the side effects women experience with hormonal contraceptive methods.

Key Findings

• Implanon use is associated with unpredictable bleeding patterns, including amenorrhea and infrequent, frequent, and/or prolonged bleeding 6.
• The bleeding pattern experienced during the first three months of Implanon use is broadly predictive of future bleeding patterns for many women 6.
• COCP and NSAID can be effective in managing bleeding irregularities among etonogestrel implant users 2, 3.
• Higher levels of progestin from the contraceptive implant may be associated with bleeding side effects experienced by women 5.