Nexplanon Does NOT Need to Be Removed for Oophorectomy
The Nexplanon implant does not need to be removed prior to oophorectomy, even in a patient with Factor V Leiden. The implant can safely remain in place during and after the surgery.
Rationale Based on Thrombotic Risk
Factor V Leiden and Progestin-Only Contraception
According to the 2024 CDC Selected Practice Recommendations for Contraceptive Use, progestin-only implants receive a Category 2 classification for patients with Factor V Leiden thrombophilia 1. This means the advantages of using the method generally outweigh the theoretical or proven risks. Importantly:
- Implants are NOT contraindicated in patients with thrombophilia, including Factor V Leiden
- The classification is Category 2 (benefits outweigh risks), not Category 3 or 4 (which would suggest avoiding use)
- This applies even to patients with higher thrombotic risk factors 1
Surgery-Related Thrombotic Risk
The same guidelines address surgical considerations 1:
- Major surgery WITHOUT prolonged immobilization: Category 1 for implants (no restriction)
- Major surgery WITH prolonged immobilization: Category 2 for implants (benefits generally outweigh risks)
Oophorectomy typically does not involve prolonged immobilization, making the implant even safer in this context. The progestin-only nature of Nexplanon carries substantially lower thrombotic risk compared to combined hormonal contraceptives (CHCs), which receive Category 4 ratings (unacceptable health risk) for Factor V Leiden 1.
Why Removal Is Unnecessary
Mechanism and Safety Profile
- Nexplanon contains only etonogestrel (a progestin), with no estrogen component 2
- Estrogen is the primary driver of thrombotic risk in hormonal contraception
- Progestin-only methods like implants have minimal impact on coagulation parameters
- The implant's systemic progestin levels are lower than oral progestins
Practical Considerations
Removing the implant would create unnecessary risks and burdens:
- Requires a separate minor surgical procedure with its own risks (infection, nerve injury, bleeding) 2
- May leave the patient without contraception postoperatively when pregnancy prevention remains important
- Adds no meaningful reduction in perioperative thrombotic risk
- The patient would need alternative contraception arranged
Perioperative Thromboprophylaxis
The appropriate management focuses on standard perioperative VTE prophylaxis, not implant removal:
- Mechanical prophylaxis (sequential compression devices)
- Pharmacologic anticoagulation as indicated by surgical risk assessment and Factor V Leiden status 3
- Early mobilization postoperatively
- Risk stratification based on heterozygous vs homozygous Factor V Leiden status 4
The French Society of Endocrinology guidelines note that progestin-only implants can be used after surgery, with the main restriction being avoiding combined estrogen-progestin contraceptives in the first 6 weeks post-surgery due to thrombotic risk 5. This further supports leaving the progestin-only implant in place.
Key Clinical Pitfall to Avoid
Do not confuse the contraindications for combined hormonal contraceptives (pills, patches, rings) with those for progestin-only methods like Nexplanon. The thrombotic risk profiles are fundamentally different. Factor V Leiden is a Category 4 (unacceptable risk) for CHCs but only Category 2 (generally safe) for implants 1.
The implant should remain in place, and standard perioperative VTE prophylaxis protocols should be followed based on the patient's Factor V Leiden status and surgical risk factors.