What is the workup and cause of new vaginal bleeding in a patient 1 year after Nexplanon (etonogestrel) implant insertion?

From the Guidelines

New vaginal bleeding one year after Nexplanon insertion requires immediate evaluation to rule out underlying gynecological problems, such as pregnancy, infection, or anatomical causes, and consideration of the implant itself as a potential cause of irregular bleeding patterns 1. The workup should begin with a pregnancy test, followed by a pelvic examination to check for cervical lesions, polyps, or signs of infection. Additional testing may include cervical cultures, a Pap smear if due, and possibly transvaginal ultrasound to evaluate the endometrium and rule out structural abnormalities. Some key points to consider in the workup and management of new vaginal bleeding in a patient with a Nexplanon implant include:

• The most common cause of this bleeding is a normal side effect of the implant itself, as Nexplanon can lead to irregular bleeding patterns in up to 33% of users throughout its use 1.
• Etonogestrel, the active metabolite in Nexplanon, causes thinning of the endometrial lining, making it more fragile and prone to breakthrough bleeding.
• Management options include observation if bleeding is mild, or short-term treatment with NSAIDs like ibuprofen 600-800mg three times daily for 5-7 days to reduce bleeding 1.
• For persistent bothersome bleeding, a short course of combined oral contraceptives or estrogen supplementation may be prescribed 1.
• If bleeding is severe or other pathology is identified, removal of the implant and alternative contraception should be considered 1.

From the Research

Workup for New Vaginal Bleeding on Nexplanon

• The workup for new vaginal bleeding in a patient 1 year after Nexplanon (etonogestrel) implant insertion may involve evaluating the patient's medical history, performing a physical examination, and conducting laboratory tests to rule out any underlying conditions that may be causing the bleeding 2.
• A thorough medical history should include questions about the patient's menstrual history, any changes in bleeding patterns, and any other symptoms such as pelvic pain or discharge.
• A physical examination should include a pelvic exam to check for any abnormalities in the reproductive organs.

Possible Causes of New Vaginal Bleeding on Nexplanon

• One possible cause of new vaginal bleeding on Nexplanon is a broken or fractured implant, as seen in a case report where a patient experienced persistent and prolonged vaginal bleeding after her Implanon device was broken during a physical activity 3.
• Another possible cause is endometrial intraepithelial neoplasia, a precursor lesion to endometrial adenocarcinoma, which has been shown to regress with the use of the etonogestrel subdermal implant 4.
• Other possible causes of vaginal bleeding on Nexplanon may include hormonal changes, uterine fibroids, or other gynecological conditions.

Evaluation and Management

• The evaluation and management of new vaginal bleeding on Nexplanon should be individualized based on the patient's medical history, physical examination, and laboratory test results.
• The patient's implant should be checked to ensure it is intact and properly placed, and any underlying conditions that may be causing the bleeding should be treated accordingly.
• The patient should be counseled on the potential causes of vaginal bleeding on Nexplanon and the importance of follow-up appointments to monitor her condition 5, 6.