From the Guidelines
For breakthrough bleeding in patients on Nexplanon (etonogestrel implant), the primary treatment options include hormonal treatment, antifibrinolytic agents, and nonsteroidal anti-inflammatory drugs (NSAIDs), with the choice of treatment depending on the patient’s preferences, treatment goals, and medical history, as recommended by the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.
Treatment Options
- Hormonal treatment, such as 20–30 μg ethinylestradiol (EE) combined oral contraceptives (COCs) or estrogen, can be used to improve bleeding irregularities during treatment use, with treatment repeated as needed 1.
- Antifibrinolytic agents, such as tranexamic acid, can be used for 5 days to improve bleeding irregularities during treatment use, with treatment repeated as needed 1.
- NSAIDs, such as celecoxib, ibuprofen, or mefenamic acid, can be used for 5–7 days to improve bleeding irregularities during treatment use, with treatment repeated as needed, and whose effects might persist for some time after treatment cessation 1.
Patient-Centered Approach
- Explore patient goals, including continued implant use (with or without treatment for bleeding irregularities) or implant removal, and provide reassurance and advise the patient that they may contact their provider at any time to discuss bleeding irregularities or other side effects 1.
- If the patient desires implant removal at any time, remove the implant, offer counseling on alternative contraceptive methods, and initiate another method if desired 1.
Underlying Health Conditions
- If clinically indicated, consider an underlying health condition, such as interactions with other medications, sexually transmitted infections (STIs), pregnancy, thyroid disorders, or new pathologic uterine conditions (e.g., polyps or fibroids), and treat the condition or refer for care 1.
From the Research
Treatment for Breakthrough Bleeding in Patients on Nexplanon (Etonogestrel)
- Breakthrough bleeding is a common side effect of hormonal contraception, including Nexplanon (etonogestrel) 2, 3, 4.
- There is limited research specifically on treating breakthrough bleeding in patients on Nexplanon, but studies suggest that combined hormonal contraceptives may be effective in reducing breakthrough bleeding 4.
- A randomized controlled trial found that a 14-day oral contraceptive pill regimen can temporarily interrupt bleeding in etonogestrel implant users, but bleeding often resumes within days of treatment cessation 5.
- The use of St John's wort, a popular herbal remedy, may reduce the efficacy of oral contraceptives and increase the risk of breakthrough bleeding due to its induction of cytochrome P450 (CYP) 3A enzymes 6.
Management Options
- Temporary interruption of bleeding using a 14-day oral contraceptive pill regimen may be an option for managing breakthrough bleeding in patients on Nexplanon 5.
- Combined hormonal contraceptives may be considered as an alternative to progestin-only pills, such as Nexplanon, to reduce the risk of breakthrough bleeding 4.
- Patients should be counseled to expect breakthrough bleeding when using Nexplanon and to consider adding a barrier method of contraception when consuming St John's wort 6.
Considerations
- The risk of breakthrough bleeding should be weighed against the benefits of using Nexplanon, including its convenience and effectiveness as a contraceptive method.
- Patients experiencing breakthrough bleeding should be evaluated for any underlying conditions that may be contributing to the bleeding, and treatment should be individualized based on their specific needs and medical history.