Will removal of Nexplanon (etonogestrel implant) stop heavy bleeding in a 43-year-old female with severe anemia (low hemoglobin level) or are additional interventions necessary?

Management of Heavy Bleeding with Nexplanon Implant

Recommendation for Nexplanon Removal

Removal of the Nexplanon implant is strongly recommended for this patient with severe anemia (hemoglobin 8.5 g/dL) due to prolonged heavy bleeding, and additional interventions should be implemented to address the anemia.

Understanding the Clinical Situation

This 43-year-old female presents with:

• Nexplanon implant in place for 3 years
• 10 days of heavy bleeding
• Hemoglobin of 8.5 g/dL (severe anemia)

Management Algorithm

1. Immediate Management

• Remove the Nexplanon implant

  • Removal of the implant is the definitive treatment for implant-related bleeding
  • Bleeding typically improves within days after removal 1
  • The patient's expressed desire for removal should be respected

• Address the severe anemia

  • Hemoglobin of 8.5 g/dL requires prompt attention
  • Consider oral iron supplementation to replenish iron stores
  • Monitor hemoglobin levels until normalized

2. Pharmacological Options While Awaiting Removal

If immediate removal is not possible, consider temporary measures:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Can reduce bleeding volume
  • Short course (5-7 days)

• Combined hormonal contraceptives

  • Can stabilize the endometrium
  • Consider for 10-20 days if no contraindications

3. Post-Removal Care

• Iron supplementation

  • Continue until hemoglobin normalizes and iron stores replenish
  • Consider intravenous iron if severe symptoms or poor oral absorption

• Alternative contraception counseling

  • Discuss other contraceptive options that may have better bleeding profiles
  • Consider patient's reproductive goals and medical history

Clinical Considerations

Severity of Anemia

• Hemoglobin of 8.5 g/dL represents significant anemia that requires intervention
• Symptomatic anemia (fatigue, dizziness, shortness of breath) should be treated promptly
• Consider transfusion only if hemodynamically unstable or symptomatic despite other measures 1

Bleeding Pattern with Nexplanon

• Irregular bleeding is a common side effect of Nexplanon
• Prolonged or heavy bleeding can lead to significant anemia as seen in this patient
• When bleeding becomes severe enough to cause significant anemia, removal is appropriate

Risk of Recurrent Anemia

• Heavy menstrual bleeding can lead to potentially life-threatening anemia if not addressed 2
• Some women may not recognize the serious nature of their blood loss
• This patient's hemoglobin of 8.5 g/dL indicates significant blood loss requiring intervention

Important Caveats

1. Rule out other causes of bleeding

   • While Nexplanon is likely the cause, consider other etiologies of abnormal uterine bleeding
   • Approximately 4.8% of cases of severe anemia from menstrual bleeding may be due to underlying malignancy 2

2. Don't delay treatment

   • Chronic excessive blood loss should be treated as both an urgent and potentially recurrent problem
   • Avoid the common pitfall of discharging patients without offering therapy to prevent subsequent bleeding 2

3. Follow-up is essential

   • Schedule follow-up to ensure bleeding has resolved and anemia is improving
   • Consider additional workup if bleeding persists after implant removal

By removing the Nexplanon implant and addressing the anemia, this patient should experience resolution of her heavy bleeding and improvement in her hemoglobin levels.