How to manage bleeding in patients with Nexplanon (etonogestrel implant)

Management of Bleeding with Nexplanon (Etonogestrel Implant)

For patients experiencing bleeding with Nexplanon, first rule out underlying gynecological conditions, then use NSAIDs for short-term treatment (5-7 days) or hormonal treatment with low-dose combined oral contraceptives for 10-20 days if medically eligible. 1

Initial Assessment

Before initiating treatment for bleeding associated with Nexplanon, consider:

1. Rule out underlying gynecological conditions:

   • Interactions with other medications
   • Sexually transmitted infections
   • Pregnancy
   • Pathologic uterine conditions (polyps, fibroids)
   • If any underlying condition is found, treat accordingly or refer for care 1

2. Understand bleeding patterns with Nexplanon:

   • Irregular bleeding is common and expected
   • Data shows 22% of users experience amenorrhea, 34% experience infrequent spotting, 7% experience frequent bleeding, and 18% experience prolonged bleeding 1
   • Most bleeding patterns are not harmful and may improve over time

Treatment Algorithm for Nexplanon-Related Bleeding

Step 1: Patient Counseling

• Reassure that irregular bleeding is common, expected, and generally not harmful
• Enhanced counseling about expected bleeding patterns has been shown to reduce discontinuation 1

Step 2: Treatment Options (if bleeding is bothersome to patient)

For active bleeding episodes:

1. First-line: NSAIDs for 5-7 days 1

   • Mefenamic acid 500mg three times daily for 5 days has shown significant cessation of bleeding within 7 days compared to placebo 1
   • Celecoxib 200mg daily for 5 days has also demonstrated effectiveness 1
   • Ibuprofen has shown mixed results in studies 1

2. Second-line: Hormonal treatment for 10-20 days (if medically eligible) 1

   • Low-dose combined oral contraceptives (COCs)
     • COCPs containing 20mcg ethinyl estradiol/150mg desogestrel for two continuous cycles have been shown to be more effective than NSAIDs, with 76.2% of women stopping bleeding within 7 days versus 35.7% with NSAIDs 2
   • Ethinyl estradiol alone (20-50mcg daily)
     • Studies show ethinyl estradiol can reduce bleeding days during treatment 1, 3

Step 3: Follow-up Management

• If bleeding persists despite treatment and is unacceptable to the patient:

  • Counsel on alternative contraceptive methods
  • Offer another method if desired 1

• For amenorrhea:

  • Reassurance only, no medical treatment required
  • Rule out pregnancy if there is an abrupt change from regular bleeding to amenorrhea
  • If amenorrhea is unacceptable to the patient, counsel on alternative methods 1

Evidence Strength and Considerations

• Studies specifically examining etonogestrel implant (Nexplanon) bleeding management are limited, with some evidence extrapolated from levonorgestrel implant studies
• The most recent evidence shows combined oral contraceptives are more effective than NSAIDs for managing bleeding irregularities in etonogestrel implant users 2
• Mifepristone combined with either ethinyl estradiol or doxycycline has shown effectiveness in stopping bleeding episodes but does not improve subsequent bleeding patterns 4

Important Caveats

• Bleeding patterns often improve over time with continued use
• Treatment is only necessary if the bleeding is bothersome to the patient
• Efficacy of Nexplanon may be reduced with hepatic enzyme-inducing medications 5
• Nexplanon does not protect against sexually transmitted infections; condoms should be used if STI protection is needed 5
• Recent assessment of etonogestrel-releasing implants suggests they do not induce a prothrombotic state during the first 6 months of use 1

Remember that despite bleeding irregularities, Nexplanon remains highly effective with failure rates less than 0.05% 5, 6, and many women find the benefits outweigh the inconvenience of irregular bleeding.