What are the next steps for a patient on Nexplanon (etonogestrel) experiencing a small volume of vaginal bleeding with old, brown blood after not having regular periods for many years?

Management of Brown Vaginal Bleeding with Nexplanon

Irregular bleeding patterns, including old brown blood, are common with Nexplanon use and typically do not require intervention unless symptoms are severe or concerning for underlying pathology.

Understanding Bleeding Patterns with Nexplanon

Irregular menstrual bleeding patterns are common among healthy women using progestin-only contraceptives (POCs) like Nexplanon. The CDC guidelines specifically note that:

• POC use frequently induces irregular bleeding patterns 1
• Implant use might induce irregular bleeding patterns, especially during the first 3-6 months, but these patterns may persist longer 1
• Brown blood typically represents old blood that has oxidized, which is common with breakthrough bleeding on hormonal contraceptives

Assessment Algorithm

1. Determine severity and characteristics of bleeding:

   • Small volume of old, brown blood after years of amenorrhea is consistent with expected breakthrough bleeding
   • No intervention is needed if bleeding is minimal and not concerning to patient

2. Rule out concerning features that would require further evaluation:

   • Heavy or prolonged bleeding
   • Severe pain
   • Foul odor
   • Fresh red blood in large amounts
   • Signs of infection

3. Consider timing of implant placement:

   • If Nexplanon has been in place for >3 years (approaching expiration), consider replacement
   • If recently placed (<6 months), reassure that irregular bleeding commonly occurs during initial use

Management Options

First-line approach:

• Reassurance and monitoring if bleeding is minimal and not bothersome
• Explain that irregular bleeding patterns are expected with Nexplanon and do not indicate decreased effectiveness 1, 2

If bleeding becomes bothersome:

1. NSAIDs for short-term treatment (5-7 days) during bleeding episodes 2

   • Ibuprofen 400-800mg three times daily can reduce bleeding duration and volume

2. Short-term hormonal treatment if NSAIDs are ineffective:

   • Low-dose combined oral contraceptives for 10-20 days 2
   • This approach may temporarily regulate bleeding while maintaining Nexplanon's contraceptive effect

When to seek further evaluation:

• If bleeding becomes heavy or prolonged
• If unexplained vaginal bleeding persists or worsens
• If there are concerns for underlying pathology

Important Considerations

• Effectiveness remains high: Irregular bleeding does not reduce the contraceptive effectiveness of Nexplanon (typical failure rate <1%) 2

• Ruling out other causes: If bleeding patterns change significantly or persist, consider evaluation to rule out other causes such as:

  • Pregnancy (although extremely unlikely with proper Nexplanon use)
  • Infection
  • Anatomical abnormalities
  • Malignancy (rare)

• Pitfall to avoid: Do not remove Nexplanon prematurely due to expected bleeding patterns unless the patient finds them unacceptable after trying management options

• Documentation: The FDA label for etonogestrel implants notes that "breakthrough bleeding and spotting are sometimes encountered in patients on hormonal contraceptives, especially during the first three months of use" 3

Follow-up Recommendations

• Return for evaluation if bleeding becomes heavy, painful, or concerning
• Annual follow-up to assess satisfaction with method and address any concerns
• Remember that Nexplanon is effective for up to 3 years and should be replaced at that time

If the patient finds the bleeding patterns unacceptable despite management attempts, consider alternative contraceptive methods while emphasizing that all hormonal methods may cause some degree of irregular bleeding.