What are the characteristics and considerations of Nexplanon (etonogestrel) as a contraceptive option?

Nexplanon (Etonogestrel) Contraceptive Review

Nexplanon is a highly effective long-acting reversible contraceptive (LARC) with a failure rate of less than 0.2%, making it one of the most reliable contraceptive options available. 1

Key Characteristics

• Composition and Design:

  • Single-rod subdermal implant containing 68 mg of etonogestrel
  • Non-biodegradable, flexible, transparent device
  • Radiopaque for visibility on X-ray
  • Not made with natural rubber latex
  • Releases approximately 0.12 mg/day of etonogestrel 2

• Effectiveness:

  • Extremely high efficacy with a Pearl Index of 0.02 during use 3
  • Approved for 3 years of continuous use 1
  • No pregnancies occurred during proper use in clinical trials 4

• Mechanism of Action:

  • Primary mechanism: Suppression of ovulation
  • Secondary mechanisms: Thickening cervical mucus and thinning endometrial lining 5

Insertion and Removal

• Insertion:

  • Office-based procedure requiring specific training
  • Average insertion time is approximately 0.5 minutes
  • Inserted subdermally in the inner side of the upper non-dominant arm 5

• Removal:

  • Must be removed by the end of the third year of use
  • Average removal time is approximately 2-3.5 minutes
  • Most common removal complication is fibrosis around the implant (4.4%) 4

Benefits

• Contraceptive Benefits:

  • No need for daily, weekly, or monthly compliance
  • Rapid return to fertility after removal 5
  • Can be used during breastfeeding 1
  • Appropriate for women with medical conditions where estrogen is contraindicated 6

• Non-Contraceptive Benefits:

  • May be beneficial for women with heavy menstrual bleeding
  • Potential use for symptomatic treatment of endometriosis and premenstrual syndrome 7

Side Effects and Considerations

• Bleeding Pattern Changes:

  • Most common adverse effect is change in menstrual bleeding patterns
  • Infrequent bleeding is the most common pattern
  • Amenorrhea occurs in 14-20% of users
  • Bleeding irregularities are the most common reason for discontinuation (13%) 8

• Other Common Side Effects:

  • Emotional lability (6.1%)
  • Weight increase (3.3%)
  • Depression (2.4%)
  • Acne (1.5%) 8

Management of Bleeding Irregularities

• Counseling: Reassurance that bleeding irregularities typically decrease with continued use
• Iron Supplementation: Consider if bleeding is heavy or prolonged
• Medical Management Options:
  • NSAIDs for 5-7 days during bleeding episodes
  • Short-term hormonal treatment with low-dose combined oral contraceptives if NSAIDs are ineffective 6

Contraindications

• Absolute Contraindications:
  • Current breast cancer
  • Unexplained vaginal bleeding
  • Severe liver disease 6

Special Populations

• Adolescents: Safe and effective for postpubertal adolescents
• Breastfeeding Women: Compatible with breastfeeding
• Women with Medical Conditions: Often a suitable option for women with conditions where estrogen is contraindicated 1, 6

Clinical Pearls

• Counsel patients thoroughly about expected bleeding pattern changes before insertion to improve continuation rates
• Rapid return to fertility occurs after removal
• Consider Nexplanon for women at high risk for medical complications from pregnancy
• The implant must be palpable after insertion; if not palpable, use alternative contraception until confirmed

Nexplanon represents an excellent contraceptive choice for women seeking a highly effective, long-acting, and reversible method that requires minimal user intervention once placed.