What are the guidelines for Nexplanon (etonogestrel) placement?

Guidelines for Nexplanon (Etonogestrel) Placement

Nexplanon should be inserted subdermally in the inner side of the non-dominant upper arm, within the first 5 days of menstrual cycle onset for immediate contraceptive effect, or at any time if pregnancy can be reasonably excluded, with backup contraception for 7 days if inserted after day 5. 1

Timing of Insertion

The timing of Nexplanon insertion depends on the woman's current situation:

Menstruating Women

• Insert within first 5 days since menstrual bleeding started for immediate contraceptive protection 1
• If inserted >5 days since menstrual bleeding started, backup contraception needed for 7 days 1

Amenorrheic Women (Not Postpartum)

• Can be inserted anytime if reasonably certain woman is not pregnant
• Backup contraception needed for 7 days 1

Postpartum Women

• Breastfeeding women: Can be inserted anytime (U.S. MEC 2 if <1 month postpartum; U.S. MEC 1 if ≥1 month postpartum) 1
• Non-breastfeeding women: Can be inserted anytime, including immediately postpartum (U.S. MEC 1) 1
• Backup contraception needed for 7 days if ≥21 days postpartum without return of menstrual cycle 1

Post-abortion

• Can be inserted within 7 days, including immediately after abortion (U.S. MEC 1) 1
• No backup contraception needed if placed at time of surgical abortion
• Otherwise, backup contraception needed for 7 days 1

Switching from Another Method

• Can be inserted immediately; waiting for next menstrual period unnecessary 1
• Backup contraception needed for 7 days if >5 days since menstrual bleeding started 1
• When switching from IUD, special considerations apply to prevent risk of pregnancy 1

Pre-Insertion Requirements

Among healthy women, no examinations or tests are needed before Nexplanon insertion 1:

• No pelvic examination required
• No liver enzyme tests required
• Baseline weight/BMI measurement may be useful for monitoring over time 1

Insertion Procedure

Proper insertion technique is critical to prevent complications:

• Must be performed by healthcare providers who completed the Nexplanon clinical training program 2, 3
• Inserted subdermally in the inner side of the non-dominant upper arm
• Proper insertion technique reduces risk of incorrect placement (12.6 per 1000 insertions) 2

Common Complications and Prevention

Complications associated with insertion and removal are rare when performed by trained clinicians 2:

• Incorrect insertion (non-insertion, partial insertion, or deep insertion): 12.6 per 1000 insertions 2
• Pins and needles/numbness in arm/hand/fingers: most common patient-reported event 2
• Removal complications: encasement of implant in fibrotic tissue most common 2

Post-Insertion Care

• Apply sterile dressing daily with local disinfection until granulation occurs (usually 1-7 days) 4
• Counsel patients about potential side effects, particularly irregular bleeding patterns 4
• Remind patients that Nexplanon does not protect against STIs 4

Removal Considerations

• Nexplanon should be removed by the end of the third year of use 3
• All removals in the NORA study were successful except one (due to deep muscle tissue location) 2
• Mean removal time is approximately 2 minutes 5
• Rapid return to fertility occurs after removal 3

Special Considerations

• For women taking enzyme-inducing medications (certain antiretrovirals, anticonvulsants), additional contraceptive methods may be warranted due to potential reduced efficacy 4
• Immediate postpartum placement is safe and effective 4

By following these guidelines for Nexplanon placement, healthcare providers can ensure high contraceptive efficacy while minimizing complications associated with insertion and removal.