What is the best course of action for a 19-year-old female with irregular menstrual cycles, currently on Nexplanon (etonogestrel) and previously on NuvaRing (ethinyl estradiol and etonogestrel), who has been experiencing prolonged menstrual bleeding for over a month?

Management of Prolonged Bleeding in a 19-Year-Old with Nexplanon and Previous NuvaRing Use

For a 19-year-old experiencing prolonged bleeding for over a month with Nexplanon implant and previous NuvaRing use, the most effective treatment is a short course of NSAIDs such as mefenamic acid (500 mg three times daily for 5 days) or celecoxib (200 mg daily for 5 days), or alternatively, a short course of low-dose combined oral contraceptives for 10-20 days if medically eligible. 1

Initial Assessment

• Rule out underlying gynecological problems that could cause prolonged bleeding, including:
  • Pregnancy (perform pregnancy test despite contraceptive use) 1
  • Sexually transmitted infections 1
  • Medication interactions with Nexplanon 1
  • Pathologic uterine conditions (polyps, fibroids) 1, 2

Understanding the Bleeding Pattern with Nexplanon

• Irregular bleeding with Nexplanon is common and expected:
  • 18% of Nexplanon users experience prolonged bleeding 1
  • 7% experience frequent bleeding 1
  • These bleeding patterns are generally not harmful but can be bothersome 1
  • Bleeding irregularities may or may not decrease with continued implant use 1

Treatment Options for Prolonged Bleeding

First-line pharmacological options:

• NSAIDs for short-term treatment (5-7 days): 1

  • Mefenamic acid 500 mg three times daily for 5 days has shown significant cessation of bleeding within 7 days 1
  • Celecoxib 200 mg daily for 5 days has also demonstrated effectiveness 1
  • These medications work by reducing prostaglandin production that contributes to bleeding

• Hormonal treatment if medically eligible: 1

  • Low-dose combined oral contraceptives for 10-20 days 1
  • Estrogen therapy for 10-20 days 1
  • These treatments help stabilize the endometrium and reduce bleeding

Other potential treatments with varying evidence:

• Tranexamic acid can reduce bleeding days, but has safety limitations in patients with thromboembolic risk factors 1, 3
• Mifepristone combined with ethinyl estradiol has shown some efficacy but is not typically first-line 1

Follow-up Management

• If bleeding persists after initial treatment and remains unacceptable to the patient:

  • Counsel on alternative contraceptive methods 1
  • Consider removing Nexplanon if bleeding is severely impacting quality of life 1
  • Offer another contraceptive method if desired 1

• For patients who wish to continue with Nexplanon despite irregular bleeding:

  • Provide reassurance that bleeding irregularities are generally not harmful 1
  • Consider intermittent treatment with NSAIDs during episodes of bleeding 1

Important Considerations

• Enhanced counseling about expected bleeding patterns with Nexplanon can improve continuation rates 1
• Prolonged bleeding with Nexplanon is uncommon but can occur, especially in the first year of use 1
• If bleeding persists despite treatment and impacts quality of life, consider alternative contraceptive methods 1
• Avoid aspirin as it may worsen bleeding in some cases 1

Pitfalls to Avoid

• Don't assume bleeding is only due to Nexplanon without ruling out other causes 1, 2
• Don't continue ineffective treatments for prolonged periods if the patient finds the bleeding unacceptable 1
• Don't overlook the possibility of a pathologic cause requiring specific treatment, especially with prolonged bleeding lasting over a month 2
• Don't dismiss the patient's concerns about prolonged bleeding, as it can significantly impact quality of life 3