What is the treatment for heavy bleeding associated with Nexplanon (etonogestrel) insertion?

Treatment for Heavy Bleeding with Nexplanon Insertion

NSAIDs are the first-line treatment for heavy bleeding associated with Nexplanon (etonogestrel) implant, with mefenamic acid 500 mg three times daily for 5 days or celecoxib 200 mg daily for 5 days being the most effective options. 1

Initial Assessment

• Rule out underlying gynecological problems that could cause prolonged bleeding, including pregnancy, sexually transmitted infections, and pathologic uterine conditions (e.g., polyps or fibroids) 1
• Verify proper placement of the Nexplanon implant, as displacement can sometimes cause abnormal bleeding patterns 2
• Recognize that irregular bleeding is common with Nexplanon use - approximately 18% of users experience prolonged bleeding and 7% experience frequent bleeding 1

Treatment Algorithm

First-Line Treatment:

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 2, 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 demonstrated similar effectiveness 1
  • Other NSAIDs like naproxen, ibuprofen, or diclofenac sodium may also be effective 2, 3

Second-Line Treatment (if NSAIDs ineffective and patient is medically eligible):

• Low-dose combined oral contraceptives for 10-20 days 1, 2
  • This hormonal treatment can help stabilize the endometrium and reduce bleeding 2
  • Should only be used in women without contraindications to estrogen 2

If Bleeding Persists:

• Reassess for underlying gynecological problems 2, 1
• If no underlying problem is found and bleeding remains unacceptable to the patient, counsel on alternative contraceptive methods 2, 1
• Consider removal of the Nexplanon implant if bleeding severely impacts quality of life 1

Important Clinical Considerations

• Enhanced counseling about expected bleeding patterns with Nexplanon can improve continuation rates 1
• Bleeding irregularities with Nexplanon are generally not harmful but can significantly impact quality of life 1
• Tranexamic acid may be considered in some cases but should be used with caution due to potential thrombosis risk in patients with history or risk of thromboembolism 2, 4
• NSAIDs work by reducing prostaglandin levels, which are elevated in women with excessive menstrual bleeding 5
• The evidence for NSAIDs in treating implant-related bleeding is extrapolated from studies on heavy menstrual bleeding and IUD-related bleeding, where they have shown effectiveness 6, 3, 5

Common Pitfalls and Caveats

• Avoid attributing all bleeding to the Nexplanon implant without first investigating other potential causes 4
• Do not continue ineffective treatments for prolonged periods - if initial treatment with NSAIDs fails to improve bleeding after 1-2 cycles, consider alternative approaches 1
• Remember that some women may need to try multiple treatment options before finding an effective solution 1
• NSAIDs are less effective than tranexamic acid for heavy bleeding, but tranexamic acid has more safety concerns 5
• Avoid aspirin for treatment of heavy bleeding, as it may actually increase blood loss in some women 2