When can Implanon (etonogestrel implant) be inserted in a postpartum patient with a 2-day history of spotting at 10 weeks postpartum?

Implanon Insertion Timing for Postpartum Patient with Spotting

Implanon can be inserted immediately in a patient who is 10 weeks postpartum with 2 days of spotting, as spotting is not a contraindication to insertion and may actually be an expected side effect of the implant.

Timing of Insertion

• Implanon can be inserted at any time if it is reasonably certain that the woman is not pregnant 1
• For postpartum women (not breastfeeding) who are ≥21 days postpartum and have not experienced return of menstrual cycles, Implanon can be inserted immediately 1
• If menstrual cycles have returned (as suggested by the spotting), Implanon can still be inserted immediately 1
• The Centers for Disease Control and Prevention supports immediate postpartum insertion of implants as a safe and effective practice that removes barriers to care 1

Need for Back-Up Contraception

• If inserting during the first 5 days of menstrual bleeding, no additional contraceptive protection is needed 2
• If the spotting represents the return of menstrual cycles and it has been >7 days since menstrual bleeding started, the woman needs to use additional contraceptive protection for the next 7 days after insertion 1
• If the spotting is not considered a true menstrual period, additional contraceptive protection for 7 days after insertion is recommended 1

Counseling About Bleeding Patterns

• Before implant insertion, provide counseling about potential changes in bleeding patterns 1
• Unscheduled spotting or light bleeding is common with implant use, and some women experience amenorrhea 1
• In clinical studies, 22.2% of women experienced amenorrhea, 33.6% had infrequent bleeding, 6.7% had frequent bleeding, and 17.7% had prolonged bleeding 3
• The bleeding pattern experienced during the first three months is broadly predictive of future bleeding patterns for many women 3
• Enhanced counseling about expected bleeding patterns has been shown to reduce discontinuation rates 1

Management of Bleeding Irregularities

• If irregular bleeding persists and becomes unacceptable to the patient, treatment options include:
  • NSAIDs for short-term treatment (5-7 days) 1
  • Hormonal treatment with low-dose combined oral contraceptives or estrogen for short-term treatment (10-20 days) if medically eligible 1
• Amenorrhea does not require any medical treatment, only reassurance 1

Important Considerations

• Implanon is highly effective with typical and perfect use failure rates of less than 1% 1
• The implant is inserted into the inside of the upper arm by a clinician who has completed the requisite training 1
• Insertion is a simple procedure that takes approximately 1.1 minutes on average 4
• No routine follow-up visit is required after implant insertion 1
• Most women (77%) who had baseline dysmenorrhea experience complete resolution of symptoms with Implanon 3

Potential Pitfalls

• Failing to counsel about expected bleeding pattern changes may lead to unnecessary discontinuation 3
• Approximately 13% of women discontinue Implanon use due to bleeding irregularities 3
• Spotting at 10 weeks postpartum could represent normal postpartum bleeding changes or the beginning of menstrual cycle return, but does not contraindicate Implanon insertion 1