What is the next step for a patient with a Nexplanon (etonogestrel implant) experiencing heavy menstrual bleeding?

Management of Heavy Menstrual Bleeding with Nexplanon

For a patient with Nexplanon experiencing heavy menstrual bleeding, first rule out pregnancy and underlying pathology, then initiate a trial of mefenamic acid 500 mg three times daily for 5 days or celecoxib 200 mg daily for 5 days; if bleeding persists despite treatment and remains unacceptable to the patient, remove the implant and transition to a levonorgestrel-releasing IUD. 1

Initial Assessment Steps

Rule out pregnancy immediately in all reproductive-age women with abnormal bleeding, as this could indicate pregnancy including ectopic pregnancy. 1, 2

Assess hemodynamic stability by checking for tachycardia or hypotension—bleeding that saturates a large pad or tampon hourly for at least 4 hours warrants urgent evaluation. 1, 2

Screen for underlying gynecological conditions:

• Test for sexually transmitted infections, particularly in adolescents 1
• Consider medication interactions, especially if the patient is on anticoagulants (factor Xa inhibitors cause 32% incidence of abnormal uterine bleeding) 1, 2
• Evaluate for new pathologic uterine conditions such as polyps or fibroids 3
• Consider rare implant fracture, though this is uncommon 1

Understanding Nexplanon Bleeding Patterns

Prolonged bleeding affects approximately 18% of Nexplanon users and is the most common reason for discontinuation. 1 Unlike other continuous contraceptive methods, bleeding patterns with Nexplanon may not improve over time—this is a critical counseling point. 1

Pharmacologic Treatment Algorithm

If no underlying pathology is identified and the patient desires treatment:

First-line NSAIDs:

• Mefenamic acid 500 mg three times daily for 5 days (demonstrated significant cessation of bleeding within 7 days) 1
• Celecoxib 200 mg daily for 5 days (also demonstrated efficacy) 1

Second-line hormonal options (if medically eligible):

• Low-dose combined oral contraceptives for 10-20 days 3, 1
• Estrogen therapy for 10-20 days 3, 1

When to Remove the Implant

Remove Nexplanon if:

• Bleeding remains unacceptable despite treatment attempts 1
• Patient experiences hemodynamic instability 1
• Underlying pathology is identified that contraindicates continued use 1
• Patient preference dictates removal after informed discussion of alternatives 1

Alternative Contraceptive Strategy

Transition to a levonorgestrel-releasing IUD (20 μg/day) as the preferred alternative long-acting reversible contraceptive. This device reduces menstrual blood loss by 71-95% and is the most effective medical approach for heavy menstrual bleeding, comparable to endometrial ablation. 3, 1, 2 The main effect is at the endometrial level with minimal systemic progesterone absorption. 3

Critical Counseling Points

Enhanced counseling before insertion about expected bleeding patterns has been shown to reduce discontinuation rates in clinical trials. 1 Reassurance that bleeding irregularities are generally not harmful is essential, though this reassurance must be balanced against the reality that Nexplanon bleeding patterns may not improve over time. 1

Common pitfall to avoid: Do not assume bleeding will improve with time as it does with other progestin-only methods—Nexplanon is unique in that bleeding patterns often persist. 1