Why is Nexplanon (etonogestrel implant) falling out of favor as a birth control method?

Nexplanon Is NOT Falling Out of Favor—It Remains the Most Effective Reversible Contraceptive

Nexplanon is not actually falling out of favor; it remains the single most effective reversible contraceptive method available, with a failure rate of only 0.05% and an 84% continuation rate at one year, which is higher than any other hormonal method. 1

The premise of this question appears to be based on a misconception. The evidence strongly supports Nexplanon as a first-line contraceptive option, particularly for adolescents and young women.

Why Nexplanon Remains Highly Recommended

Superior Efficacy Profile

• Nexplanon has the lowest failure rate of any reversible contraceptive at 0.05%, significantly better than IUDs (0.2-0.8%), injectable contraceptives (6%), or oral contraceptives (9%). 1
• The American Academy of Pediatrics explicitly recommends counseling patients about LARC methods first, starting with implants, because they are the most effective. 1
• Typical-use effectiveness approximates perfect-use effectiveness because adherence requirements are minimal. 1

High Continuation Rates

• At one year, 84% of users continue with the implant, compared to 67% for oral contraceptives, 56% for injectable contraceptives, and 78-80% for IUDs. 1
• This high continuation rate demonstrates overall user satisfaction despite bleeding irregularities. 1

The Main Challenge: Bleeding Irregularities

Understanding the Issue

• Unpredictable bleeding or spotting is the most common reason for discontinuation, affecting approximately 18% of users. 1, 2
• In clinical trials, while 64% of women experienced amenorrhea or infrequent bleeding (often viewed positively), 15% reported frequent or prolonged bleeding. 1
• Unlike other continuous methods, bleeding patterns may not improve over time with Nexplanon. 2

Effective Management Strategies

When bleeding irregularities occur, they can be successfully managed pharmacologically:

• Mefenamic acid 500 mg three times daily for 5 days shows significant cessation of bleeding within 7 days. 2
• Celecoxib 200 mg daily for 5 days also demonstrates efficacy. 2
• Low-dose combined oral contraceptives or estrogen therapy for 10-20 days can be used as hormonal options. 2

The Critical Role of Counseling

• Enhanced pre-insertion counseling about expected bleeding patterns has been shown to reduce discontinuation rates in clinical trials. 2, 3
• Routine counseling may be sufficient for many women to help reduce premature discontinuation rates. 3
• In a randomized trial, discontinuation rates due to bleeding were only 2.1% for the ENG-implant when appropriate counseling was provided. 3

Important Clinical Considerations

Drug Interactions (Specific Populations)

• Efavirenz-containing antiretroviral therapy may decrease the efficacy of etonogestrel implants, with contraceptive failures reported in 2 patients receiving efavirenz-based therapy. 1
• The NIH recommends using an alternative or additional contraceptive method when efavirenz, nevirapine, or most protease inhibitors are administered. 1
• However, the CDC and WHO state that the benefits of using progestin implants outweigh any risks with concomitant antiretroviral administration. 1

Safety Profile

• Over 10 years of surveillance in France, only 7% of reported adverse events were serious. 4
• The most common adverse effects are gynecological (bleeding changes), skin reactions, and metabolic effects—none life-threatening. 4, 5
• Serious adverse events are infrequent, with the main concerns being infectious complications at the implant site and unintended pregnancies (usually due to insertion technique failures or drug interactions). 4

Insertion and Removal Improvements

• The newer Nexplanon formulation has decreased the incidence of migrations, removal difficulties, and insertion complications compared to the older Implanon (0.92 vs. 1.31 per 1000 patients). 4
• All healthcare providers must be trained before performing insertions or removals. 6, 4

When to Consider Alternatives

Nexplanon should be reconsidered only in specific circumstances:

• If bleeding remains unacceptable despite pharmacologic treatment attempts. 2
• If the patient is on efavirenz-based antiretroviral therapy and additional contraceptive protection cannot be ensured. 1
• If patient preference dictates after informed discussion, particularly if the levonorgestrel IUD (which reduces menstrual blood loss by 71-95%) would be better tolerated. 2

The Bottom Line

Nexplanon is not falling out of favor—it remains the gold standard for reversible contraception based on efficacy, continuation rates, and safety. 1 The key to maximizing its benefits is thorough pre-insertion counseling about bleeding patterns and having a management plan ready for bleeding irregularities. 2, 3 When properly counseled and supported, the vast majority of users continue successfully with this highly effective method. 3