How to manage irregular spotting in patients with an Implanon (etonogestrel implant)?

Management of Irregular Spotting with Implanon

For irregular spotting with Implanon (etonogestrel implant), first reassure the patient that this is common and generally not harmful, then rule out pregnancy and underlying pathology, and if treatment is desired, use NSAIDs for 5-7 days during bleeding episodes as first-line therapy, with low-dose combined oral contraceptives or estrogen for 10-20 days as second-line options if medically eligible. 1

Initial Counseling and Reassurance

• Irregular bleeding is the most common side effect of Implanon, occurring in approximately 58.5% of users during the first 90 days 2
• Unscheduled spotting or bleeding is generally not harmful and may or may not decrease with continued use 3
• Pre-insertion counseling about expected bleeding pattern changes is crucial to reduce discontinuation rates 3, 1

Clinical Evaluation Before Treatment

Before initiating any treatment for irregular spotting, systematically rule out:

• Pregnancy: Especially if the bleeding pattern changes abruptly 4, 1
• Sexually transmitted infections: Screen for STDs that can cause irregular bleeding 1
• Medication interactions: Assess for antibiotics, anticonvulsants, or other drugs affecting contraceptive efficacy 1
• Pathologic uterine conditions: Evaluate for polyps, fibroids, or endometrial abnormalities through appropriate imaging if bleeding persists 1

Treatment Algorithm

First-Line Pharmacologic Treatment

• NSAIDs for 5-7 days during bleeding episodes are recommended as the initial treatment approach 1
• Options include indomethacin, mefenamic acid, flufenamic acid, or diclofenac sodium 1
• Avoid aspirin as it may increase bleeding in some patients 1

Second-Line Treatment Options (if NSAIDs fail)

If irregular bleeding persists and is unacceptable to the patient after NSAID therapy:

• Low-dose combined oral contraceptives for 10-20 days (if medically eligible) 3, 1
• Estrogen therapy for 10-20 days (if medically eligible) 3, 1

When No Treatment is Needed

• If amenorrhea develops (occurs in approximately 22% of users), no medical treatment is required—only reassurance 4, 3
• No routine follow-up visit is required after implant insertion 3

Critical Pitfalls to Avoid

• Do not initiate treatment without excluding pregnancy, STDs, and structural pathology 1
• Enhanced counseling about expected bleeding patterns significantly reduces discontinuation rates 1
• Irregular bleeding is most common during the first 3-6 months and typically improves with continued use 5, 6

When to Consider Alternative Contraception

• If irregular bleeding persists despite treatment and the patient finds it unacceptable, counsel on alternative contraceptive methods and offer to switch 5, 1
• In clinical trials, approximately 13% of women discontinued Implanon due to bleeding pattern changes 6
• Discontinuation rates vary by region, ranging from 0.9% to 30.2% 7