How to manage abnormal uterine bleeding in patients using Nexplanon (etonogestrel implant)?

Management of Abnormal Uterine Bleeding with Nexplanon

For patients experiencing abnormal uterine bleeding with Nexplanon, first rule out pregnancy and other gynecologic pathology, then offer NSAIDs (5-7 days) or combined oral contraceptives/estrogen (10-20 days) during bleeding episodes; if bleeding remains unacceptable despite treatment, counsel on alternative contraceptive methods. 1

Initial Assessment and Exclusion of Pathology

Before attributing bleeding to the implant itself, systematically exclude other causes:

• Rule out pregnancy with β-hCG testing, as pregnancy must be excluded before any hormonal treatment 2, 3
• Screen for sexually transmitted infections, as unscheduled bleeding can indicate STI in adolescents and adults 1
• Evaluate for drug interactions and new pathologic uterine conditions such as fibroids or polyps 1
• Consider imaging with transvaginal ultrasound if structural pathology is suspected based on clinical presentation 3

Understanding Expected Bleeding Patterns

Counseling about bleeding patterns should occur before insertion, as this reduces discontinuation rates:

• 22% of Nexplanon users experience amenorrhea and 34% have infrequent spotting over the first two years 1
• 15-18% experience prolonged bleeding and 7% report frequent bleeding 1
• Bleeding patterns in the first 3 months may predict future patterns, though individual variation is high 1
• Heavier women may experience more bleeding than lighter women with the implant 1
• Unlike other continuous methods, bleeding patterns do not necessarily improve over time with Nexplanon 1

Medical Treatment Options

First-Line Pharmacologic Management

When no underlying pathology is found and the patient desires treatment:

NSAIDs (Preferred Initial Option):

• Mefenamic acid 500 mg three times daily for 5 days significantly stops bleeding within 7 days compared to placebo 1
• Celecoxib 200 mg daily for 5 days also achieves significant bleeding cessation within 7 days 1
• Use during days of active bleeding only 1
• Avoid in patients with cardiovascular disease due to MI and thrombosis risk 2, 3

Hormonal Treatment (Second-Line):

• Low-dose combined oral contraceptives for 10-20 days during bleeding episodes 1
• Estrogen therapy for 10-20 days during bleeding episodes (if medically eligible) 1
• Rule out cardiovascular disease and SCAD before prescribing estrogen, as it is contraindicated in these conditions 2

Evidence for Other Agents

The evidence base shows variable results for additional treatments:

• Mifepristone combined with ethinyl estradiol improved bleeding cessation in etonogestrel implant users, but mifepristone alone did not 1
• Doxycycline alone or combined with ethinyl estradiol did not improve bleeding cessation 1
• Ibuprofen showed mixed results across studies, with one showing benefit and another showing no difference versus placebo 1
• Vitamin E had conflicting evidence, with one small study showing benefit but a larger study showing no difference 1

Management of Amenorrhea

Amenorrhea requires no medical treatment—provide reassurance only 1

• If bleeding pattern changes abruptly to amenorrhea, consider ruling out pregnancy 1
• If amenorrhea is unacceptable to the patient despite reassurance, counsel on alternative contraceptive methods 1

When to Offer Alternative Contraception

If irregular bleeding persists despite treatment and the patient finds it unacceptable, counsel on alternative contraceptive methods and offer another method 1

This is a critical decision point:

• More than half of adolescent implant users discontinued before 24 months, with abnormal bleeding being the most common reason 1
• The 84% continuation rate at one year for implants is still higher than most other methods, but bleeding remains the primary reason for early removal 1
• Switching to a levonorgestrel-releasing IUD reduces menstrual blood loss by 71-95% and may be the most effective alternative for long-term bleeding control 2

Common Pitfalls to Avoid

• Do not assume all bleeding is benign—always exclude pregnancy, STIs, and structural pathology first 1
• Do not prescribe estrogen without screening for cardiovascular contraindications, particularly spontaneous coronary artery dissection 2
• Do not use NSAIDs in patients with known cardiovascular disease due to thrombotic risk 2, 3
• Do not continue ineffective treatments indefinitely—if bleeding remains unacceptable after appropriate trials, offer method change rather than prolonging patient dissatisfaction 1
• Do not forget to reassess antiplatelet/anticoagulant therapy if present, as 9-14% of women on these medications experience exacerbated bleeding 2