Managing Spotting After 1 Year of Nexplanon Use
For spotting after 1 year of Nexplanon use, first-line treatment is NSAIDs (mefenamic acid 500 mg three times daily or celecoxib 200 mg daily) for 5-7 days during active bleeding episodes; if this fails and bleeding remains unacceptable, consider short-term hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days, or counsel about switching to an alternative contraceptive method. 1
Initial Assessment
Before initiating any treatment, rule out underlying gynecological problems that could be causing the bleeding 1:
- Pregnancy - Perform a pregnancy test if clinically indicated, especially if bleeding pattern changed abruptly 1, 2
- Sexually transmitted infections - Screen for STDs that can alter bleeding patterns 1, 2
- Medication interactions - Review all current medications for potential interactions 1
- Structural pathology - Consider new uterine conditions such as polyps or fibroids, particularly if bleeding is heavy or prolonged 1
- Implant displacement - Verify proper placement if concerns exist 1
Treatment Algorithm
Step 1: NSAIDs (First-Line)
If no underlying pathology is found and the patient desires treatment 1:
- Mefenamic acid 500 mg three times daily for 5 days during active bleeding 1, 2
- Celecoxib 200 mg daily for 5 days during active bleeding 1, 2
Evidence shows these NSAIDs significantly stop bleeding within 7 days compared to placebo in implant users 1
Step 2: Hormonal Treatment (Second-Line)
If NSAIDs fail and bleeding persists 1:
- Low-dose combined oral contraceptives for 10-20 days (if medically eligible) 1, 2
- Estrogen alone for 10-20 days (if medically eligible) 1
Important caveat: Combined hormonal contraceptives increase venous thromboembolism risk three to fourfold, so verify medical eligibility before prescribing 2
Step 3: Method Switching
If bleeding persists despite treatment and remains unacceptable to the patient 1:
- Counsel on alternative contraceptive methods 1
- Offer another method if desired, such as the levonorgestrel-releasing IUD which reduces menstrual blood loss by 71-95% 2
- Consider implant removal if patient prefers 1
Context and Reassurance
Spotting after 1 year of Nexplanon is common but generally not harmful 1. Clinical trial data shows that 34% of etonogestrel implant users experience infrequent spotting, while 7% report frequent bleeding and 18% report prolonged bleeding 1. These patterns may or may not decrease with continued use 1.
Enhanced counseling about expected bleeding patterns has been shown to reduce discontinuation rates with hormonal contraceptives 1, 3. Reassure the patient that irregular bleeding does not indicate implant failure or health risk 1.
Common Pitfalls to Avoid
- Don't assume functional bleeding without excluding structural pathology, especially in women over 35 where polyps and fibroids are more common 4
- Don't initiate treatment without first ruling out pregnancy, STDs, and medication interactions 1, 2
- Don't prescribe combined hormonal contraceptives without verifying medical eligibility due to thromboembolism risk 2
- Don't dismiss patient concerns - if bleeding is unacceptable despite reassurance, offer alternative contraceptive options 1
Treatment Evidence
Studies specifically examining etonogestrel implant users found that mifepristone combined with either ethinyl estradiol or doxycycline was more effective than placebo in stopping bleeding episodes (mean 4.0-4.4 days vs 6.4 days), though subsequent bleeding patterns did not improve 5. Earlier studies with levonorgestrel implants showed ethinyl estradiol reduced bleeding days more effectively than ibuprofen, levonorgestrel, or placebo over one year 6.