How is Nexplanon (etonogestrel implant) insertion site pain managed?

Management of Nexplanon Insertion Site Pain

For Nexplanon insertion site pain, administer naproxen 440-550 mg orally 1-2 hours before insertion, followed by scheduled dosing every 12 hours with food for the first 24 hours post-procedure to optimize pain control. 1

Pre-Procedure Pain Prevention

Pharmacological Premedication

• Naproxen 500-550 mg orally 1-2 hours before insertion is the preferred first-line option, allowing time to reach peak effect during the procedure 1
• Ibuprofen 800 mg orally 1-2 hours before insertion serves as an effective alternative if naproxen is contraindicated 1
• Ketorolac 20 mg orally 40-60 minutes before insertion provides faster onset for patients requiring more rapid analgesia 1, 2
• Ketorolac 30 mg IM 20 minutes prior can be considered for patients unable to take oral medications 1

Local Anesthetic Options

While the evidence base primarily addresses IUD insertion, similar principles apply to subdermal implant procedures:

• Topical EMLA cream (2.5% lidocaine/2.5% prilocaine) applied to the insertion site 5-7 minutes before the procedure can reduce needle-related discomfort 1, 2
• 10% lidocaine spray applied 3 minutes before insertion offers a faster-onset topical option 1
• Local infiltration with 1-2 mL of 1% lidocaine at the insertion site immediately before needle placement is standard practice for subdermal procedures 1

During Procedure Techniques

Environmental and Non-Pharmacological Measures

• Provide low lighting and slow-rhythm music to reduce anxiety and pain perception 1
• Apply warm towels to the arm to promote vasodilation and comfort 1
• Use trauma-informed language and explain each step before proceeding, allowing the patient to feel in control 1, 2
• Encourage yoga-based breathing techniques during the actual insertion to reduce tension 1

Technical Considerations to Minimize Pain

• Ensure correct anatomical placement in the inner aspect of the non-dominant upper arm, 8-10 cm from the medial epicondyle, to avoid nerve injury 3
• Use proper insertion technique with the redesigned Nexplanon applicator to prevent complications including nerve contact 3
• Verbally check in for discomfort and offer to pause if the patient experiences significant pain 1

Post-Procedure Pain Management

Immediate Post-Insertion Care

• Keep the patient's arm in a comfortable position for 5 minutes after insertion to prevent vasovagal reactions 1
• Apply acupressure bilaterally at Large Intestine-4 (LI4) or Spleen-6 (SP6) points for several minutes to reduce cramping and discomfort 1, 4
• Offer a cold compress or ice pack to the insertion site to reduce swelling and provide comfort 1
• Provide a beverage and snack to help prevent vasovagal symptoms 1

Scheduled Analgesia for First 24 Hours

• Naproxen 440-550 mg every 12 hours with food is the preferred regimen for post-insertion pain control 1
• Ibuprofen 600-800 mg every 6-8 hours with food serves as an alternative NSAID option 1
• Emphasize taking NSAIDs on a scheduled basis rather than as-needed to maintain therapeutic levels 1

Complementary Approaches

• Aromatherapy with lavender may increase satisfaction and reduce pain perception 1, 4
• Peppermint essential oil can help with any associated nausea 1, 4
• Self-administered acupressure at LI4 and SP6 points can be continued at home for ongoing discomfort 1, 4, 2

Important Clinical Caveats

Red Flags Requiring Further Evaluation

• Severe, persistent pain beyond 48 hours may indicate nerve injury, particularly if accompanied by numbness or paresthesias in the forearm 3
• Direct implant contact with the medial cutaneous nerve of the forearm can cause significant neuropathic pain and requires prompt evaluation 3
• Pain unresponsive to scheduled NSAIDs warrants assessment for improper placement or infection 5

Contraindications to NSAIDs

• For patients with NSAID allergies or contraindications (peptic ulcer disease, renal insufficiency), acetaminophen 1000 mg every 6 hours (maximum 3000 mg daily) can be used, though it is less effective for inflammatory pain 6
• Avoid combining NSAIDs with other anticoagulants without appropriate monitoring 1