What is the best course of treatment for a 28-year-old female kindergarten teacher with moderate anxiety (GAD-7 score of 12) and increased menstrual flow, which began after receiving the Nexplanon (etonogestrel) implant, with a history of previous successful use of Nexplanon at age 21, currently presenting with work-related stress and heavy menstrual bleeding, and recently started on Sertraline (sertraline) 25mg orally once a day?

Management of Nexplanon-Related Heavy Menstrual Bleeding and Moderate Anxiety

Continue sertraline 25mg daily with planned uptitration and mental health referral for the anxiety, while simultaneously treating the heavy menstrual bleeding with NSAIDs (mefenamic acid 500mg three times daily for 5-7 days) or short-term low-dose combined oral contraceptives (30-35 μg ethinyl estradiol for 10-20 days) during bleeding episodes, after first ruling out underlying gynecological pathology.

Addressing the Heavy Menstrual Bleeding from Nexplanon

Initial Evaluation Required

• Rule out underlying gynecological problems first, including pregnancy, sexually transmitted infections, medication interactions, or new pathologic uterine conditions such as polyps or fibroids before attributing bleeding solely to the implant 1.
• The urinalysis showing 3+ blood with 3-10 RBCs is consistent with menstrual contamination as documented, but persistent heavy bleeding (4 extra-large pads/tampons daily for 5 days) warrants evaluation to exclude structural pathology 2.
• Heavy or prolonged bleeding is uncommon with etonogestrel implants (only 18% experience prolonged bleeding), making it important to investigate other causes 1, 3.

Treatment Algorithm for Nexplanon-Related Bleeding

If no underlying pathology is found, the CDC guidelines provide clear treatment options 1:

First-Line Pharmacologic Options:

• NSAIDs for 5-7 days during bleeding episodes: Mefenamic acid 500mg three times daily has demonstrated significant bleeding cessation within 7 days compared to placebo in etonogestrel implant users 1.
• Hormonal treatment for 10-20 days if medically eligible: Low-dose combined oral contraceptives (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) can be used during bleeding episodes 1, 4.

Important Considerations:

• Celecoxib 200mg daily for 5 days is another evidence-based NSAID option that showed significant bleeding cessation in small studies 1.
• The patient's normal hemoglobin, hematocrit, and iron studies indicate she has not developed anemia despite heavy bleeding, but continued monitoring is warranted given the bleeding volume [@case presentation@].
• If bleeding persists and becomes unacceptable to the patient, counsel on alternative contraceptive methods and offer removal with transition to another method 1.

Critical Pitfall to Avoid:

Do not assume this is simply "normal" implant-related bleeding without investigation—the CDC explicitly warns against assuming functional bleeding without excluding structural pathology, especially when bleeding is heavy 4. Her previous successful experience with Nexplanon at age 21 makes this current heavy bleeding pattern more concerning for an underlying issue.

Managing the Moderate Anxiety

Sertraline Dosing Strategy

• The current 25mg daily dose is appropriate as initial therapy for anxiety disorders (panic disorder, PTSD, social anxiety disorder), with planned increase to 50mg after one week 5.
• The FDA label specifies that for anxiety disorders, treatment should start at 25mg daily for one week, then increase to 50mg daily, which is the recommended initial therapeutic dose 5.
• Patients not responding to 50mg may benefit from dose increases up to 200mg daily, with dose changes occurring at intervals of at least one week given sertraline's 24-hour elimination half-life 5.

Monitoring and Follow-Up

• The mental health referral for CBT is evidence-based and essential—combining sertraline with CBT provides superior outcomes compared to either intervention alone for anxiety disorders [@case presentation@].
• Monitor for serotonin syndrome, particularly given the patient's coffee consumption (caffeine can have mild serotonergic effects), though this risk is low with sertraline monotherapy 5.
• Screen for bipolar disorder risk before continuing antidepressant therapy, as treating unrecognized bipolar disorder with antidepressants alone may precipitate manic episodes 5.

Addressing the Temporal Association with Nexplanon

• While the patient attributes anxiety onset to Nexplanon insertion, progestin-only contraceptives like etonogestrel implants are not strongly associated with clinical depression or anxiety in controlled studies 6.
• The work-related stressors (kindergarten teacher with increased benchmark pressures) are more likely primary contributors to her anxiety [@case presentation@].
• Do not remove the Nexplanon based solely on perceived anxiety association without first optimizing anxiety treatment and addressing work stressors through therapy.

Integrated Management Plan

Immediate Actions:

1. Prescribe NSAIDs (mefenamic acid 500mg TID for 5-7 days) to use during heavy bleeding episodes 1.
2. Continue sertraline 25mg daily with plan to increase to 50mg after one week 5.
3. Ensure mental health counseling appointment is scheduled for CBT [@case presentation@].

Short-Term Follow-Up (2-4 weeks):

• Assess bleeding response to NSAID therapy.
• Evaluate anxiety response to sertraline 50mg.
• If bleeding persists despite NSAIDs, consider short-term low-dose COCs (10-20 days during bleeding) 1.
• Monitor for sertraline side effects and therapeutic response.

Medium-Term Management (3 months):

• If bleeding remains unacceptable despite medical management, discuss Nexplanon removal and alternative contraception 1.
• Optimize sertraline dosing based on anxiety response (may require up to 200mg daily) 5.
• Reassess need for maintenance anxiety treatment.

Key Clinical Pearls:

• The bleeding pattern during the first 3 months of implant use broadly predicts future patterns for many women, but this patient's previous successful experience suggests her current pattern is atypical 3.
• Enhanced counseling about bleeding irregularities reduces discontinuation rates with hormonal contraceptives 1.
• The patient's borderline elevated LDL (103 mg/dL) is a relative consideration if using short-term COCs for bleeding management, though not a contraindication for brief therapeutic use [@case presentation@].