Should a subdermal (under the skin) contraceptive implant be removed in a female patient of reproductive age due to severe side effects?

Should a Subdermal Contraceptive Implant Be Removed Due to Side Effects?

If the patient desires removal due to side effects at any time, remove the implant immediately, offer counseling on alternative contraceptive methods, and initiate another method if desired. 1

Patient-Centered Decision Making

The decision to remove a contraceptive implant should be driven entirely by the patient's tolerance of side effects and desire for continued use, not by provider judgment about whether side effects are "severe enough." 1

Immediate Removal Indications

• Patient request is sufficient justification - No minimum threshold of side effect severity is required for removal 1
• Remove the implant if the patient wants it out, regardless of provider assessment of side effect severity 1
• Delays in removal after patient request can cause frustration and undermine trust in contraceptive counseling 2

Common Side Effects Leading to Removal

Bleeding Irregularities (Most Common)

• Unscheduled spotting or light bleeding is common with implant use and generally not harmful 1
• Heavy or prolonged bleeding is uncommon but can occur 1
• Bleeding irregularities are the most frequently cited reason for early removal 2
• Before attributing bleeding to the implant, rule out underlying conditions: medication interactions, STDs, pregnancy, thyroid disorders, or new uterine pathology (polyps, fibroids) 1

Other Hormonal Side Effects

• Weight gain (reported by 54.76% of users in one study) 3
• Mood swings, headaches 2
• Often a combination of factors reaches a "tipping point" where negative experiences outweigh benefits 2

Management Algorithm Before Removal

Step 1: Explore Patient Goals

• Determine if patient wants continued use (with or without treatment), or removal 1
• Provide reassurance that contact is available anytime for side effects 1

Step 2: If Patient Wants Treatment (Not Removal)

For spotting or light bleeding:

• NSAIDs for 5-7 days (treatment may be repeated as needed) 1

For heavy or prolonged bleeding:

• NSAIDs for 5-7 days 1
• Hormonal treatment (e.g., low-dose combined oral contraceptives or estrogen) for 10-20 days 1
• Antifibrinolytic agents (e.g., tranexamic acid) for 5 days 1
• Treatments with persistent effects: NSAIDs (celecoxib, ibuprofen, mefenamic acid) for 5-7 days, or SERMs (tamoxifen) for 7-10 days 1

Step 3: If Patient Wants Removal

• Remove immediately - do not attempt to convince patient to continue 1, 2
• Offer counseling on alternative methods 1
• Initiate another contraceptive method if desired 1

Alternative Contraceptive Options After Removal

Highly Effective Alternatives (Pregnancy Rate <1% per year)

• Copper IUD or levonorgestrel IUD - equally effective as implant, different side effect profile 1
• Another subdermal implant (if side effects were tolerable and removal was for other reasons) 1

Effective Alternatives (Pregnancy Rate 3-8% per year)

• Combined estrogen-progestin methods 1
• Depot medroxyprogesterone acetate (DMPA) injections 1
• Progestin-only pills 1

Critical Counseling Pitfall

Many women feel insufficiently warned about possible side effects before insertion 2. This contributes to dissatisfaction and early removal. When counseling about implant insertion initially, comprehensive discussion of bleeding irregularities and other hormonal side effects is essential to set realistic expectations 1, 2.

Special Consideration: Pregnancy with Implant

If pregnancy occurs with implant in place:

• Confirm pregnancy and establish gestational age 4
• Evaluate for ectopic pregnancy (though risk is not increased with implants) 4
• Remove implant as soon as possible if patient desires to continue pregnancy 4
• Unlike IUDs, implant removal does not improve pregnancy outcomes, but removal is still recommended 4

Bottom Line

Supporting women's contraceptive choice means accepting that some women cannot tolerate the implant, and encouraging retention without addressing distressing side effects is counterproductive. 2 Remove the implant when requested, provide alternative options, and maintain the therapeutic relationship for future contraceptive needs.