What are the indications and considerations for using Nexplanon (etonogestrel) as a contraceptive method in a female of reproductive age with no history of breast cancer, liver disease, or thromboembolic events?

Nexplanon (Etonogestrel Implant) for Contraception

Primary Indication and Recommendation

Nexplanon is indicated for use by females of reproductive age to prevent pregnancy and represents the most effective long-acting reversible contraceptive available, with a failure rate of less than 1%. 1, 2 For a woman of reproductive age with no history of breast cancer, liver disease, or thromboembolic events, Nexplanon is an excellent first-line contraceptive option with essentially no restrictions to use. 3

Key Clinical Advantages

Efficacy Profile

• Nexplanon provides the highest contraceptive efficacy of all reversible methods, with pregnancy rates <1% per year, superior to combined hormonal methods (3-8% failure rate) and barrier methods (18-28% failure rate). 3, 1
• The device provides effective contraception for 3 years and requires no user adherence after insertion. 4, 2
• Fertility returns rapidly after removal. 2

Safety Profile for Your Patient Population

• The U.S. Medical Eligibility Criteria classifies Nexplanon as Category 1 (no restrictions) for most healthy women of reproductive age. 3
• The implant contains no estrogen, making it safe for women who cannot use combined hormonal contraceptives due to cardiovascular disease, stroke history, thromboembolic disorders, or migraine with aura. 1
• Women with hypertension, diabetes, hyperlipidemia, anemia, thrombogenic mutations, cervical conditions, STDs, or HIV infection can use Nexplanon without restriction (U.S. MEC 1) or generally can use it (U.S. MEC 2). 3

Absolute Contraindications to Rule Out

Current or history of breast cancer is the only absolute contraindication (U.S. MEC Category 4) to Nexplanon use. 3, 1 Since your patient has no history of breast cancer, this is not a concern.

Current pregnancy is also Category 4. 1 A pregnancy test should be performed before insertion if there is any uncertainty. 3

Women with certain active liver diseases generally should not use implants (U.S. MEC 3), but screening for liver disease before initiation is not necessary due to low prevalence and high likelihood of prior diagnosis. 3 Since your patient has no history of liver disease, this is not a concern.

Pre-Insertion Requirements

No Routine Examinations Needed

Among healthy women, no examinations or tests are needed before initiation of Nexplanon. 3 Specifically:

• Pelvic examination is not necessary before insertion because it would not detect conditions making implant use unsafe. 3
• Clinical breast examination is not required for asymptomatic women due to low breast cancer prevalence in reproductive-age women. 3
• Liver enzyme testing is not necessary due to low prevalence of liver disorders. 3
• Screening for hypertension, diabetes, hyperlipidemia, anemia, thrombogenic mutations, cervical conditions, STDs, or HIV is not required for safe initiation. 3

Baseline Measurements

• A baseline weight and BMI measurement might be useful for monitoring over time, though obesity is not a contraindication (U.S. MEC 1). 3

Insertion Timing and Backup Contraception

Nexplanon can be inserted at any time if reasonably certain the woman is not pregnant. 3 The timing determines backup contraception needs:

• If inserted within the first 5 days of menstrual cycle: No backup contraception needed. 3
• If inserted at any other time: Use backup contraception or abstain from intercourse for 7 days after insertion. 3

Common Side Effects and Management

Bleeding Pattern Changes

The most common adverse reaction is change in menstrual bleeding patterns, including unscheduled spotting, light bleeding, or amenorrhea. 2 These changes are generally not harmful and may or may not decrease with continued use. 3

If irregular bleeding persists and is bothersome, NSAIDs for 5-7 days can be used for management. 1

Other Common Adverse Reactions

Additional adverse reactions (≥2% in trials) include headache, mood changes, device-related events, nausea/vomiting, vaginal discharge, weight changes, breast tenderness, dysmenorrhea, abdominal pain, acne, and decreased libido. 5

Follow-Up Care

No routine follow-up visit is required after Nexplanon insertion. 3 However, advise the patient to return at any time to:

• Discuss side effects or problems
• Change contraceptive methods
• Remove or replace the device at 3 years 3

Special Populations Where Nexplanon Excels

High-Risk Medical Conditions

LARC methods including Nexplanon are recommended (GRADE 1B) for women at highest risk for adverse health events from future pregnancy, including those with cardiovascular disease, diabetes, epilepsy, systemic lupus erythematosus, thrombophilia, chronic renal disease, and chronic hypertension. 3

Antiphospholipid Antibody-Positive Patients

For aPL-positive patients, progestin implants are strongly recommended over combined estrogen-progestin contraceptives due to thrombosis risk. 3 However, note that some guidelines express concern about the newer etonogestrel implant due to inadequate VTE data in this specific population. 3

Adolescents and Young Adults

Long-acting reversible contraceptives including Nexplanon are encouraged as first-line contraceptives for all appropriate candidates, including nulliparous women and adolescents. 3 In adolescents and young women, LARC has significantly lower failure rates than oral contraceptives (0.27 vs 4.55). 3

Clinical Pearls

• All healthcare providers must be trained on Nexplanon before performing insertions or removals. 2
• The device is radiopaque (contains barium sulfate) and visible on X-ray, facilitating localization if needed. 6
• Mean removal time is approximately 2 minutes when properly palpable. 6
• Extremely rare allergic reactions to barium sulfate have been reported. 7