From the Guidelines
For a patient experiencing breakthrough bleeding with Nexplanon, the most effective option is to try a short course of combined hormonal therapy, such as a combined oral contraceptive pill containing ethinyl estradiol 35mcg with norethindrone 1mg daily for 10-20 days, as this approach can help regulate the bleeding while minimizing the risk of morbidity and mortality associated with uncontrolled bleeding. When managing abnormal uterine bleeding associated with ovulatory dysfunction, as seen with progestin-only contraception like Nexplanon, it's essential to consider the PALM-COEIN classification system, which categorizes causes into structural and nonstructural etiologies 1. Given the context of Nexplanon use, nonstructural causes, particularly those related to iatrogenic effects of the progestin-only contraceptive, are most relevant. The use of progestin-only contraceptives like Nexplanon can lead to irregular endometrial thinning and fragile blood vessels, resulting in breakthrough bleeding, which affects up to 20% of users 1. Options for managing this breakthrough bleeding include:
- Combined hormonal therapy for a short course
- Estrogen supplementation alone
- Non-steroidal anti-inflammatory drugs to reduce bleeding by affecting prostaglandin levels
- Consideration of doxycycline for its potential in reducing matrix metalloproteinases that contribute to endometrial breakdown, although this is less commonly recommended as a first-line approach. It's crucial to counsel patients that most bleeding episodes improve with time as the body adjusts to the hormone levels, but if bleeding remains problematic, removal and switching to a different contraceptive method may be necessary, prioritizing the patient's quality of life and minimizing morbidity and mortality risks associated with prolonged or severe bleeding.
From the Research
Management Options for Breakthrough Bleeding with Nexplanon
- Combined oral contraceptive pills (COCP) have been shown to be effective in managing bleeding irregularities among etonogestrel implant users, with 76.2% of women in one study stopping bleeding within 7 days of treatment 2.
- Nonsteroidal anti-inflammatory drugs (NSAID) such as mefenamic acid may also be used to manage bleeding, although they may be less effective than COCP, with 35.7% of women in one study stopping bleeding within 7 days of treatment 2.
- Tamoxifen has been shown to reduce bleeding/spotting days and provide a longer cessation of bleeding/spotting in etonogestrel implant users, with women randomized to tamoxifen reporting 5 fewer days of bleeding/spotting over 30 days compared to those randomized to placebo 3.
- Doxycycline and ibuprofen may also be used to manage etonogestrel subdermal implant-related bleeding, with reassurance plus doxycycline associated with lower removal rates for bleeding than reassurance alone 4.
- A 14-day oral contraceptive pill regimen has been shown to result in temporary interruption of bleeding for etonogestrel implant users, with 87.5% of women in one study experiencing a temporary interruption of bleeding during the study drug period 5.
Comparison of Management Options
- COCP may be more effective than NSAID in managing bleeding irregularities among etonogestrel implant users 2.
- Tamoxifen may be a useful option for women experiencing frequent or prolonged bleeding with the etonogestrel implant, although further study is needed to determine whether this effect is maintained with repeat use 3.
- The choice of management option may depend on individual patient factors, such as medical history and preferences, and should be made in consultation with a healthcare provider.