What are the benefits and risks of using Nexplanon (etonogestrel) as a form of birth control in a 32-year-old woman with a history of diabetes, currently taking GLP-1 (Glucagon-like peptide-1) Mounjaro (tirzepatide)?

Nexplanon Education for a 32-Year-Old Woman on Mounjaro (Tirzepatide)

Nexplanon is an excellent contraceptive choice for your patient with diabetes on Mounjaro, as women with well-controlled diabetes can safely use all contraceptive methods, and the risk of unplanned pregnancy far outweighs any contraceptive risk. 1, 2

Why Nexplanon is Appropriate for This Patient

Long-acting reversible contraception like Nexplanon is ideal for women with diabetes because planning pregnancy is critical to achieve optimal glycemic control (ideally A1C <6.5%) before conception to prevent congenital malformations. 1, 2 The etonogestrel implant is the most effective contraceptive method available, with fewer than 1 woman out of 100 becoming pregnant in the first year of typical use. 3, 4

Key Advantages:

• No drug interactions with Mounjaro (tirzepatide) - there are no documented interactions between GLP-1 receptor agonists and progestin-only contraceptives 5, 6
• Does not affect glucose metabolism unlike combined hormonal contraceptives 7
• Highly effective with perfect and typical use failure rates of less than 1% 8, 9
• Reversible with rapid return to fertility once removed 4

The Insertion Process

Timing of Insertion

• Nexplanon can be inserted at any time if it is reasonably certain she is not pregnant 3, 8
• If inserted within the first 5 days of her menstrual cycle, no backup contraception is needed 3
• If inserted after day 5 of her cycle, she must use backup contraception (condoms) for 7 days 3, 8

The Procedure Itself

• The implant is a single flexible rod (4 cm long, 2 mm diameter) containing 68 mg of etonogestrel 3
• It is inserted subdermally in the inner side of the non-dominant upper arm 9
• The procedure is office-based and takes only minutes 4
• The implant is radiopaque (visible on X-ray) and palpable, which facilitates removal 9
• All providers must be trained on Nexplanon insertion before performing the procedure 4

Duration and Removal

• The implant remains effective for 3 years and must be removed by the end of the third year 4
• Mean removal time is approximately 2 minutes 9
• The most common removal complication is fibrosis around the implant (4.4% of cases) 9
• No routine follow-up visits are required after insertion 8

Expected Bleeding Changes (Critical Counseling Point)

Before insertion, counsel extensively about bleeding pattern changes, as this is the most common reason for discontinuation. 3, 8

What to Expect:

• Unscheduled spotting or light bleeding is common and generally not harmful 3
• 22% of women experience amenorrhea (no periods) 3
• 34% experience infrequent spotting 3
• 7% report frequent bleeding 3
• 18% report prolonged bleeding 3
• These bleeding changes are not harmful and may or may not decrease with continued use 3

Management of Bleeding Irregularities:

If irregular bleeding becomes bothersome:

• NSAIDs (like ibuprofen) for 5-7 days during bleeding episodes can help 3
• Short-term hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days (if medically eligible) 3
• Amenorrhea requires no treatment - only reassurance 3

Enhanced counseling about expected bleeding patterns has been shown to reduce discontinuation rates 8

Potential Side Effects

Common Adverse Reactions (≥2%):

• Headache (including migraine) 10
• Mood changes (depression, mood swings) 10
• Device-related events (discomfort, foreign body sensation) 10
• Nausea 10
• Breast tenderness 10
• Weight changes 10
• Acne 10
• Decreased libido 10

Serious Considerations:

• Serious adverse events occurred in 5.3% of women in clinical trials, but none were judged as drug-related 9
• Mood changes led to discontinuation in some women 11
• Weight gain, acne, and decreased libido were reasons for removal in a small percentage 11
• Importantly, bleeding complaints were rarely a reason for discontinuation when proper counseling was provided 11

Special Considerations for Diabetes

Women with diabetes have the same contraceptive options as those without diabetes - the risk of unplanned pregnancy outweighs any contraceptive risk. 1, 12, 2

Important Points:

• Progestin-only methods like Nexplanon do not increase cardiovascular risk unlike combined hormonal contraceptives 7
• No glucose or lipid screening is required before initiating Nexplanon 7
• Regular monitoring of glycemic control should continue as part of routine diabetes care 7
• Combined hormonal contraceptives would be contraindicated if she had complicated diabetes, severe hypertension, or significant dyslipidemia, but Nexplanon avoids these concerns 7

What She Should Know About Pregnancy Planning

When she's ready to conceive:

• She should have the implant removed and achieve optimal glycemic control (A1C <6.5%) before attempting pregnancy 1, 2
• Fertility returns rapidly after removal 4
• Preconception planning is essential for women with diabetes to prevent congenital malformations 1, 2

No Interaction with Mounjaro

There are no documented interactions between tirzepatide (Mounjaro) and etonogestrel (Nexplanon). Tirzepatide is a dual GIP/GLP-1 receptor agonist that works through incretin pathways to lower glucose and reduce appetite 5, 6, while Nexplanon works by suppressing ovulation through progestin effects 4. These mechanisms do not interfere with each other.

When to Seek Medical Attention

Advise her to contact her provider if she experiences:

• Signs of infection at the insertion site
• Migration or expulsion of the implant
• Severe abdominal pain (to rule out ectopic pregnancy, though extremely rare)
• Persistent heavy bleeding
• Severe mood changes
• Any symptoms concerning for toxic shock syndrome (fever, rash, hypotension) 10