Heavy Menstrual Cycles with Nexplanon (Etonogestrel) Implants
Yes, heavy menstrual cycles can occur with Nexplanon, but they are uncommon—most users experience reduced bleeding or amenorrhea over time, with the majority having light bleeding or spotting that decreases with continued use.
Expected Bleeding Patterns with Nexplanon
Unscheduled spotting or light bleeding is expected during the first 3-6 months of Nexplanon use and is generally not harmful, decreasing with continued use 1.
Approximately 64% of users report amenorrhea or infrequent bleeding over the first 2 years, while only 15% experience frequent or prolonged bleeding 1.
Total menstrual blood loss typically decreases by more than 50% during the first 6 months compared to pre-treatment cycles, though individual variation exists 2.
Heavy or prolonged bleeding is uncommon during Nexplanon use 1.
When Heavy Bleeding Occurs: Evaluation
Before treating heavy bleeding with Nexplanon, you must rule out underlying pathology:
Exclude pregnancy, sexually transmitted infections (particularly in reproductive-aged women), and new pathologic uterine conditions such as polyps or fibroids 1, 3, 4.
Consider implant displacement as a potential cause 1.
Assess for medication interactions that could affect bleeding patterns 4.
Management of Heavy Bleeding with Nexplanon
If heavy bleeding occurs and underlying pathology is excluded:
First-line treatment: NSAIDs for 5-7 days during bleeding episodes to acutely reduce blood flow 3, 4.
Provide reassurance and enhanced counseling about expected bleeding patterns, as this reduces discontinuation rates 1, 3.
If bleeding persists beyond 3-6 months and remains unacceptable to the patient despite treatment, counsel on alternative contraceptive methods and offer another method if desired 1, 3.
Important Counseling Points
Counsel patients before insertion about potential changes in bleeding patterns, emphasizing that irregular bleeding in the first 3-6 months is normal and not harmful 1, 3.
Reassure patients that bleeding generally decreases over time, with many women experiencing only light menstrual bleeding or amenorrhea 1.
The experience in the first 3 months may help predict future bleeding patterns, though individual variation is highly variable 1.
Common Pitfall to Avoid
The most common reason for early discontinuation of Nexplanon is abnormal uterine bleeding, with more than half of users in observational studies discontinuing before 24 months due to bleeding concerns 1. This highlights the critical importance of pre-insertion counseling about expected bleeding changes to improve continuation rates and patient satisfaction.