Unanticipated bleeding with the etonogestrel implant: advice and therapeutic interventions.

To cite: Dickson J, Hoggart L, Newton VL. J Fam Plann Reprod Health Care 2014;40:158–160. THE PROBLEM The etonogestrel contraceptive implant (Implanon, Nexplanon) is widely recognised as a reliable and cost-effective form of contraception. However, continuation rates are of concern as the method loses cost effectiveness when discontinued early. It has been calculated that 60% of implant removals are for irregular or unpredictable bleeding. Guidelines for standard practice in implant provision emphasise the importance of adequate counselling about side effects, especially bleeding irregularities, before implant insertion. In our recently published study 5 we showed that even in cases where young women have been made aware of the possibility of irregular bleeding, the clinician’s messages are not always fully absorbed. In this study the women each had their own interpretations of the advice they had been given, and individualised responses to their experience of side effects. It was confirmed that the predominant reason for requests for implant removal was irregular bleeding. It was also evident that: 1 The women had not been prepared for the reality of prolonged bleeding or irregular bleeding patterns, even when they could recall being informed about these at their initial consultation. 2 They often persevered with their implants, waiting for the bleeding pattern ‘to settle’, so often tolerated significant amounts of discomfort and inconvenience. 3 Bleeding in conjunction with other side effects was particularly problematic. Patients are often advised to ‘persevere’ with the method in the anticipation that their symptoms may ultimately resolve. However, if the situation does not improve, the ‘therapeutic window’ for some form of intervention is missed. In our study, the women had reached a ‘tipping point’ at which intervention was no longer possible. Our study showed the importance of recognising the real impact of troublesome bleeding: the impact it has on sex life, relationships and finances, and the anxiety caused by unpredictability. It is important to intervene as soon as possible when bleeding is presented as a problem, rather than encouraging acceptance of the situation. Research into methods of controlling the bleeding problems related to contraceptive implants is inconclusive, so a pragmatic approach to management should be employed.