Focus on the contraceptive implant — Insert it in your family planning practice

Where does the contraceptive implant (etonogestrel subdermal implant Nexplanon, Merck, Whitehouse Station, NJ) fit in your practice? About 30% of participants in the 2015 Contraceptive Technology Update Contraception Survey reported 25 or more implant insertions in the past year, with 14% saying they inserted 11 to 24 devices in that time period.

The implant represents the most effective form of reversible contraception available, with a failure rate of 0.05 in the first year among typical users.¹ Data indicate the device provides effective use past its approved duration. Three studies in which 275 women used the etonogestrel implant Implanon for longer than three years found no pregnancies during the fourth year of use.² A recent study of women using the implant and intrauterine device indicates both methods remain highly effective one year beyond their approved duration of use.³ (Contraceptive Technology Update reported on the research. See “Intrauterine device and implant are effective beyond use approved by the FDA,” May 2015.)

“The growth in the use of implants is very important,” observes Anita Nelson, MD, professor emeritus in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. “This is a method that can be used by virtually all women and can be placed by virtually every clinician, even very busy primary care providers.”

LOOK CLOSER AT METHOD

The progestin-only implant measures 4 cm long and 2 mm in diameter, and it is inserted just under the skin at the inner side of the non-dominant upper arm. The drug release rate is 60-70 mcg per day in weeks 5-6; it decreases to approximately 35-45 mcg/day at the end of the first year, to approximately 30-40 mcg/day at the end of the second year, and then to approximately 25-30 mcg/day at the end of the third year.⁴ It provides contraception through ovulation suppression and thickening of cervical mucous.

In a multicenter safety and efficacy clinical trial of the implant, the most common bleeding pattern observed throughout the study was infrequent bleeding, defined as less than three episodes of bleeding in a reference period (excluding amenorrhea).⁵ The return to normal menstrual cycles and fertility is rapid after removal, according to trial results.

A review of data from 11 clinical trials indicates that implant use is associated with an unpredictable bleeding pattern, which includes amenorrhea and infrequent, frequent, and/or prolonged bleeding.⁶

The bleeding pattern experienced during the first three months is broadly predictive of future bleeding patterns for many women. Effective preinsertion counseling on the possible changes in bleeding patterns might improve continuation rates, the review states.

CHECK OTHER BENEFITS

In addition to its contraceptive efficacy, the implant offers non-contraceptive benefits as well. Anne Burke, MD, MPH, associate professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University of School of Medicine in Baltimore, spoke on such benefits at the 2015 Contraceptive Technology Quest for Excellence conference in Atlanta.⁷

Researchers conducted a small pilot study designed to evaluate the beneficial effects of Implanon on pelvic pain in women with pelvic congestion syndrome (PCS). The efficacy of pain control, amount and frequency of menstrual loss, degree of patient’s satisfaction, and objective pelvic venography scores were analyzed. According to study results, Implanon appears to be an effective hormonal alternative for long-term treatment of properly selected patients with pure PCS-related pelvic pain.⁸

Another small study looked at use of the implant compared to the contraceptive injection depot medroxyprogesterone acetate (DMPA) for relief of pain associated with endometriosis, During a one-year follow-up period, researchers recorded a clear improvement in pain intensity for both treatment options. After six months, the average decrease in pain was 68% in the Implanon group and 53% in the DMPA group. The side-effects profile and the overall degree of satisfaction after study termination were comparable for both treatment options, researchers report.⁹

REFERENCES

1. Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
2. Raymond EG. Contraceptive implants. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
3. McNicholas C, Maddipati R, Zhao Q, et al. Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the U.S. Food and Drug Administration-approved duration. Obstet Gynecol 2015; 125(3):599-604.
4. Merck & Co. Highlights of Nexplanon prescribing information. Accessed at http://bit.ly/1P58b72.
5. Funk S, Miller MM, Mishell DR Jr, et al; Implanon US Study Group. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contracep-tion 2005; 71(5):319-326.
6. Mansour D, Korver T, Marintcheva-Petrova M, et al. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care 2008; 13 Suppl 1:13-28.
7. Burke A. Non-contraceptive benefits of LARC. Presented at the 2015 Contraceptive Technology Quest for Excellence conference. Atlanta; November 2015.
8. Shokeir T, Amr M, Abdelshaheed M. The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study. Arch Gynecol Obstet 2009; 280(3):437-443.
9. Walch K, Unfried G, Huber J, et al. Implanon versus medroxyprogesterone acetate: Effects on pain scores in patients with symptomatic endometriosis — A pilot study. Contraception 2009; 79(1):29-34.