Ways to Help Patients with Bleeding from Contraceptive Implant
June 1, 2023 4 minutes read
EXECUTIVE SUMMARY
Young patients often report bothersome bleeding after receiving a contraceptive implant, according to investigators.
- Subsequent bleeding was reported by 27% of people with an average age of 19 years.
- Contraceptive implants can effectively prevent pregnancy for four to five years, although it could be shorter for people with a high body mass index.
- The implant is rated as one of the most effective contraceptives.
Some patients experience bothersome uterine bleeding after receiving a contraceptive implant, according to a new study of implants and adolescent/young adult patients.1
Investigators found that 27% of people with an average age of about 19 years reported subsequent bleeding. Those who reported irregular menses before the implant were more likely to report bleeding after receiving the implant.
Implants are another option for people seeking long-acting reversible contraception (LARC). “Some people like the easy-on and easy-off with pills; some like something that lasts 10 years, and they don’t mind it in their uterus. Others want an implant in their arm so they don’t have to come into an office for a shot every three months,” says Sarah Pitts, MD, study co-author and co-director of the adolescent/young adult LARC program in the division of adolescent/young adult medicine at Boston Children’s Hospital. “Implants are becoming increasingly popular as more people learn about it. When we started the LARC program in 2013, we wanted to take a quality improvement approach to it and provide safe care and comprehensive care and management.”
The goal was to better understand side effects so physicians could provide better counseling for patients.
“We wanted to work with colleagues at other institutions to provide safe care and to make sure there weren’t variable experiences across the country,” says Pitts, an assistant professor of pediatrics at Harvard Medical School. “This study came from that collaborative.”
Pitts and colleagues studied patients’ side effects, discontinuation rates, complications of the procedure, and special populations of young people, based on medical history. Each site contributed to the quality improvement database to inform local care. They also studied the database retrospectively to see what experiences were common across all sites. For example, irregular bleeding happens with all contraceptives with hormonal agents, and implants are no different, Pitts says.
One-fourth of study participants experienced bleeding that was bothersome enough to bring up at a follow-up visit. “Research has limitations. If people didn’t come back to us, we didn’t know their experience,” Pitts explains. “Only 27% of the group reported being bothered by the bleeding, and they rated it as a concern at their clinic visit.”
When patients report concerns about a side effect, clinicians can ask them if they would like to give the contraceptive method a little more time. They also can start the patient on medicine, such as a birth control pill, to suppress bleeding.
“With LARC and non-LARC methods, we can have irregular bleeding,” Pitts says. “This happens with pills, rings, the patch, shots, implants, and IUDs.”
Providers can counsel patients on what to expect and reassure them when they question whether their symptoms are unusual. They also can suggest a pregnancy test and testing for sexually transmitted infections to rule out another cause for bleeding.
“If someone is bleeding heavily, we would make sure they weren’t anemic and their iron levels weren’t low,” Pitts says. “The most common response is, ‘Give it a couple of months.’”
Sixty-one percent of patients who reported bothersome bleeding received some type of medication management, which often was a hormonal agent and sometimes included ibuprofen. Providers would ask patients to return in a few months to see if their bleeding improved.
“It was joint decision-making around what the patient wanted,” Pitts says. Some patients would opt to take out the implant, she adds.
“My take-home message is doing a trial of medication management may help some patients, but it won’t help everyone,” Pitts says. “But you don’t know who it’s going to help.”
For people who are not eager to remove their implant, birth control pills and pain relievers are a nice tool in the toolbox to help them. “A significant number of our patients, who had ever had medication management, kept the implant in for three years,” Pitts says. “For some people, the implant is really great, and it’s important to counsel people in advance that bleeding can happen and to give them some tricks up our sleeve to help them — like ibuprofen, the birth control pill, or progestin pill. From the birth control standpoint, you may not need that.”
Typically, the contraceptive implant is used for four years, and some studies say it is effective for up to five years, Pitts notes. For people with a higher body mass index, it may not last as long.
“We talk with people at three years and say, ‘It’s officially expired, but research shows this,’ and if they say, ‘Yes,’ we’re happy to keep it in for another year,” Pitts says. “So far, the people we know who kept it in longer have not had any unplanned pregnancies.”
The contraceptive implant is rated one of the most effective at preventing pregnancy — even higher than hormonal IUDs — so many people are willing to endure irregular bleeding. Plus, young people may be less interested in taking a pill every day, receiving a shot every few months, or undergoing IUD insertion.
“We try to take a very reproductive justice approach and not make assumptions about what a person’s reproductive choices are, so it’s awesome to have IUDs and implants in our contraceptive toolbox,” Pitts notes.
REFERENCE
- Milliren CE, DiVasta AD, Edwards AJ, et al. Contraceptive implant-associated bleeding in adolescent/young adult clinical practice: Associated factors, management, and rates of discontinuation. J Adolesc Health 2023;72:583-590.
Some patients experience bothersome uterine bleeding after receiving a contraceptive implant, according to a new study of implants and adolescent/young adult patients. Investigators found that 27% of people with an average age of about 19 years reported subsequent bleeding. Those who reported irregular menses before the implant were more likely to report bleeding after receiving the implant.
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