9 CONTRACEPTION. Date Revised: April 2013

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1 9 CONTRACEPTION 9.5 ETONOGESTREL IMPLANT IMPLANON NXT WOMEN AND NEWBORN HEALTH SERVICE CLINICAL GUIDELINES SECTION A : OBSTETRICS AND GYNAECOLOGY Authorised by: OGCCU Key words: Etonogestrel Implant, Implanon NXT, Contraception, Background information Key points Efficacy Contra-indications Side-effects Initiation of Implanon Medical history and examination prior to insertion Counselling prior to insertion Follow-up following Implanon insertion Insertion of Implanon Non-routine removal of an Implanon implant References BACKGROUND INFORMATION Implanon NXT is a single-rod progestogen implant containing Etonogestrel (ENG) which is placed subdermally in the upper arm of a woman. It is an effective contraception for up to 3 years and prevents pregnancy by inhibiting ovulation, altering the endometrium, and causing thickening of the cervical mucus. 1 Implanon contains 68 mg of ENG dispersed in a membrane of ethylene vinyl acetate and is licensed for 3 years of use. 2 Implanon NXT provides an alternative form of contraception for women with medical conditions where oestrogen-containing contraception is contra-indicated, or when an oestrogen side-effect such as nausea becomes problematic. Women with inflammatory bowel disease or other enteral malabsorption conditions may find this form of contraception a suitable option. 1 Irregular vaginal bleeding is the primary reason most women give for early discontinuation of the implants, so pre-insertion counselling is essential. This may have implications for women with religious or cultural restrictions during menstrual bleeding. 3 KEY POINTS 1. Implanon is a progestogen only implant that is a highly effective, long acting reversible contraceptive Medical practitioners must attend a training course before inserting Implanon. 3. Pregnancy should be excluded prior to insertion. Careful history taking and awareness of the limitations of pregnancy testing can reduce the risk of missing an implantation bleed or ectopic pregnancy A single Implanon rod provides effective contraception for 3 years. 1 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 5

2 5. Women with a BMI > 30 kg/m 2 can use a progestogen-only implant without restriction 2, and while product information suggests heavier women may be at increased risk of failure in the third year of use evidence does not support this view, and therefore a recommendation for earlier replacement is not required Women should be advised an Implanon implant results in changes of menstrual patterns for all users, ranging from amenorrhoea to frequent and/or prolonged bleeding. 1 20% of users will experience no bleeding, while almost 50% of users will have infrequent, frequent, or prolonged bleeding. If there is persistent, annoying bleeding in the first 3 months of use, the bleeding pattern is likely to remain irregular Women should be informed there is no delay in return of (pre-existing) fertility following removal of the ENG implant The ENG implant can be safely used in women who are breastfeeding. 2 EFFICACY Typical use results in 99.9% efficacy. 1 CONTRAINDICATIONS ABSOLUTE CONTRA-INDICATION Breast cancer diagnosed in the last 5 years 2 STRONG RELATIVE CONTRA-INDICATIONS Current deep vein thrombosis/pulmonary embolus currently being treated with anticoagulants 2 Past history of breast cancer with no current disease for 5 years 2 Development for the first time during use ischaemic heart disease, stroke, migraine with aura 2 Unexplained vaginal bleeding 2 Active viral liver disease (not including hepatitis virus carriers), decompensated cirrhosis 2 Liver tumours 2 Concurrent use with liver enzyme-inducing drugs 2 Gestational trophoblastic disease with abnormal βhcg 2 SIDE-EFFECTS Possible side effects associated with Implanon include: weight gain 2 bleeding irregularities may be irregular and unpredictable The menstrual pattern may vary from amenorrhoea to frequent and/or prolonged bleeding 2 emotional lability 2 breast tenderness 2 acne 2 local reaction to the insertion site, scarring 2 deep insertion may lead to difficult removal later All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 5

3 INITIATION OF IMPLANON 2 SITUATION STARTING IMPLANT EFFECT No contraception or barriers Combined pill DPMA injection Progestogen only pills Day 1 (first day of bleeding) to day 5 of a normal menstrual cycle. Any other time if pregnancy is excluded. Anytime if pills have been taken correctly. Any time if within 14 weeks of injection Any time if pills have been taken correctly; otherwise exclude pregnancy Abortion Copper or levonorgestrel IUD Implant Day 1 (first day of bleeding) to day 5 of a normal menstrual cycle. Other times condoms for prior to the removal of the IUD If before the expiry time of the implant If the implant has expired, exclude pregnancy, or continue progestogen only pill for 7 additional days, or leave IUD in place for 7 additional days Post partum (fully breastfeeding) Post partum (not, or not fully, breastfeeding) Less than 6 weeks post partum More than 6 weeks post partum and no menses any time if pregnancy excluded. Menstrual cycles resumed as above for no contraception or barriers Less than 21 days postpartum any time More than 21 days post partum and no menses any time if pregnancy excluded Menstrual cycles resumed as above for no contraception or barriers As above As above All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 5

4 MEDICAL HISTORY AND EXAMINATION PRIOR TO INSERTION Medical History The medical history should include: menstrual history last menstrual period, type and duration of menses to exclude implantation bleeds or ectopic pregnancy, history of unprotected sex 1 cardiovascular risk factors thromboembolic disease keloid scarring - insertion may cause excessive scarring lactation implants are considered safe in lactating women liver disease ENG is metabolised in the liver medications ENG implants may be less effective with liver enzyme-inducing medications e.g. Rifampicin Examination 1. Perform a blood pressure measurement 2. Assess the woman s weight and height to calculate the BMI. 3. Assess for sexually transmitted infection (STI) as required 4. Perform cervical screening as required. COUNSELLING PRIOR TO INSERTION Prior to insertion women should be counselled about 1 : changes in menstrual patterns side-effects and complications follow-up with the medical practitioner Implanon information e.g. mechanism and duration of use, efficacy, and return of fertility after removal Provide written information which is available from Family Planning of Western Australia at FOLLOW-UP FOLLOWING IMPLANON INSERTION Follow-up by a medical practitioner is recommended within 2-3 months to 1 : palpate the implant assess for side-effects check for new medical conditions, medications assess bleeding patterns assess for STI risks INSERTION OF IMPLANON See Clinical Guideline Insertion of Implanon All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 5

5 NON-ROUTINE REMOVAL OF AN IMPLANON IMPLANT See Clinical Guideline Non-routine removal of an Implanon implant. REFERENCES 1. Sexual Health & Family Planning Australia. Contraception: an Australian clinical practice handbook. 2nd ed. Canberra Faculty of Sexual and Reproductive Healthcare. Progestogen-only Implants. 2008; Available from: 3. Fisher MA. Implanon: A New Contraception Implant. AWHONN. 2008;37(3): All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 5