Implanon Research Articles

Pilot study of a novel, alternative subdermal scapular insertion site for the etonogestrel contraceptive implant

ObjectivesTo assess the pharmacokinetics and pharmacodynamics of the etonogestrel (ENG) contraceptive implant when inserted at an alternative scapular site. Study DesignWe conducted a pilot study of healthy, reproductive-age females who underwent subdermal insertion of an ENG implant over the inferior edge of the non-dominant scapula (scapular insertion). We measured serum ENG levels over one year at nine time points. Participants completed questionnaires on insertion site and bleeding side effects. We collected photographs and video recordings of insertion and removal techniques. ResultsWe enrolled five participants (as prespecified), their median age was 26.0 years (range: 19.6-30.3) and median body mass index was 25.0 kg/m2 (range: 22.0-28.0). All serum ENG concentrations remained >90pg/mL during the first year of use and were within range of published data for arm insertion of ENG implant at all time points. The mean serum ENG level was 511.7pg/mL (±168.2) at one week and 136.6pg/mL (±21.8) at 12 months. During the first week after insertion, 4/5 participants noted insertion site pain with a median pain score of 2 (range 1-3), but all noted resolution by week two. Participants reported variable bleeding patterns consistent with standard ENG implant placement. At the end of the study, all participants reported satisfaction with the implant and would recommend scapular insertion to a friend. ConclusionsScapular insertion of the ENG contraceptive implant has similar pharmacokinetics to arm insertion over one year of use. This novel, alternative site was well tolerated and demonstrated similar bleeding side effects to standard arm insertion. IMPLICATIONSSubdermal scapular insertion of the etonogestrel contraceptive implant demonstrated similar pharmacokinetics to arm insertion over one year of use. Our pilot data supports scapular insertion as an alternative site for ENG contraceptive implants, which could be beneficial for certain patient populations.

RWD25 Usage and Costs Profile of Long-Term Contraception Users at a Health Plan Operator in the Brazil

To evaluate the profile of health resource utilization and costs linked to contraception in users of Etonogestrel Contraceptive Implant (ETN-IMP) and Levonorgestrel Intrauterine System (LNG-IUS).

Pharmacokinetics of levonorgestrel and etonogestrel contraceptive implants over 48 weeks with rilpivirine- or darunavir-based antiretroviral therapy.

Pharmacokinetic data are lacking for progestin-releasing subdermal contraceptive implants when used with either rilpivirine- or darunavir/ritonavir-based ART. To characterize the pharmacokinetics of etonogestrel or levonorgestrel implants when administered with these ART regimens over 48 weeks. Two separate, parallel, three-group, non-randomized, pharmacokinetic studies evaluated either etonogestrel or levonorgestrel in women receiving rilpivirine- or darunavir-based ART compared with women without HIV (control group). Participants on ART were switched to rilpivirine-based ART with a run-in period of 6 weeks or darunavir-based ART with a run-in of 2 weeks prior to implant insertion. Plasma was collected on Day 0, and 1, 4, 12, 24, 36 and 48 weeks post-insertion. Plasma progestin concentrations were compared between ART and control groups by geometric mean ratio (GMR) and 90% CI. At the primary endpoint of Week 24, progestin concentrations were similar between the rilpivirine and control groups [etonogestrel: 1.18 (0.99-1.37); levonorgestrel: 1.16 (0.97-1.33)]. At Week 24, progestin exposure was higher in the darunavir groups compared with the control group [etonogestrel: 2.56 (1.69-3.28); levonorgestrel: 1.89 (1.38-2.29)]. Results remained consistent through to Week 48. No differences in etonogestrel-related adverse events were observed, but both ART groups experienced more menstrual abnormalities versus the control group with levonorgestrel. Etonogestrel and levonorgestrel concentrations were not altered by rilpivirine-based ART. Although progestin concentrations were higher in the ART groups containing ritonavir-boosted darunavir, no implant-related serious adverse events were observed. Both progestin-releasing implants are an appropriate contraceptive option with either rilpivirine- or darunavir/ritonavir-based ART.

EFFECTS OF LONG-TERM USE OF ETONOGESTREL CONTRACEPTIVE IMPLANT: LITERATURE REVIEW

Implantable contraceptives are a long-term birth control option for women. However, contraceptive implants are not suitable for everyone. One of the contraceptive implants that is often used is etonogestrel. Etonogestrel is a progestin, or synthetic progestogen, and is therefore an agonist of the progesterone receptor, the biological target of progestogens such as progesterone. It works by stopping ovulation, thickening the mucus around the cervical opening, and changing the lining of the uterus. It has very weak androgenic and glucocorticoid activity and no other important hormonal activity. The purpose of this study was to determine the side effects of long-term use of the etonogestrel implant contraceptive through a literature study. The three databases used are Pubmed, ScienceDirect, and Scopus in this study. The literature search was carried out after the PICO was determined and used the keywords “Effect”, “Etonogestrel Contraceptive Implant”, “Long Term”. Based on the analysis of the 11 articles obtained in this study, it can be concluded that the Etonogestrel Implant Contraceptive is a safe and effective contraceptive method for use in women of childbearing age. Even so, etonogestrel has side effects such as menstrual irregularities, breast tenderness, mood swings, acne, headaches, vaginitis

Early Removal of the Etonogestrel Contraceptive Implant and Associated Factors Among Users at the Urban Family Planning Clinic in Siriraj Hospital, Bangkok, Thailand

Objective: To study the rate and reasons for the early removal of etonogestrel contraceptive implants and associated factors at the family planning clinic in Siriraj Hospital. Materials and Methods: This retrospective cohort study was conducted between May 2015 and December 2019 and contained 1,030 women who received the etonogestrel contraceptive implant. The medical records of demographic characteristics and clinical factors i.e., implant insertion date, implant removal date, reason for implant removal, contraceptive use before implant insertion and after implant removal, documented bleeding pattern and acceptability, were identified. Results: The mean age of participants was 28.6 ± 6.9 years. About 21% of women (218/1030) prematurely discontinued their etonogestrel implant. A desire to become pregnant was the most common reason for early removal of the etonogestrel implant (32%). Meanwhile, the most common side-effect contributing to early removal was unscheduled bleeding. The associated variables of early etonogestrel implant removal were low BMI (p-value = 0.021) and unacceptability of bleeding pattern at one year (p-value < 0.001) and two years (p-value < 0.001) after insertion. Conclusion: Early etonogestrel implant discontinuation rate was remarkable and the main reasons for it include a desire to become pregnant and bleeding side effects. Moreover, a lower BMI and unacceptability of bleeding problems also increased the likelihood of early removal of this contraceptive method.

Subfascial\u2010located contraceptive devices requiring surgical removal

BackgroundSubdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted.Case presentationHere we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19–33) and BMI was 24.0 kg/m^2 (19.1–36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication.ConclusionsInsertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia.

In 2009, the Government of Ethiopia initiated the implant scale-up initiative, which expanded contraceptive access by training health extension workers (HEWs) to insert single-rod etonogestrel contraceptive implants (Implanon) at rural health posts. Removals were provided by referrals to higher levels of the health system. However, little was known about whether women were getting their implants removed at the recommended 3-year postinsertion date or what barriers they faced to removal. Between June and July 2016, 1,860 Ethiopian women, who had a 1-rod etonogestrel implant inserted by either an HEW or another health care provider between 3 and 6 years prior, were surveyed. We describe the characteristics of the sample and use multivariable logistic regression to predict factors associated with keeping implants inserted beyond 3 years. Women who had received their implants from HEWs were significantly more likely to report keeping them inserted for more than 3 years (adjusted odds ratio=2.50; 95% confidence interval=1.19, 5.24), compared with those who got their implant from another health care provider. Women who reported distance to the facility or transportation as a barrier were also significantly more likely to keep their implant for more than 3 years. Married and educated women were less likely to keep their implants for an extended duration. Among women who had their implant for 3 years or less, women who had had it inserted by an HEW were significantly more likely to report that the provider was unable or refused to provide removal as a barrier. Efforts to expand lower level and community-based access to contraceptive implants that do not ensure reliable access to removals at the same level as insertions may lead to women using implants beyond the recommended duration.

Etonogestrel concentrations among contraceptive implant users in Botswana using and not using dolutegravir-based antiretroviral therapy

ObjectivesTo evaluate whether etonogestrel concentrations are reduced to a level that could potentially reduce contraceptive efficacy when the etonogestrel contraceptive implant is used concomitantly with dolutegravir-based antiretroviral therapy (ART). Study designWe conducted a non-randomized, open-label, cross-sectional pharmacokinetic study among women using single-rod etonogestrel contraceptive implants in Botswana. We compared plasma etonogestrel concentrations, sampled at a single time-point between 3 and 12 months from implant insertion, among implant users living with HIV and receiving dolutegravir-based ART with HIV-negative implant users. We also assessed concentrations among implant users living with HIV and receiving efavirenz-based ART. We compared geometric mean etonogestrel concentrations analyzing data from 142 participants: 97 HIV-negative, 30 using dolutegravir, and 15 using efavirenz. ResultsThe groups were similar. Duration of implant use was between 3 and 12 months (median = 5). Geometric mean etonogestrel plasma concentrations and 90% confidence intervals of the mean were 227.5(212.4–243.8), 289.6(251.8–333.0) and 76.4(63.9–91.4) pg/mL among the HIV-negative, dolutegravir- and efavirenz-based ART groups, respectively. All women in the HIV-negative and dolutegravir-based ART groups had etonogestrel concentrations above 90 pg/mL; 9/15 women (60%) using efavirenz-based ART had concentrations below 90 pg/mL. On average, etonogestrel levels were lower among individuals who had implants inserted for longer durations. ConclusionsImplant users receiving dolutegravir-based ART had a higher mean etonogestrel concentration compared to HIV-negative women, and none had etonogestrel concentrations below the posited threshold for ovulation suppression. In contrast, women in the efavirenz-group had much lower etonogestrel concentrations. Overall, these data provide evidence that the etonogestrel implant may be effectively combined with dolutegravir-based ART regimens. ImplicationsThe etonogestrel implant remains a highly effective contraceptive option for women living with HIV who use dolutegravir-based ART.

Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism [01J

INTRODUCTION: Placement of the etonogestrel contraceptive implant (ECI) during the delivery admission provides immediate, reliable and convenient contraception. The implant manufacturer recommends delaying placement until 21 days postpartum due to concern for increased risk of postpartum venous thromboembolism (VTE). This study compares the rate of VTE between women with and without delivery admission contraceptive implant insertion. METHODS: The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum ECI, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared to the number of women readmitted for VTE who did not have the contraceptive implant placed during delivery admission. RESULTS: Of 3,387,120 deliveries, 8,369 women underwent ECI placement during the delivery admission. Of women readmitted with VTE, 7 had received a postpartum ECI (0.8 per 1,000 deliveries) compared to 1,192 without an ECI (0.4 per 1,000 deliveries), Odds Ratio (OR) 2.41; 95th CI 0.58-9.89. The rates of diabetes, thrombophilia, lupus and cesarean delivery did not differ between groups. Women that underwent ECI placement were younger, on Medicaid, smoked, had hypertension, intrauterine growth restriction, peripartum infection, or postpartum hemorrhage (P<.01). Adjusting for these confounders showed no impact, adjusted OR 1.80; 95th CI 0.44-7.37. CONCLUSION: No significant difference was noted in the rate of VTE in women after immediate postpartum insertion of the ECI, suggesting that the implant may not be associated with VTE if placed in the immediate postpartum period.

207. Body Mass Index (BMI) Changes in Adolescent Users of Long Acting Reversible Contraception (LARC)

LARCs are the most effective forms of reversible contraception currently on the market, yet uptake is still quite low among adolescents. As weight concerns are frequently considered by adolescents choosing a contraceptive method, we sought to compare BMI changes within the first two years of use in girls using non-hormonal (copper) and levonorgestrel (LNG) intrauterine devices (IUDs) as well as etonogestrel (ENG) contraceptive implants and to examine the influence of baseline BMI prior to LARC insertion on BMI changes after insertion.

Fourth poem for Nexplanon

Fourth poem for Nexplanon

Relationship between patient characteristics and serum etonogestrel concentrations in contraceptive implant users

ObjectiveTo determine whether serum etonogestrel concentrations in contraceptive implant users are associated with certain individual patient characteristics. Study designWe enrolled reproductive-age women using etonogestrel contraceptive implants between 12–36 months duration and measured a single serum etonogestrel concentration. Participants also completed a questionnaire about demographics. ResultsWe enrolled 350 participants; median age was 22.5 years (range 18.0–39.1), median months of implant use was 26.0 (range 12.0–36.0), and median body mass index was 25.7 kg/m2 (range 18.5–52.0). Our study population was primarily white/Caucasian (46.6% [163/350]) and Hispanic/Latina ethnicity (51.4% [180/350]). The median serum etonogestrel concentration was 137.4 pg/ml and etonogestrel concentrations varied 12.4 fold in the population (range 55.8–695.1 pg/ml). Using forward stepwise linear regression, months of implant use (β=−1.74, p<.001) and body mass index (β=−3.10, p<.001) were both significantly associated with decreased serum etonogestrel concentration with Black/African American race as a positive effect modifier (β=18.24, p=.099); R-squared for the model=0.13. ConclusionsIndividuals demonstrated a wide variability in serum etonogestrel concentrations, which can potentially affect side-effect profiles and efficacy. Increasing body mass index and longer duration of implant use were associated with small decreases in serum etonogestrel concentrations, while self-reported Black/African American race was associated with a non-significant increase. Despite these findings, most of etonogestrel variability was unaccounted for, suggesting that other clinical, pharmacologic, and genetic factors contributing to variability in etonogestrel concentrations remain to be determined. ImplicationsAlthough increases in body mass index are associated with lower etonogestrel levels in contraceptive implant users, the majority of women will maintain serum concentrations that consistently suppress ovulation. Furthermore, certain patient characteristics can only explain a small portion (13%) of the variability in serum etonogestrel levels among contraceptive implant users.

Reducing Bleeding Associated with Etonogestrel Implants

Etonogestrel contraceptive implant users may experience unscheduled uterine bleeding that leads to method discontinuation. In a trial involving 63

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

ObjectivesWe aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care. Study designWe reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach. ResultsTwo patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety. ConclusionWhen necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Evaluation of some haematological indices of implanon (etonogestrel) acceptors after 36 months of use in a tertiary institution

Introduction: Implanon as a contraceptive method is used by all women of reproductive ages. It is important to continue to document its safety amongst acceptors to enhance its continuity that will increase uptake and reduction in maternal morbidity and mortalityObjective: To evaluate some haematological indices of users of Implanon over the 36 months period.Methods: The ongoing prospective longitudinal study of forty six healthy informed volunteers recruited from our family planning clinic in 2007 evaluated the haematological indices after 24 and 36months of use.Results: The mean age and parity of the clients were 34.3 ± 4.9years and 3 ± 2respectively. The mean body weight and blood pressure at pre-insertion were 71.8± 11.6kg and 119 ± 14.7/76.6 ± 9.9 mmHg. There was no statistical significant change in the body weight over the study period. The blood pressure showed a significant but within normal reduction at 12months of study 110.3± 12.7/72.3 ±8.1mmHg; p = 0.01/0/05 without any significant change at 24 and 36 months of use. The mean packed cell volume at pre-insertion was 37.3 ± 2.5%. The value rose to a statistical significant mean value of 38.6 ±1.9%; p = 0.01 at 36 months. The mean platelet concentration at pre-insertion was 177333.3 ± 54351.5 per μl. The value rose to a significant normal level of 206333.3 ± 78097.7 per ul; p =0.05 at 12 monthsof study without any significant change at 24 and 36 months. The white cell count did not show any significant change over the 36 months period. During the study period six clients discontinued use due to menorrhagia, headache and request for removal to get pregnant giving a continuation rate of 95.7%, 91.3% and 86.9% at 12, 24 and 36months of study. The efficacy was 100%.Conclusion: Implanon was an effective contraceptive method with a safe haematological profile.Keywords: Implanon (etonogestrel): haematological indices

Quality Improvement

Quality Improvement

Stopping Spotting in Contraceptive Implant Users

The subdermal etonogestrel implant (Nexplanon) is one of the most effective contraceptives, with continuation rates similar to intrauterine devices and considerably higher than oral contraceptives. Nonetheless, bothersome vaginal bleeding is a common reason women discontinue implant use. To assess whether combined oral contraceptives (COCs) can diminish …

Profile of Implanon® acceptors and pattern of side effects

Objective To determine the social and biological characteristics of Implanon® acceptors at Ibadan Nigeria, and also to describe reasons why they opt for this choice and their concerns. Methods This was a descriptive study that retrospectively reviewed all records of the Implanon® acceptors from January 2006 to December 2009 at University College Hospital, Ibadan, Nigeria. Results One hundred and twenty-eight women accepted Implanon® as a modern contraception accounting 4.3% of the total number of clients seen (2 972) during the period. The age range of the client that accepted Implanon® was 26–43 years with a mean of 33.6 ±2.4 years. Of the 128 Implanon® acceptors, 101 (78.9%) had used other contraceptive methods before. The commonest reason for switching to Implanon® by clients was failure of the contraceptive method that was previously used (32.7%). Within the first year follow-up of insertion, none of the Implanon® acceptors had expressed desire for removal due to any of the side effects, and none contraceptive failure was observed during their follow-up evaluation. Conclusion The findings suggest that Implanon® could safely be used by all women of reproductive age group including those who desire future fertility.

Extended Use of the Etonogestrel Implant and Levonorgestrel Intrauterine Device

The etonogestrel implant (Nexplanon) and levonorgestrel-releasing intrauterine device (LNG IUD; Mirena) excel in their effectiveness and user

Preventing Isotretinoin-Exposed Pregnancies in 1 Minute or Less

Isotretinoin, an effective therapy for nodulocystic and recalcitrant severe acne, is a high-grade teratogen. Despite the FDA's iPLEDGE program (https://www.ipledgeprogram.com/), unintended pregnancies continue to occur — and although most women know that isotretinoin is a teratogen, many have limited knowledge about contraception. Investigators developed a one-page chart detailing eight contraceptive options (Nexplanon implant, Mirena and ParaGard intrauterine devices [IUDs], Depo-Provera shot, NuvaRing, Evra patch, …