Elsevier

Contraception

Volume 83, Issue 3, March 2011, Pages 202-210
Contraception

Review article
The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users

https://doi.org/10.1016/j.contraception.2010.08.001Get rights and content

Abstract

The aim of this guidance is to review the management of unacceptable vaginal bleeding patterns in etonogestrel (ENG)-releasing contraceptive implant users concentrating, where possible, on the evidence for pharmacological treatments and identifying a pragmatic approach where this is not possible.

This article was developed in accordance with methodology used for producing Royal College of Obstetricians and Gynaecologists' Green Top Guidelines.

The Cochrane Library (including the Cochrane Database of Systematic Reviews, DARE and EMBASE) and Medline (1966–2010) were searched using the relevant MeSH terms, including all subheadings, and this was combined with a keyword search. Search words included “progestogen only contraceptives,” “contraceptive implants,” “progestogen implants,” “etonogestrel implants,” “irregular bleeding,” “unpredictable bleeding,” “bleeding irregularity” and “bleeding pattern,” and the search was limited to humans and English language. Enquiries for relevant information were also made to the pharmaceutical industry and researchers for missing studies.

Although this is not a systematic review, two of the authors (D.M., I.S.F.), qualitatively assessed those papers reporting quantitative results involving treatments given either to stop or prevent bleeding in ENG or levonorgestrel contraceptive implants users.

Introduction

ENG contraceptive implants are becoming an increasingly popular birth control choice with approximately six million women using this method worldwide (data on file, Merck, Sharp, Dohme). This safe, highly effective, long-acting and reversible contraceptive is suitable for most women of reproductive age, with recent guidelines supporting its use in women with a history of venous thromboembolism or congenital and acquired cardiovascular disease [1], [2].

Section snippets

How effective is the ENG contraceptive implant?

Recent data have shown that the ENG implant is one of the most effective reversible contraceptives with a method failure rate of 0.01 per 100 implants fitted [3].

Recent reanalysis of initial trial data and postmarketing reporting figures show ENG implants to be one of the most effective female contraceptives with overall typical failure rates of 0.049 per 100 implants fitted (method failure rate−0.01 per 100 implants fitted) [3]. This has led to some health insurance schemes fully reimbursing

Future directions and areas for research

Future research aimed at understanding the disturbed endometrial mechanisms in women with more extreme, persistent and troublesome symptoms (compared with those who develop amenorrhea or light, infrequent periods) will be critical to eliminate this common cause of premature discontinuation of implant use. A number of theories have been proposed including estrogen withdrawal or estrogen fluctuation but most have concentrated on molecular and cellular mechanisms at the endometrial level. It is

Conclusion

This guidance has reviewed the practical management of unacceptable vaginal bleeding in ENG contraceptive implant users and provided an approach to investigating and stopping a specific episode of troublesome bleeding. Preventing such episodes is more difficult. If progestogen-only implants are to be more widely accepted and continuation rates improved, research must focus on understanding the underlying mechanisms provoking unscheduled endometrial breakdown. This must be allied with the study

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    Competing interests: The authors have received an educational grant from Merck Sharp & Dohme Limited to cover their time and expenses in writing this article. The content is the total responsibility of the authors, and the MSD Company has had no input into any aspect of the review. All authors have been members of national and international pharmaceutical advisory boards and received honoraria for lecturing, expenses for attending scientific conferences and research grants from a number of pharmaceutical companies.

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