Implant: Unpredictable Bleeding and Management

About 11.1% to 14.4% of users ask for early implant removal because of bleeding complaints, according to US trials. Providing patients with tools and ideas to deal with prolonged or heavy bleeding episodes may decrease frustration they may have with potential bothersome bleeding and improve satisfaction, write Melissa Chen, MD, MPH, and Melissa Matulich, MD, MAS, in the new edition of Contraceptive Technology.

With the suppression of ovulation and the progestin effects on the endometrium, most people notice that their periods change. In general, periods become lighter with time, but people can have all kinds of different bleeding patterns at the beginning. Some people have no bleeding, some have spotting or light bleeding, while others may even experience heavier bleeding or bleeding that goes on for a long time.

Unpredictable Bleeding

While it is not possible to anticipate the bleeding pattern for any particular user, reanalysis of clinical studies has revealed some general patterns. In the first 3 months of use, about one-third of implant users experienced favorable bleeding patterns (0 to 28 spotting or bleeding days), which usually continued over the next 2 years of use. In the second 3 months, another one-third developed favorable patterns. However, after 6 months of use, one-third still experienced bleeding patterns that were identified as unfavorable (e.g., frequent or prolonged bleeding). Some studies suggest that unfavorable bleeding patterns may be more common among users with lower BMIs and that patients switching from combined hormonal contraception are less likely to have heavy or prolonged bleeding during the early transitional months. In general, prolonged bleeding (uninterrupted episode lasting more than 14 days in one 90-day reference period) or frequent bleeding (more than five episodes in one 90-day reference period) occurs more frequently in the early months of implant use, perhaps related to higher ENG levels.

Several other analyses about bleeding patterns can be helpful when counseling interested candidates. In 75% of 90-day reference periods, the number of spotting or bleeding days was less than or the same as what participants had experienced with their normal cycles, but those spotting or bleeding days occurred at unpredictable intervals, reported Chen and Matulich.

Managing Unfavorable bleeding

Counseling can include the information that higher levels of ENG are associated with unfavorable bleeding patterns and that over time these unfavorable patterns often resolve. Also a prophylactic prescription for NSAIDs to use as needed for prolonged or heavy bleeding episodes can be considered. (See below for details related to this regimen.)

An evaluation is suggested for patients with bothersome or unexpected bleeding, especially if other concerning symptoms develop (e.g., nausea, vomiting, pain, temperature intolerance, etc.) or if the bleeding patterns change part way through implant use. Once pregnancy and other gynecologic or endocrine problems such as infection, thyroid abnormalities, polyps, fibroids, and malignancy are ruled out as causes of unfavorable bleeding, reassurance can be helpful. Review the patient’s bleeding patterns to see if there has been improvement over time, as this is often the case.

Since the circulating levels of ENG are low, the addition of combined hormonal contraceptives to control bothersome heavy or prolonged bleeding or spotting is generally well tolerated. Mono-phasic combined oral contraceptives can be given cyclically or continuously (using only active pills). The vaginal ring may be especially useful in treating unfavorable bleeding because it provides continuous, steady levels of hormonal support. Typically, relief occurs within 2 weeks of combined hormonal contraception use, but bothersome bleeding usually returns after cessation of the treatment; therefore, some patients may choose to continue combination hormonal therapy for 2 to 3 months or even longer to experience more relief. No serious adverse events occurred in a 6-month study evaluating simultaneous use of the ENG implant with combined oral contraceptives, and the frequency of reported side effects did not increase. Another multicenter trial is underway evaluating simultaneous use for 12 months (NCT#04423055). However, some may prefer implant removal if short- term interventions do not provide them adequate relief, and patient autonomy in these situations should always be respected. Before starting a combined hormonal method, remind Chen and Matulich, providers should ensure the patient does not have any contraindications to exogenous estrogen use.

Practice tips: how to control bothersome bleeding with progestin-only implant

Treatment options that have been tested for unfavorable or bothersome bleeding with progestin-only methods are listed below.

  • Ulipristal acetate 15 mg daily for 7 days.
    • This dose may not be easily available clinically.
  • Mifepristone 50 mg once monthly
    • Benefit with levonorgestrel contraceptive implant but minimal short-term benefit and no long-term benefit over placebo in ENG implant users.
    • Access to this medication is challenging and use of this antiprogesterone medication may compromise contraceptive efficacy.
  • Mifepristone in combination with ethinyl estradiol or doxycycline is more effective in terminating an episode of bleeding than doxycycline alone or in combination with ethinyl estradiol, or placebo.
Nonhormonal therapies
  • Ibuprofen 800 mg 3 times a day for up to 5 days or naproxen 500 mg 2 times a day for up to 5 days to stop heavy or prolonged bleeding.
    • Can provide counseling about NSAIDs or prophylactic prescription after implant placement.
    • Treatment can be repeated if problem bleeding returns.
  • Tranexamic acid 650 mg three times a day for up to 5 days.
  • Doxycycline 100 mg twice daily for 5 days.
    • This treatment was initially found to be more effective than placebo in reducing bleeding and spotting, but this benefit was not replicated in a larger trial.

The complete listing of references are in Chapter 9 of Contraceptive Technology, 22ne edition