The Canadian Paediatric Society endorses long-acting reversible contraception (LARC) methods as first line in the adolescent population (1). Previously, the only options on the Canadian market were intrauterine devices (IUDs), either copper or hormonal. The Nexplanon contraceptive implant is a new option for our patients, which is now available following Health Canada approval in 2020.
MECHANISM OF ACTION
Nexplanon contains 68 mg of etonogestrel (ENG), which is continuously released over a period of 3 years (2). The mechanism of action is primarily through inhibition of ovulation, with serum ENG reaching therapeutic levels within hours of insertion (2). Changes in the cervical mucous and endometrium occur and contribute to contraceptive efficacy (2).
EFFICACY
The implant is highly effective and does not rely on user compliance. The Pearl Index (pregnancies per 100 woman-years) is reported between 0.24 and 0.36, falling to 0.006 when pregnancies not related to failure of the implant itself were excluded (2).
While excluded from initial safety trials, obese women have been included in a number of subsequent studies, none of which have identified a significant difference in device failure rate in overweight or obese patients (2,3).
INDICATIONS
As a progestin-only method, the implant is an option for patients in whom estrogen is contraindicated. It is also the only LARC method available for patients with Müllerian anomalies that cannot accommodate an IUD. Use in the postpartum period is safe, with no effect on quantity or quality of breastmilk (2).
Nexplanon has been demonstrated to improve health-related quality of life in patients with endometriosis, improving dysmenorrhea (with complete resolution in 77% of patients), and endometriosis-related noncyclic pelvic pain (2,4).
CONTRAINDICATIONS
Contraindications to Nexplanon use include pregnancy, liver disease/tumors, history of stroke or ischemic heart disease, undiagnosed vaginal bleeding, a history of breast cancer, and systemic lupus erythematous with antiphospholipid antibodies (2).
For specific recommendations and safety data with medical conditions, we recommend use of the CDC Contraception 2016 app as an easily accessible, up to date and reliable resource.
COST
Based on our review of local pharmacies, the Nexplanon device costs approximately $300 CAD. At the time of writing, it is not yet funded as a noninsured health benefit for First Nation and Inuit populations.
INSERTION PROCEDURE
The implant is inserted subdermally on the medial surface of the upper arm using a preloaded disposable applicator (2). The procedure generally takes place in an office setting under local anesthetic. Unlike an IUD insertion, a pelvic examination is not required for insertion, nor is intravenous sedation in an operating theatre.
Training programs are currently being offered virtually through the manufacturer, with training models mailed to participants to decrease barriers to access. Providers wanting more information should visit www.etonogestrel-implant-training.ca/.
ACCEPTABILITY AND CONTINUATION
When adolescent patients were offered no-cost contraception after counselling, 72% chose a LARC method, with 34.5% opting for the implant (5). Continuation rates have been found to be high, nearly 80% at 1 year in one retrospective cohort (6).
The most common reason for removal in teens was found to be device expiration, followed by unscheduled bleeding (6). Approximately 30% of adolescent patients having their implants removed had a new device reinserted, suggesting acceptability of this contraceptive method (6).
COUNSELLING
Patients should be counselled to expect changes in their menstrual bleeding, as 20% of patients will become amenorrheic, 30% will have infrequent bleeding, and 7% will have frequent bleeding (2).
Patients presenting with unusual bleeding should have a careful history taken and be tested for pregnancy and sexually transmitted infections. Pelvic examination should be performed if bleeding persists after several months or medical management fails. Concurrent use of an oral contraceptive containing estrogen may help stabilize the endometrium in the short term (2). Of those who initially establish an unfavourable bleeding pattern, approximately 50% will see improvement within the first year of use (2).
When studied in adults, 24% of patients developed acne with implant use, while 61% of patients with baseline acne reported improvement (2).
The implant was found to be weight-neutral in a study of adolescents and young adults with matched controls (7).
Providers should emphasize a need for ongoing condom use, as adolescent users of LARC methods were found to be 60% less likely to use condoms than than their peers using oral contraceptives (8).
CONCLUSIONS
Despite ENG implant being used internationally for two decades, many Canadian providers have not had any exposure during their training. As education and awareness grows, we hope to see an increase in LARC use attributable to the implant in coming years.
While Health Canada has not authorized the use of Nexplanon in patients under the age of 18, based on this population being excluded from the initial safety trials, there is no biologically plausible reason to restrict the device from menstruating adolescents following an informed consent discussion.
Funding: There are no funders to report for this manuscript.
Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
- 1.Di Meglio G, Crowther C, Simms J. Contraceptive care for Canadian youth. Paediatr Child Health 2018;23(4):271–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Palomba S, Falbo A, Di Cello A, Materazzo C, Zullo F. Nexplanon: The new implant for long-term contraception. A comprehensive descriptive review. Gynecol Endocrinol 2012;28(9):710–21. [DOI] [PubMed] [Google Scholar]
- 3.Xu H, Wade JA, Peipert JF, Zhao Q, Madden T, Secura GM. Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women. Obstet Gynecol 2012;120(1):21–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Carvalho N, Margatho D, Cursino K, Benetti-Pinto CL, Bahamondes L. Control of endometriosis-associated pain with etonogestrel-releasing contraceptive implant and 52-mg levonorgestrel-releasing intrauterine system: Randomized clinical trial. Fertil Steril 2018;110(6):1129–36. [DOI] [PubMed] [Google Scholar]
- 5.Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014;371(14):1316–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Tyson N, Lopez M, Merchant M, Postlethwaite D. Subdermal contraceptive implant insertion trends and retention in adolescents. J Pediatr Adolesc Gynecol. 2020:S1083–3188(20)30433-2. doi: 10.1016/j.jpag.2020.12.019. [DOI] [PubMed] [Google Scholar]
- 7.Romano ME, Braun-Courville DK. Assessing weight status in adolescent and young adult users of the etonogestrel contraceptive implant. J Pediatr Adolesc Gynecol 2019;32(4):409–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Steiner RJ, Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention. JAMA Pediatr 2016;170(5):428–34. [DOI] [PMC free article] [PubMed] [Google Scholar]