Association of body mass index with removal of etonogestrel subdermal implant

Amenorrhea in adolescents using the etonogestrel contraceptive implant

OBJECTIVE

Clinical factors related to development of amenorrhea in adolescents with the etonogestrel contraceptive implant are not well-understood. The purpose of this study is to describe what baseline clinical characteristics are associated with amenorrhea in adolescents with a contraceptive implant 12 months after placement.

STUDY DESIGN

This retrospective cohort study included 252 post-menarchal individuals aged 12-22 years with a contraceptive implant placed between 2016-2020. Data abstracted at insertion, three months post-insertion, and 12 months post-insertion included demographics, baseline bleeding pattern, prior contraception use, post-insertion bleeding pattern, and method discontinuation. We assessed possible predictive characteristics of our outcomes using bivariate and multivariable logistic regression analyses.

RESULTS

Twenty nine percent of patients were amenorrheic 12 months after placement. Patients who were amenorrheic at 12 months were more likely to be obese (41.1% vs 24.6%, p = 0.01), to have been amenorrheic prior to implant insertion (16.9% vs 5.4%, p < 0.01, to have used hormonal contraception immediately prior to insertion (42.5% vs 26.3%, p = 0.01), to have had the most recent contraceptive method being another implant (12.3% vs 3.6%, p = 0.02), and to have developed amenorrhea within three months after placement (22.2% vs 12.6%, p < 0.01). After multivariable regression analysis, only obesity (adjusted odds ratio [aOR] 2.2 95% CI 1.1-4.2) and amenorrhea at three months (aOR 3.6, CI 1.1-11.5) were associated with amenorrhea at 12 months.

CONCLUSION

Obesity and early amenorrhea were associated with 12-month amenorrhea in adolescents using the etonogestrel subdermal implant. Understanding this can help with contraceptive method selection and counseling for patients and providers.

IMPLICATIONS

Obesity and early amenorrhea with the etonogestrel contraceptive implant are associated with longer-term amenorrhea in adolescents using this method. These findings can aid providers with method selection and pre-insertion decision-making for adolescents considering contraceptive implant use, as well as continued counseling after placement.

[Evolution of contraceptive practices in France: An overview from 2014 to 2019]

OBJECTIVES

To study the use of reimbursed contraceptive methods in France between 2014 and 2019, with an analysis of the profile of users by age group and an analysis by type of prescriber.

METHODS

We conducted a national descriptive study using data from the Assurance Maladie Open Data database on the use of contraceptive methods reimbursed in France from January 1, 2014, to December 31, 2019. We analyzed the number of users by year, by age group (<20years, 20-60years), and by prescriber (liberal general practitioner, liberal gynecologist, hospital practitioner, liberal midwife).

RESULTS

In 2019, 50.1% (5,345,122) of women of childbearing age used a reimbursed contraceptive method. Hormonal oral contraception was the leading contraceptive method used (42.3%), followed by the intrauterine device (6.2%) and the implant (1.6%). Use of combined estrogen-progestogen oral contraception had been declining since 2015 (-8.1 points), to the benefit of the micro progestin pill (+9.1 points) and the copper intrauterine device (+1.4 points). Among women under 20, the hormonal implant was the second most popular contraceptive method (1.2%), followed by the copper intrauterine device (0.8%) and the hormonal intrauterine system (0.2%). Among women over 20years of age of childbearing age, the copper IUD was the second most-reimbursed contraceptive method (2.4%), followed by the hormonal intrauterine system (1.6%) and the hormonal implant (1.2%). There are disparities in prescribing practices: in 2019, 51% of prescribers were general practitioners and 97% of them prescribed hormonal oral contraception.

CONCLUSION

The contraceptive supply in France is diversifying, although oral contraception remains predominant. Disparities exist between age groups of users and there is great heterogeneity in practices among contraceptive prescribers.

Considerations in Adolescent Use of the Etonogestrel Subdermal Implant: A Cohort Study

Objectives: To describe bleeding patterns and other side effects in adolescent implant users and characterize their impact on early discontinuation of the implant.

Study Design: This is a retrospective cohort study of female patients under 18 years who had an implant placed from 2013 to 2018. Data were collected on demographics, medical history, and side effects.

Results: Of 212 adolescents, the average age at insertion was 16 years and 84% desired placement for contraception. Common side effects included AUB (80%), mood changes (10%), and perceived weight gain (9%). Most (76%) used the implant for at least 12 months. Average time to removal was 22.1 months (SD 13.0 months) and this did not depend on presence of side effects. Twenty-seven percent of teens were able to achieve amenorrhea. Adolescents with frequent or prolonged bleeding were more likely to have implant removal prior to 12 months than those with other bleeding patterns (p = 0.003). Early removal was also more common in girls reporting weight or mood issues than those who did not (p < 0.001 and p = 0.045, respectively). BMI increased in 64% of adolescents. Average percentage change in BMI was 3.2% (0.87 kg/m²). There was no difference in baseline use of any mood-modulating medications in patients who did and did not complain of mood side effects following implant placement (p = 0.801).

Conclusion: Characterization of bleeding patterns following implant placement in adolescents have not previously been reported. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal of the implant. A relatively small number had early removal of the implant due to weight or mood complaints. Therefore, a history of obesity, depression, or other mood disorders should not be a deterrent to implant placement.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Prevalence of early discontinuation and associated factors among a retrospective cohort of etonogestrel contraceptive implant users

Purpose: To characterise the frequency of and predictors of contraceptive implant discontinuation within 12 months of insertion in our clinical setting.Materials and methods: This retrospective cohort study included women receiving the etonogestrel contraceptive implant at our hospital between May 2007 and May 2012. We abstracted data from charts including implant removal date, bleeding complaints, reproductive and demographic characteristics, prior contraceptive use, tobacco use and implant insertion timing. Our primary outcome was implant discontinuation within 12 months following insertion. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used to generate frequencies, bivariate analyses and multivariate logistic regression models.Results: Implant discontinuation was documented in 16% of implant users prior to 12 months (89/544). Women with documented bleeding complaints in the medical record were more likely to discontinue within 12 months (OR: 4.36, CI: 2.71, 7.00). No other demographic or clinical characteristics were associated with premature discontinuation. Having less than two prior pregnancies and tobacco use were associated with documented bleeding complaints.Conclusions: Discontinuation of the implant is associated with bleeding complaints. Women with lower parity and tobacco users may be more likely to experience bleeding or to find it intolerable.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes

INTRODUCTION

Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review.

METHODS

We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers.

RESULTS

We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains.

CONCLUSIONS

Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

Progestin-only contraceptives: effects on weight

BACKGROUND

Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. POCs include injectables, intrauterine contraception, implants, and oral contraceptives. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users.

OBJECTIVES

The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight.

SEARCH METHODS

Until 4 August 2016, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. For the initial review, we contacted investigators to identify other trials.

SELECTION CRITERIA

We considered comparative studies that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data. Non-randomized studies (NRS) need to control for confounding factors. We used adjusted measures for the primary effects in NRS or the results of matched analysis from paired samples. If the report did not provide adjusted measures for the primary analysis, we used unadjusted outcomes. For RCTs and NRS without adjusted measures, we computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% CI.

MAIN RESULTS

We found 22 eligible studies that included a total of 11,450 women. With 6 NRS added to this update, the review includes 17 NRS and 5 RCTs. By contraceptive method, the review has 16 studies of depot medroxyprogesterone acetate (DMPA), 4 of levonorgestrel-releasing intrauterine contraception (LNG-IUC), 5 for implants, and 2 for progestin-only pills.Comparison groups did not differ significantly for weight change or other body composition measure in 15 studies. Five studies with moderate or low quality evidence showed differences between study arms. Two studies of a six-rod implant also indicated some differences, but the evidence was low quality.Three studies showed differences for DMPA users compared with women not using a hormonal method. In a retrospective study, weight gain (kg) was greater for DMPA versus copper (Cu) IUC in years one (MD 2.28, 95% CI 1.79 to 2.77), two (MD 2.71, 95% CI 2.12 to 3.30), and three (MD 3.17, 95% CI 2.51 to 3.83). A prospective study showed adolescents using DMPA had a greater increase in body fat (%) compared with a group not using a hormonal method (MD 11.00, 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00, 95% CI -6.93 to -1.07). A more recent retrospective study reported greater mean increases with use of DMPA versus Cu IUC for weight (kg) at years 1 (1.3 vs 0.2), 4 (3.5 vs 1.9), and 10 (6.6 vs 4.9).Two studies reported a greater mean increase in body fat mass (%) for POC users versus women not using a hormonal method. The method was LNG-IUC in two studies (reported means 2.5 versus -1.3; P = 0.029); (MD 1.60, 95% CI 0.45 to 2.75). One also studied a desogestrel-containing pill (MD 3.30, 95% CI 2.08 to 4.52). Both studies showed a greater decrease in lean body mass among POC users.

AUTHORS' CONCLUSIONS

We considered the overall quality of evidence to be low; more than half of the studies had low quality evidence. The main reasons for downgrading were lack of randomizations (NRS) and high loss to follow-up or early discontinuation.These 22 studies showed limited evidence of change in weight or body composition with use of POCs. Mean weight gain at 6 or 12 months was less than 2 kg (4.4 lb) for most studies. Those with multiyear data showed mean weight change was approximately twice as much at two to four years than at one year, but generally the study groups did not differ significantly. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

[Safety profile of etonogestrel contraceptive implant (Nexplanon® and Implanon®) reported in France]

OBJECTIVES

The aim of the study was to assess the incidence of adverse effects (AE) reported with etonogestrel contraceptive implant in France (Implanon^® and Nexplanon^®).

MATERIALS AND METHODS

All cases of AE or unintended pregnancies reported to health authorities or to the firm were analyzed.

RESULTS

During 10 years, 5433 AE and 789 unintended pregnancies were reported. Only 388 (7 %) were serious. There were 1137 reports of difficulties to remove, failure to locate or migration, 430 of insertion difficulties and 203 of deformation or expulsion of the implant. Among other AE, the most common were 1694 gynecological AE, 524 skin reactions and 437 metabolic AE. Since the marketing of Nexplanon^® which causes less deep insertions, the incidence of migrations, removal or insertion difficulties has decreased overall (0.92 vs. 1.31/1000 patients), particularly the incidence of removal difficulties, location failures or migrations (0.12 vs 1.01/1000). The infrequent but serious AE were infectious complications at the implant site and pregnancies. When the circumstances of the pregnancy were known, the contraceptive failure was due to the apparent inefficiency of the implant (n=224), to a technique failure (n=203) or to a drug-drug interaction (n=59).

CONCLUSION

This study confirms that AE of this implant are frequent but not serious, except for the pregnancies. The incidence of complications related to insertion decreased with Nexplanon^®. Among other preventable AE, unintended pregnancies due to a drug-drug interaction would require to be better known by the practitioner.

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

Etonogestrel Implants in Adolescents: Experience, Satisfaction, and Continuation

PURPOSE

Few studies have evaluated the use of etonogestrel subdermal implants (ESI) by U.S. adolescents. We assessed several factors, including continuation rates, the association of implant removal with postimplant management of nuisance bleeding, and the relation between bleeding and body mass index.

METHODS

We reviewed 116 charts from all adolescent females with ESI placement in our adolescent medicine clinic from January 2010 to August 2013. Data were obtained from follow-up encounters up to 36 months after insertion.

RESULTS

Of the 116 adolescents, 94% were nulliparous. Follow-up data were available for 81% (n = 94). Early ESI removal was defined as removal <32 months. ESI continuation rates at 12, 24, and 32 months were 78%, 50%, and 40%, respectively; this represents an early removal rate of 35% (33 of 94). Nuisance bleeding occurred in 48% (45 of 94). Of those complaining of bleeding, 63% (25 of 40) received medication management. Resolution of bleeding occurred in 25% of those in the early removal group versus 15% in the full retention group. Early implant removal due to nuisance bleeding occurred in 18% (17 of 94). There was no significant association between body mass index, nuisance bleeding, and early ESI removal.

CONCLUSIONS

Implant continuation rates were quite high at 12 and 24 months, with 40% of patients reaching 32 months retention, providing a significant period of pregnancy prevention. Treatments for nuisance bleeding were often not prescribed and when they were, medication regimens varied among providers. An evidence-based protocol for medication management, combined with more routine use of appropriate medications and preventive or long-term therapies, may help improve continuation of ESI.

Bleeding profile in users of an etonogestrel sub-dermal implant: effects of anthropometric variables. An observational uncontrolled preliminary study in Italian population

PURPOSE

The purpose of this study is to evaluate the menstrual profile in users of the etonogestrel (ENG)-releasing implant (Nexplanon®) and the possible correlation with anthropometric variables.

METHODS

Ninety-two healthy women, desiring long-term contraception with the ENG implant were enrolled in a prospective observational study. Anthropometric variables were measured at baseline and after 3, 6, 9, and 12 months. Patients recorded daily the occurrence of any bleeding or spotting. The bleeding/spotting pattern was evaluated over consecutive 90-day intervals ("Reference Periods" - RPs). Patients who showed a favourable bleeding profile (amenorrhoea, infrequent, or normal bleeding) for 50% or more of the RPs were assigned to group A, while patients with a favourable bleeding profile for less than 50% of the RPs were assigned to group B.

RESULTS

Sixty-eight women (79%) were assigned to group A; 18 (21%) to group B. Group B had a lower baseline body mass index (BMI) than group A (24.84 ± 4.95 kg/m(2) versus 20.75 ± 4.41 kg/m(2); p < 0.005).

CONCLUSIONS

The ENG sub-dermal implant is a well-tolerated contraceptive method, with a high proportion of women experiencing a favourable bleeding profile. The lower basal BMI in Group B in comparison with Group A may account for the higher percentage of irregular bleeding.

Contraception and hormonal management in the perimenopause

This literature review focuses on contraception in perimenopausal women. As women age, their fecundity decreases but does not disappear until menopause. After age 40, 75% of pregnancies are unplanned and may result in profound physical and emotional impact. Clinical evaluation must be relied on to diagnose menopause, since hormonal levels fluctuate widely. Until menopause is confirmed, some potential for pregnancy remains; at age 45, women's sterility rate is 55%. Older gravidas experience higher rates of diabetes, hypertension, and death. Many safe and effective contraceptive options are available to perimenopausal women. In addition to preventing an unplanned and higher-risk pregnancy, perimenopausal contraception may improve abnormal uterine bleeding, hot flashes, and menstrual migraines. Long-acting reversible contraceptives, including the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant (ESI), and the copper intrauterine device (Cu-IUD), provide high efficacy without estrogen. LNG-IUS markedly decreases menorrhagia commonly seen in perimenopause. Both ESI and LNG-IUS provide endometrial protection for women using estrogen for vasomotor symptoms. Women without cardiovascular risk factors can safely use combined hormonal contraception. The CDC's Medical Eligibility Criteria for Contraceptive Use informs choices for women with comorbidities. No medical contraindications exist for levonorgestrel emergency-contraceptive pills, though obesity does decrease efficacy. In contrast, the Cu-IUD provides reliable emergency and ongoing contraception regardless of body mass index (BMI).

Continuation rates of the subdermal contraceptive Implanon(®) and associated influencing factors

OBJECTIVES To investigate the continuation rates of the etonogestrel subdermal contraceptive implant among well-informed women, and the reasons for early discontinuation. STUDY DESIGN Retrospective consecutive cohort design. METHODS Women who had the implant inserted between 1 January 2006 and 1 January 2010 at the Atrium Medical Centre, the Netherlands were followed up for at least three years. The dates of insertion and removal were recorded, as were the reasons for removal. Statistical analysis was performed using the independent samples t-test and the Pearson alpha correlation test. RESULTS The implant was inserted in 230 women. Follow-up was possible in 214 women, with an average age of 26.7 years. Most of them were nulliparous and the majority had used a combined oral contraceptive, Implanon®, or Mirena® previously. The mean overall continuation period was 23.5 months (95% confidence interval: 21.7-25.3), with a median of 25 months. The continuation rate after 12 months was 72%; after 24 months, 53%; and after 36 months, 25%, with all women concerned having a new implant placed. The previously used contraceptive method Implanon® was associated with the highest continuation rates. An erratic bleeding pattern was the main reason for early removal. CONCLUSIONS Despite adequate counselling before insertion, the continuation rate of the etonogestrel implant was rather low compared to those reported by other investigators. The main reason for discontinuation was an irregular bleeding pattern.