Safety of implantable contraceptives for women: data from observational studies

One-year incidence of low libido in women using levonorgestrel subdermal implant as contraception. Cohort study. Armenia, Colombia, 2014-2019

Objetivo:

Definir la incidencia de deseo sexual hipoactivo (DSH) en mujeres que planifican con el implante subdérmico de levonorgestrel (LNG) después de 12 meses, y conocer otros efectos adversos.

Materiales y métodos:

Estudio de cohorte, cuyas participantes fueron mujeres mayores de 18 años sin hijos ni embarazos previos y con pareja estable, a quienes se les había insertado el implante de LNG al menos tres meses previos en una clínica privada de carácter universitario en Armenia (Quindío), Colombia, entre 2014 y 2019. Se excluyeron mujeres con antecedentes de disfunción sexual, infecciones de transmisión sexual en los últimos 6 meses, peso mayor a 89 Kg y dificultades para el seguimiento. El muestreo fue consecutivo. Se describieron las características de la población estudiada, se estimó la incidencia acumulada de DSH y efectos adversos relacionados con el implante subdérmico de LNG

Resultados:

Participaron 238 mujeres cuya edad media fue de 24,69 (DE ± 5,82) años. Se determinó una incidencia de deseo sexual hipoactivo del 18,82%. El 60,25% de las mujeres fueron diagnosticadas con DHS en los primeros 6 meses de seguimiento. Los efectos adversos se hicieron presentes desde los primeros 3 meses de la inserción del implante, el sangrado irregular (62,34%) fue el más frecuente, seguido de la amenorrea (38,91%) y el aumento de peso (33,89%).

Conclusiones:

Es importante que los médicos y las usuarias se informen sobre la presencia del trastorno de deseo sexual hipoactivo y los efectos adversos que pueden surgir con el uso del implante subdérmico de levonorgestrel. Las futuras investigaciones deben confirmar estos hallazgos, así como su eventual base fisiológica.

The Rise and Fall of Female Sterilization in Jos, Nigeria: A Cause for Concern

Background

Female sterilization is a permanent form of contraception offered to women who have completed their family size. Other methods are all temporary and meant to be reversible. A high-quality female sterilization service was introduced in Jos with the assistance of training in counseling and minilaparotomy under local anesthesia in May 1985. After training, female sterilization became available for couples desiring it on completion of family size.

Materials and Methods

This was a retrospective study of all clients who had female sterilization for contraception between 1985 and 2019. The clinic register was retrieved and evaluated for acceptances of all contraceptive methods within the period and trends observed.

Results

Over the 35 years, a total of 29,167 new clients accepted modern family planning methods. Out of these, a total of 5167 were female sterilizations, constituting 17.7% of the new acceptors. The temporary methods of contraception constituted 82.3%. The other methods used were the intrauterine device 8357 (28.7%), the oral pills 5125 (17.6%), the injectables 5235 (17.9%), and the contraceptive implants 5283 (18.1%). Although female sterilization was 4^th among the five methods studied, there was however a gradual decline in its acceptance from a peak of 36.1% in 1992 to 1.4% in the year 2018.

Conclusion

The acceptance of female sterilization rose to a peak in 1992 and declined to the lowest level in 2018, occasioned in part by the introduction of varieties of contraceptive implants providing long acting, reversible, and cheap contraception.

Sociodemographic profiles and use-dynamics of Jadelle (levonorgestrel) implants in Jos, Nigeria

Background:

Contraceptive implants (including Jadelle) are highly effective, safe, and easy to use and have a long duration of action. They do not interfere with intercourse with immediate return to fertility after removal. However, disruption of the menstrual bleeding pattern is almost inevitable and coercive prescription may be a problem because insertion and removal of implants are provider dependent. The objective of this study was to determine the sociodemographic profiles of acceptors of Jadelle and the reasons for discontinuation in Jos, Nigeria.

Materials and Methods:

This was a 6-year retrospective chart review carried out at the Jos University Teaching Hospital.

Results:

About 1401 women accepted Jadelle with a mean (±standard deviation) of 33.4 ± 5.9 years. About 88% of the women were Christians and almost three-quarters (73.5%) had at least secondary school education. The means of parity and number of children still alive at the time of accepting Jadelle were 4.1 and 3.8, respectively. Half of the women (49.5%) were breastfeeding and over half (55.9%) had future fertility desires at the time of commencing Jadelle. About 82% had previously used other contraceptives (mostly short-acting methods such as injectables, pills, and condoms), with only 18% starting Jadelle as the first-ever contraceptive method. About 90% of the women had regular menstrual cycles. The major reason for discontinuation of Jadelle was desire for pregnancy although menstrual pattern disruption was the most common reason for removal in the first 6 months of use.

Conclusion:

The main reason for discontinuation of Jadelle was to have more children although menstrual pattern disruptions accounted for earlier discontinuation.

Use of the levonorgestrel-releasing intrauterine system: an Austrian perspective

Approximately 12 million women worldwide use the levonorgestrel-releasing intrauterine system (IUS), with approximately 180,000 users of this IUS currently reported in Austria. A patient satisfaction study of 591 women in Austria revealed a high number of 'very satisfied' (79%) and 'satisfied' (19%) patients. Reliability, comfort, excellent compatibility and less severe, shorter and less painful monthly periods were the most frequently named advantages of the levonorgestrel-releasing IUS. Medication-induced cervical priming before insertion can be carried out on a routine or selective basis (for example in nullipara, in women who have undergone cervical conisation or in women who have previously experienced painful insertion). There is, at present, no evidence of an increased rate of breast cancer through use of the levonorgestrel-releasing IUS. A directly comparative study with oral contraceptives in young nullipara showed excellent results for the levonorgestrel-releasing IUS, with no perforations, inflammation or pregnancies.

Clinical experience and acceptability of the etonogestrel subdermal contraceptive implant

OBJECTIVE

To evaluate efficacy, adverse effects, and user continuation rate of an etonogestrel subdermal single-rod contraceptive implant.

METHODS

A total of 417 healthy volunteers of childbearing age were included in this multicenter trial. After implant insertion, the women were followed up during the 3 years of contraceptive action. At each visit, clinical findings, side effects, and bleeding patterns were recorded. Efficacy and continuation rates were analyzed using the Pearl Index and Kaplan-Meier life tables, respectively.

RESULTS

The observation period totaled 958.5 woman-years (27.5 months per woman). The Pearl Index score was 0. Side effects were reported by 44.4% of users, but the proportion had decreased to 16.5% by the end of the study. The continuation rate was 61.4%. The most common reason for early discontinuation (in 21.1% of the participants) was menstrual disturbances.

CONCLUSIONS

Etonogestrel subdermal contraceptive implants demonstrated high efficacy and an acceptable continuation rate. Counseling potential users explicitly about the side effects will optimize patient success with this long-acting contraceptive.

A prospective study of the forearm bone density of users of etonorgestrel- and levonorgestrel-releasing contraceptive implants

BACKGROUND

The aim of the study was to compare bone mineral density (BMD) before insertion and at 18 months of use of etonorgestrel- and levonorgestrel-releasing contraceptive implants.

METHODS

One hundred and eleven women, 19-43 years of age, were randomly allocated to two groups: 56 to etonorgestrel and 55 to levonorgestrel. BMD was evaluated at the midshaft of the ulna and at the distal radius of the non-dominant forearm using dual-energy X-ray absorptiometry before insertion and at 18 months of use.

RESULTS

There was no difference in baseline demographic or anthropometric characteristics, or in BMD of users of either model of implant. BMD was significantly lower at 18 months of use at the midshaft of the ulna in both groups of users. However, no difference was found at the distal radius. Multiple linear regression analysis showed that the variables associated with BMD at 18 months of use in both implant groups were baseline BMD, body mass index (BMI) and difference in BMI (0 versus 18 months of use).

CONCLUSIONS

Women of 19-43 years of age using either one of the implants showed lower BMD at 18 months of use at the midshaft of the ulna, however, without a difference at the distal radius.

Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial

OBJECTIVE

Women with diabetes need safe, effective contraception. Although intrauterine devices provide superior contraception, concerns remain that progestin absorbed systemically from the levonorgestrel-releasing device may impair carbohydrate metabolism. To examine the effect of the levonorgestrel-releasing intrauterine system on glucose metabolism in diabetic women.

METHODS

We randomly assigned 62 women with uncomplicated insulin-dependent diabetes mellitus to either a levonorgestrel-releasing or a copper T 380A intrauterine device. The primary outcome to assess glucose metabolism was glycosylated hemoglobin; fasting serum-glucose levels and daily insulin dose requirements over 12 months of observation were examined as well.

RESULTS

Outcome data were available for 29 women using the levonorgestrel-releasing and 30 using the copper device. At 12 months, mean glycosylated levels were similar for women of the 2 groups (6.3%, standard deviation [SD] +/- 1.5 compared with 6.3%, SD +/- 1.3, respectively). The same was true for mean fasting-serum glucose levels (7.4 mM, SD +/- 4.2 compared with 7.5 mM, SD +/- 4.2) and daily insulin doses (35.1 units, SD +/- 12.8 compared with 36.4 units, SD +/- 9.0). No important differences were noted at either 6 weeks or 6 months.

CONCLUSION

The levonorgestrel-releasing device had no adverse effect on glucose metabolism, even at the 6-week observation when systemic levels of levonorgestrel would have been higher than at later observations. Concern about a potential adverse effect of this contraceptive on glucose control is unwarranted, and its use in women with diabetes should be liberalized.

LEVEL OF EVIDENCE

I.

Safety and efficacy of Implanon™, a single-rod implantable contraceptive containing etonogestrel

OBJECTIVES

The safety and efficacy of a single-rod implantable contraceptive containing etonogestrel (Implanontrade mark) were investigated in a multicenter clinical trial.

STUDY DESIGN

Sexually active American women (N=330) with apparently normal menstrual cycles used the implant for up to 2 years. All subjects recorded bleeding and/or spotting daily in a diary. Safety was assessed through adverse experiences (AEs), laboratory tests and physical and gynecologic examinations.

RESULTS

Total exposure was 474 woman-years (6186 cycles), and 68% of subjects had at least 1 year of exposure. No pregnancies occurred. The most common bleeding pattern observed throughout the study was infrequent bleeding, defined as less than three episodes of bleeding in a reference period (excluding amenorrhea). The least common pattern was frequent bleeding, defined as more than five episodes of bleeding in a reference period. Infrequent, prolonged and frequent bleeding patterns were most common early in the study and declined thereafter. During the 3-month Reference Periods 2-8 (Months 4-24), the incidence of amenorrhea ranged from 14% to 20%. Forty-three subjects (13%) withdrew from the study because of bleeding pattern changes and 76 subjects (23%) discontinued because of other AEs. Other common AEs leading to discontinuation, besides bleeding irregularities, were emotional lability (6.1%), weight increase (3.3%), depression (2.4%) and acne (1.5%). Use of Implanon (etonogestrel subdermal implant, referred to herein as ENG implant) for up to 2 years had no clinically significant effects on laboratory parameters, physical and pelvic examinations, vital signs or body mass index. The average length of time required for ENG implant insertion and that for removal were 0.5 and 3.5 min, respectively, and all the procedures were uncomplicated. The return to normal menstrual cycles and fertility was rapid after removal.

CONCLUSIONS

Implanon is a safe, highly effective and rapidly reversible new method of contraception.

Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants

Levonorgestrel-releasing implants are long acting contraceptives, approved for 5 years of continuous use. Two marketed systems, the six capsule Norplant use of tradenames is for product identification purposes only and does not imply endorsement. and the two rod Jadelle, have essentially equal rates of drug release, pregnancy and adverse events over 5 years of use. Randomised clinical trials and controlled cohort observations indicate that for the first 3 years, when pregnancy rates are at or almost zero, no other contraceptive system is more effective, although etonogestrel implants provide equal effectiveness. Annual pregnancy rates rise in the fifth year of continuous use but remain below 1 per 100 women. Annual pregnancy rates of Norplant users remain below 1 per 100 throughout 7 years of continuous use. Levonorgestrel implants provide low progestogen doses; 40-50 microg/day at 1 year of use, decreasing to 25-30 microg/day in the fifth year. Serum levels of levonorgestrel at 5 years are 60-65% of those levels measured at 1 month of use. Adverse effects with levonorgestrel implants are similar to those observed with progestogen only and combined oral contraceptives. Risks of ectopic pregnancy, other pregnancy complications and pelvic inflammatory disease are reduced in comparison with those of women using copper or non-medicated intrauterine devices. Risks of developing gallbladder disease and hypertension or borderline hypertension, although small, are about 1.5 and 1.8 times greater, respectively, in women using levonorgestrel implants than in women not using hormonal contraception. Other serious diseases have not been found to occur significantly more frequently in levonorgestrel implant users than in women not using hormonal contraception. The great majority of levonorgestrel implant users experience menstrual problems, but serious bleeding problems are not more frequent than in controls. Other health problems reported more frequently by levonogestrel implant users than by women not using hormonal contraception in a study of 16000 women included skin conditions, headache, upper limb neuropathies, dizziness, nervousness, malaise, minor visual disturbances, respiratory conditions, arthropathies, weight change, anxiety and non-clinical depression. Clinical depression is not more frequent in women using implants compared with those not using hormonal contraception (i.e. using intrauterine devices, sterilisation). Removal problems occur less frequently with Jadelle than with Norplant. The mean removal time for Jadelle is half that of Norplant. Levonorgestrel implants in nationally representative scientific samples, in randomised trials, and in controlled cohort studies have continuation rates as high as or higher than any other reversible contraceptive over a duration of 5 years. This would imply that the satisfaction women derive from the contraceptive effectiveness of levonorgestrel implants greatly outweighs the dissatisfaction that may accompany menstrual disturbances and other adverse effects associated with implants.

Risk-benefit effects of implantable contraceptives in women

Contraceptive implant technology has been used by millions of women throughout the world. The three marketed implant systems today are levonorgestrel-releasing implants: Norplant and Jadelle, and a single etonogestrel-releasing implant, Implanon. The main benefits common to these delivery systems are their safety, high effectiveness, ease of use, long duration of action (3 - 5 years) and reversibility. Bleeding disturbances are the main adverse events associated with implantable contraceptives. Other minor risks relate to the insertion and removal procedures, which require adequately trained providers as well as aseptic techniques. Furthermore, since initiation and discontinuation of use is provider-dependent and not controlled by the user, there may be a risk of coercion of use on the one hand or, on the other hand, difficulty in access to initiating use, if trained providers are not readily available. Although no single contraceptive method is perfect or appealing to all, contraceptive implants are safe and fulfil a very important need among fertility regulation methods.