Insertion and removal of Implanon

Long acting systemic HIV pre-exposure prophylaxis: an examination of the field

Oral pre-exposure prophylaxis for the prevention of HIV-1 transmission (HIV PrEP) has been widely successful as demonstrated by a number of clinical trials. However, studies have also demonstrated the need for patients to tightly adhere to oral dosing regimens in order to maintain protective plasma and tissue concentrations. This is especially true for women, who experience less forgiveness from dose skipping than men in clinical trials of HIV PrEP. There is increasing interest in long-acting (LA), user-independent forms of HIV PrEP that could overcome this adherence challenge. These technologies have taken multiple forms including LA injectables and implantables. Phase III efficacy trials are ongoing for a LA injectable candidate for HIV PrEP. This review will focus on the design considerations for both LA injectable and implantable platforms for HIV PrEP. Additionally, we have summarized the existing LA technologies currently in clinical and pre-clinical studies for HIV PrEP as well as other technologies that have been applied to HIV PrEP and contraceptives. Our discussion will focus on the potential application of these technologies in low resource areas, and their use in global women's health.

Factors associated with removal difficulties of etonogestrel-containing contraceptive implants (Nexplanon®)

OBJECTIVES

Nexplanon^®'s new applicator system was designed to limit deep implant placements, known to lead to difficult removals. However, removal difficulties still exist and induce specific and potentially severe complications. Our objective was to identify risk factors associated with difficult removals.

STUDY DESIGN

A retrospective single-center study was performed from January 2015 to December 2016. Participants were divided into two groups depending on whether implant was removed during a standard ("standard removal" group) or difficult consultation ("difficult removal" group) after an initial failed removal attempt.

RESULTS

The difficult and standard removal groups comprised 63 and 660 women, respectively. In a univariate analysis, significant intergroup differences were found for weight gain (3.7 ± 7.3 kg in the difficult removal group vs. 1.3 ± 5.1 in the standard removal group), proportion of placements performed in private practice (66.7% vs. 19.8%, respectively), and duration of Nexplanon^® placement (29.4 ± 11.3 months versus 26 ± 13.6, respectively). We also reported more frequent sub-brachial fascia placements when Nexplanon^® was implanted by a private practitioner (7.5% cases versus 0.4% in hospital implantations, p < 0.001). In a stepwise binary logistic regression analysis, placement by a private practitioner, weight gain >1 kg since placement, and duration of implant placement >25 months were confirmed as independent risk factors for removal difficulties (respective risk ratios 7.63 [95% IC 4.35-13.33], 2.10 [1.18-3.70], and 1.91 [1.06-3.44], p < 0.05).

CONCLUSIONS

Awareness of these three simple parameters might help physicians to identify "at risk-patients", and suggest a specific consultation before risking a potentially hazardous removal (with its associated, specific morbidity). Our results also emphasize importance of training in implant insertion.

Complications of Subcutaneous Contraception: A Review

Over 62 million women in the United States are of childbearing age and 60% of them use contraception. Subcutaneous contraceptives include implantable contraceptives and subcutaneous injections. Implantable contraception involves subdermal time-release of synthetic progestin, which allows for several years of continuous, highly effective contraception. Its main effects are inhibition of ovulation and thickening of the cervical mucus. Many complications have been associated with subcutaneous contraception, including menstrual disturbances, headache, weight gain, acne, dizziness, mood disturbances, nausea, lower abdominal pain, hair loss, loss of libido, pain at the implant site, neuropathy, and follicular cysts. Using standard search engines, the complications of subcutaneous contraception are reviewed. Patients should be adequately counseled on the possible complications and side effects of subcutaneous contraception to help them make an informed decision when choosing the right contraceptive to meet their needs.

Contraceptive procedures

Although most women desire to control the size and spacing of their family, the rate of unintended pregnancy in the United States remains high, with approximately half of all pregnancies being unintended. Reducing unintended pregnancy is a national public health goal, and the increased use of long-acting reversible contraceptives (LARCs) (intrauterine devices and implants) can help meet this goal. LARCs are among the most effective forms of contraception available. There are few contraindications to their use, and insertion and removal are straightforward procedures that are well tolerated in the outpatient office setting.

Implant removal experience with Sino-implant (II) at four Chinese sites

OBJECTIVES

Complications during contraceptive implant removal are important for users and programs. We describe breakage rates during Sino-implant (II) removals at four Chinese family planning clinics.

STUDY DESIGN

We collected data by observation of consecutive removal cases and subsequent data transcription onto a standardized case report form. Three sites used the "pull out" removal technique, and one site used the "U" technique.

RESULTS

Sino-implant (II) rods were removed from 318 women. There were 16 implant breaks (5.0%), with the breakage rate varying by site from 0% to 7.4%. All 16 breaks occurred at the three sites that used the standard "pull out" technique. Six implants were cut by the scalpel, five were snapped by the clamp, and five were unspecified. Other contributing factors included deeper or wider positioning of the implants (n=6) and implants that were enveloped by thick fibrous tissue (n=3). There was no relationship between breakage rate and duration of implant use. Less than 1% of removals took more than 10 min.

CONCLUSIONS

Both the standard "pull out" technique as well as the "U" technique can be used to remove Sino-implant (II). Breakage during implant removal may not be problematic if all fragments of the rod are readily removable. Breakage occurs with predictable low frequency, and training is needed to assure that providers can deal with breakage events.

IMPLICATIONS

Contraceptive implant removal complications are important for users and programs. These are some of the first data on breakage during removal of Sino-implant (II). More than one removal technique can be used, but training is required to ensure that providers can deal with the infrequent implant breaks.

Developments in contraception

INTRODUCTION

Although the contraceptive options for women have expanded considerably in the last decade, these methods are often not being offered to women as choices because clinicians are not well informed, limiting the ability of women to control their fertility.

AREAS COVERED

Areas covered include the use of oestradiol instead of ethinyl oestradiol and improved progestogens utilised in hormonal contraceptives, and new delivery systems have enabled the development of long-acting methods, which require less action on the part of the user, and thereby, reduce failure rates. Effective emergency contraceptive methods have become more readily available over the counter. However, male contraception, despite much research, still remains elusive.

EXPERT OPINION

This manuscript will provide an assessment of recent advances and controversies in contraception and make suggestions about improved availability.

A multicenter randomized clinical trial of one-rod etonogestrel and two-rod levonorgestrel contraceptive implants with nonrandomized copper-IUD controls: methodology and insertion data

BACKGROUND

Comparative data on etonogestrel and two-rod levonorgestrel contraceptive implants are lacking.

STUDY DESIGN

A multicenter, open, parallel-group trial with random allocation of implants was performed. For every second implant user, an age-matched woman choosing an intrauterine device (IUD) (TCu380A) was admitted. Methods and data on implant/IUD insertion and 6-week follow-up are reported.

RESULTS

A total of 2008 women were randomized to an implant, and 974 women were enrolled in the IUD group. Results from 997 etonogestrel implant users, 997 levonorgestrel implant users and 971 IUD users were analyzed. In the etonogestrel and levonorgestrel groups, respectively, mean insertion durations were 51 (SD 50.2) s and 88 (SD 60.8) s; complication rates at insertion were 0.8% and 0.2%; and at follow-up, 27.2% and 26.7% of women, respectively, had signs or symptoms at the insertion site. At follow-up within 6 weeks after insertion, all implants were in situ, while 2.1% of IUDs were expelled.

CONCLUSION

Performance of etonogestrel and levonorgestrel implants at insertion and within the first 6 weeks is similar. Short-term (6 weeks) continuation rates appear higher for implants than TCu380A.

Determination of optimal imaging mode for ultrasonographic detection of subdermal contraceptive rods: comparison of spatial compound, conventional, and tissue harmonic imaging methods

Objective

To determine which mode of ultrasonography (US), among the conventional, spatial compound, and tissue-harmonic methods, exhibits the best performance for the detection of Implanon® with respect to generation of posterior acoustic shadowing (PAS).

Materials and Methods

A total of 21 patients, referred for localization of impalpable Implanon®, underwent US, using the three modes with default settings (i.e., wide focal zone). Representative transverse images of the rods, according to each mode for all patients, were obtained. The resulting 63 images were reviewed by four observers. The observers provided a confidence score for the presence of PAS, using a five-point scale ranging from 1 (definitely absent) to 5 (definitely present), with scores of 4 or 5 for PAS being considered as detection. The average scores of PAS, obtained from the three different modes for each observer, were compared using one-way repeated measure ANOVA. The detection rates were compared using a weighted least square method.

Results

Statistically, the tissue harmonic mode was significantly superior to the other two modes, when comparing the average scores of PAS for all observers (p < 0.00-1). The detection rate was also highest for the tissue harmonic mode (p < 0.001).

Conclusion

Tissue harmonic mode in uS appears to be the most suitable in detecting subdermal contraceptive implant rods.

Neuropathy associated with etonogestrel implant insertion

BACKGROUND

The etonogestrel contraceptive implant (Implanon®) is an effective, long-acting subdermal method of hormonal contraception for women.

CASE

We describe a case of forearm pain and hypoesthesia associated with the insertion of the Implanon® contraceptive implant in a healthy 26-year-old female. These symptoms were due to direct implant contact with the medial cutaneous nerve of the forearm. The importance of correct insertion technique is discussed.

CONCLUSION

Care should be taken to avoid nerve injury during insertion of subdermal contraceptive implants. An understanding of regional anatomy and the correct insertion technique will prevent insertion-related complications. Nexplanon® has been developed to replace Implanon®. It has a redesigned applicator intended to increase insertion accuracy.

[Contraceptive implants--aberrations from insertion and removal procedures]

BACKGROUND

Contraceptive implants with progestogens are options for women who need long-term contraception. Implanon which contains etonogestrel (the active metabolite of desogestrel) effectively prohibits ovulation over a period of three years. This study presents aberrations from insertion and removal procedures for Implanon in the period 2 February 2002 - 30 June 2008.

MATERIAL AND METHODS

Information about sales of Implanon in Norway is taken from statistics provided by Farmastat Norway. Aberrations from procedures for insertion and removal of Implanon are based on reports from doctors to the producer. Non-palpable implants to be removed at Volvat Medical Centre in Oslo, were localized by ultrasound and removed surgically.

RESULTS

In the period 2 February 2002 - 30 June 2008, the producer Organon AS (now Schering- Plough AS) sold 12 898 Implanon implants in Norway and recorded 112 aberrations from existing procedures, the first one 3 March 2003. 18 patients were referred for removal of implants (too deeply inserted) at Volvat Medical Centre in the period 19 January 2004 - 30 June 2008.

INTERPRETATION

The number of unsuccessful or wrongly inserted implants indicates that doctors should have practiced and be better informed about insertion and removal procedures before using this method. Localization and removal of implants inserted too deeply requires high-frequency ultrasound equipment and surgical experience.

Implanon: a new contraceptive implant

Women who cannot use hormonal contraception containing estrogen have a variety of progestin-only contraceptive methods from which to choose. Implanon is a new single-rod progestin-only contraceptive implant that is easily inserted and can remain in place for up to 3 years. It is highly effective with a rapid onset of action and an equally rapid return of fertility once removed. Counseling is important to help women decide if this method is appropriate for their needs.

Ultrasound-guided removal of Implanon devices

Our study has shown that ultrasound-guided localisation and removal of Implanon rods is safe, practical and highly successful. Over a 4-year period, 119 patients had successful, uncomplicated removal of their subdermal devices.The technique is particularly useful for removal of the device when it is not palpable or when an attempt at removal of a palpable device has not been successful.

A medical simulator for subcutaneous contraceptive implant insertion

New contraceptive methods like the subcutaneous implant offers a new kind of comfort for women with an efficiency similar to the contraceptive pill. Unfortunately the few numbers of unintended pregnancies that have been reported are generally due to a bad insertion of the implant. In order to give more security to patients, we have designed, in close collaboration with physicians, a new kind of medical simulator. This paper focuses on a device dedicated to a specific subcutaneous implant but it is worth noting that this simulator is relatively generic since it will be used for other subcutaneous techniques or other implant instruments. This simulator can be used for two purposes: one for training novice physicians in the correct manipulation and the other for physician certification which will help determine if they are capable of inserting the implant in vivo. This paper describes the approach which has led to the design of this simulator. It describes its functionalities, its several components but also methods used to analyze the manipulation of the implant insertion inside the patient. Finally first experimental results are reported and discussed. The system used in this paper makes possible to carry out training in a constraint-free context and provides the first mean of visualizing a maneuver that, until now, has been performed blindly.

Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy

BACKGROUND

Implantable methods of contraception offer long-acting reversible contraception. Their uptake rate in comparison to other contraceptive methods, particularly in developed countries, has historically been low.

OBJECTIVES

To assess the contraceptive effectiveness, tolerability and acceptability of subdermal implants in comparison to other reversible contraceptive methods.

SEARCH STRATEGY

Literature were identified through database searches, reference lists and individuals/organisations working in the contraceptive field.

SELECTION CRITERIA

All randomised and controlled trials comparing subdermal implants with other forms of reversible contraceptives and reporting on pre-determined outcomes in women of reproductive years. Primary outcomes were pregnancy and continuation.

DATA COLLECTION AND ANALYSIS

Quality assessment of studies and data extraction were completed independently by two reviewers. A quality checklist was designed to identify general methodological and contraceptive specific factors. Study authors and pharmaceutical companies were contacted to provide additional data.Data were collected on pregnancy rates, continuation, side effects and adverse events.

MAIN RESULTS

All nine identified trials compared different types of contraceptive implant. Eight, involving 1578 women, compared Implanon with Norplant , and one, involving 1198 women, compared Jadelle with Norplant. There was no difference between Implanon and Norplant for contraceptive effectiveness rates or continuation over 4 years. Both were highly effective methods of contraception with no pregnancies occurring in any of the trials during 26,972 and 28,108 women months of follow up respectively. The most common side-effect with Implanon and Norplant was changes in bleeding pattern. The pattern with Implanon was initially more variable, bleeding with both implants became less frequent with duration of use. After two years use the amenorrhoea rate was significantly higher with Implanon. The trials reported no significant difference in hormonal side-effects or adverse events. Implanon was significantly quicker to insert and remove than Norplant. There was no difference in contraceptive effectiveness and in continuation rates between Jadelle and Norplant. Jadelle was significantly quicker to remove than Norplant.

AUTHORS' CONCLUSIONS

Implanon, Norplant and Jadelle are highly effective contraceptive methods. No significant differences were found in contraceptive effectiveness or continuation. The most common side-effect with all implants was unpredictable vaginal bleeding. Time taken for removal of Implanon and Jadelle was less than that for Norplant.Although this systematic review was unable to provide a definitive answer on relative effectiveness, tolerability and acceptability of contraceptive implants in comparison to other contraceptive methods, it has raised issues around the conduct of contraceptive research.

Removal of etonogestrel contraceptive implants in the operating theater: report on 28 cases

OBJECTIVES

We describe removal procedures for etonogestrel contraceptive implants in the operating theater. In addition, we discuss the management of removal of contraceptive implants that are difficult to palpate or are impalpable.

DESIGN

We conducted a retrospective single-center case series analysis of Implanon removals conducted at a university hospital between January 2002 and April 2005.

MATERIALS AND METHODS

We analyzed case notes for 28 patients who had their contraceptive implant removed in the operating theater.

RESULTS

Intermenstrual bleeding was the principal reason for removal (52.4%). Ten patients already had one attempted removal of their implant. Preoperative ultrasound localized the implant in all cases. Half of the removals were done under local anesthetic, with three cases progressing to general anesthesia (11%). Thirty percent of the implants had migrated from their initial implantation, 37% were in intramuscular tissue and 11% were in the humeral neurovascular sheath. The only postoperative complications were one small seroma and transient paresthesia in the territory of the ulnar nerve. The implant was not found in one case.

CONCLUSIONS

The removal of an implant that is not palpable or difficult to palpate should take place in the operating theater following localization by ultrasound. Patients must be fully informed about the procedure, including its complications and the risk for failure.

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.

Implanon® : difficultés d'insertion et de retrait, échecs contraceptifs

OBJECTIVE

Analysis of the results of a national pharmacovigilance study on Implanon, a contraceptive implant containing 68 mg of etonogestrel.

PATIENTS AND METHODS

This survey concerns cases of pregnancies (contraception failures), of migrations and of insertion or removal problems with Implanon reported to French Regional Drug Pharmacovigilance Centres and to Organon SA between May 2001 and September 2002.

RESULTS

In France, 39 unintended pregnancies were reported over 17 months. The pregnancies were in 77% of cases (N = 30) due to an insertion technique error (implant not found when pregnancy has been diagnosed). For 3 patients (7,6%), pregnancy was due to a failure of etonogestrel contraceptive effect, explained twice by its association with an enzymatic inductor drug. For 4 patients (10%), pregnancy was due to an untimely insertion (insertion after day 5 of menstrual cycle or woman already pregnant). For two patients, no information was available. The incidence of reported pregnancies in France is estimated at 0.359 / 10(3) implants [0.246-0.482], in accordance with a typical Pearl Index of 0.06 [0.04-0.08]. Twenty-eight suspected migrations (N = 11), problems or failures in removal of the implant (N = 11) and insertion difficulties (N = 6) were notified, corresponding to an incidence of 0.257/10(3) implants [0.162-0.363].

DISCUSSION AND CONCLUSION

Occurrence of pregnancy is possible with Implanon, due to errors in the insertion technique (device not really inserted) or to a non-respect of the SPC recommendations (drug-drug interaction or untimely insertion). Insertion problems can lead to localisation problems (implant not visible by X-ray) then needing further tests and even harmful practice (removal under general anaesthesia). That is why a real and strict training is highly recommended to physicians.

Pharmacological female contraception: an overview of past and future use

Female hormonal contraceptive methods have undergone slow change over the past four decades. Due to social, political and legal reasons, as well as medical complications, several new methods have been removed from the contraceptive armamentarium almost as quickly as they have been added. With worldwide unintended pregnancy rates approaching 50% of all pregnancies, there is an increased need for the development of new methods of effective, safe, acceptable hormonal contraception. Pharmacological methods of contraception are reversible and contraceptive steroids are now formulated in pills, patches, intravaginal rings, subdermal implants and injections. All currently marketed formulations are made from synthetic steroids and contain no natural oestrogens or progestins. This article reviews the current state of female contraception and explores future directions.

Unintended pregnancies with the etonogestrel implant (Implanon): a case series from postmarketing experience in Australia

This paper describes a case series of over 200 unintended pregnancies associated with the etonogestrel implant, Implanon. These cases have been reported to the Australian Adverse Drug Reactions Advisory Committee during the first 3 years of marketing in this country. Of 218 cases included, 45 had insufficient data to assess the reason for contraceptive failure and 46 women were determined to have been already pregnant prior to Implanon insertion. Of the remaining 127 cases, the most common reason for unintended pregnancy was failure to insert the implant in 84 women. Other reasons included incorrect timing of insertion (19 cases), expulsion of Implanon (3 cases) and interaction with hepatic enzyme-inducing medicines (8 cases). The remaining 13 cases were classified as product/method failures once other reasons had been excluded. Using the 204,486 Implanon devices subsidized in this period to estimate the population exposed and the 218 pregnancies reported, the approximate failure rate in postmarketing use was 1 in 1000 insertions. These findings (and reports to medical indemnity insurers) have resulted in the development of guidelines and training for doctors inserting Implanon in Australia.

Ultrasound localisation of non-palpable Implanon

BACKGROUND

Localisation of the non-palpable Implanon is useful to confirm its presence or to assist the surgeon with its removal. Previous studies have suggested that almost all non-palpable Implanon implants can be located with ultrasound in phantoms.

AIM

To determine whether diagnostic ultrasound is a reliable method for localising non-palpable Implanon implant in-vivo.

METHODS

Ultrasound was carried out to localise the non-palpable Implanon implant. To ascertain the accuracy of the ultrasound findings, all patients were followed-up until the implant was removed or until it was proven absent by serial progesterone levels confirming ovulation or by negative etonogestrel levels.

RESULTS

In 22 out of 23 patients the Implanon was correctly identified as present. The specificity is 95.7% (95%CI 79.0-99.2%), the positive predictive value is also 95.7%. In six out of seven patients the Implanon was correctly identified as absent. The sensitivity is 85.7% (95%CI 48.7-97.4%), the negative predictive value is also 85.7%. Four patients were excluded due to incomplete follow-up.

CONCLUSION

Ultrasound is a reliable first line method for localising non-palpable Implanon. When the Implanon is localised on ultrasound, it is very likely present. When the Implanon is not seen on ultrasound, etonogestrel determination should be carried out to confirm its absence.

Acceptabilité de l’implant contraceptif à l’étonogestrel (Implanon®)

OBJECTIVES

To estimate the exact satisfaction of women toward Implanon, the sole contraceptive implant available in France. To clarify the indications of this type of contraception.

MATERIAL AND METHOD

Among a population of 182 women with Implanon" inserted in a same family planning service between May 22, 2001 and February 14, 2003, 108 women agreed to answer a questionnaire of satisfaction. Implants were inserted in one third of cases after childbirth, in another third after abortion. The average duration of use of the implant was of 16 months (2 in 24 months). Twenty-nine removals among the 108 insertions (27%) were recorded.

RESULTS

Possibility of a long-term and easy -to-use contraception was the most common reason for choosing Implanon (74% of the women). Eighty-one percent of the women were globally satisfied with Implanon but one out of two women had side-effects. Only 62% of the women were ready to use it again. Adverse events were first, menstrual disturbance in 83% of the women, mainly amenorrhea (26%) and bleeding irregularity (40%). Bleeding irregularity was one of the main motives for discontinuing the implant in 41% of cases. Except weight gain present for 37% of patients, the other side-effects, even though they were frequent, were less often the reason for removal. Headache, acne, breast pain, mood and decreased libido were the main reasons for removal.

CONCLUSION

Implanon has certainly a place among current contraceptive methods. Because of the frequency raised by adverse events and by their lower tolerance in Europe, this place has to remain limited to the incapacity of classic methods. Preinsertion counseling announcing Implanon's benefit and risk effects is necessary to minimize the early discontinuation rates.

Recent developments in hormone delivery systems

Women who want safe, effective contraception have many more options than they did only a few years ago. Each option must be weighed carefully according to the needs and lifestyle of each particular woman. One method that provides long-term convenience with a side-effect profile that is comparable to that of oral contraceptives is the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. Another option is the levonorgestrel-releasing intrauterine contraceptive system that offers pregnancy prevention for 5 years. Finally, hormonal implants that release low doses of progestins have been used for more than 30 years by a total of 10 million women, and easier-to-use implants will soon be available.

New options in contraception for teenagers

PURPOSE OF REVIEW

Unintended pregnancy continues to exact a considerable economic, social and personal cost in industrialized nations despite the ready availability of safe, reliable and highly effective methods of contraception. Adolescents still demonstrate some of the highest rates of unintended pregnancy and thus may benefit from considering new contraceptive options that provide unique side effect profiles or delivery systems that could facilitate and improve compliance of contraceptive methods.

RECENT FINDINGS

The recent launch of several new combination oral contraceptive pills with novel side effect profiles has expanded the choices for teenagers who choose to use a daily oral contraceptive. Of potentially greater interest is the recent availability of several nondaily contraceptives, as compliance remains a critical issue with successful contraceptive use in adolescents.

SUMMARY

New contraceptive methods bring unique side effect profiles and delivery systems that may improve overall contraceptive compliance, especially among teenagers who are more prone to misuse from a wide array of side effect and compliance issues. Even the most accepted method, however, will not provide effective contraception if the process by which contraception is provided fails to address the unique concerns and lifestyle issues of each individual adolescent.

Local side effects observed among long-term users of norplant contraceptive implants

The prevalence of local signs and symptoms related to the site of insertion of implants, and the association of these signs and symptoms with time of use, skin color and body mass index (BMI) was evaluated among users of the Norplant implant system. Three hundred and three Norplant users attending at the reproductive health clinic of PROFAMILIA in Santo Domingo, Dominican Republic, were asked if they had ever had any discomfort at the site/arm of implant insertion and the implant insertion area was examined and hyperpigmentation and hollowing of the surface was recorded. Half of the subjects reported either pain or paresthesia or both, in almost equal numbers, some time since insertion. Hyperpigmentation was observed in 35.6% and hollowing in 22.4% of the subjects. Report of pain and paresthesia was inversely associated to time of use and to BMI. Hyperpigmentation was directly associated to time of use and darker skin, and hollowing of the arm surface in the implants area with time of use and BMI. Local signs and symptoms were more frequent than previously reported, although they were of mild nature and appeared not to worry most of the users.

Advances in Female Hormonal Contraception

Despite the wide variety of reversible contraceptives, unintended pregnancy rates in developed nations are still considered markedly elevated by most epidemiologists and clinicians. Indeed, the US has one of the highest unintended pregnancy rates among the industrialized nations of the world. Although many factors appear to influence this problem, what may play an important role in this apparent paradox is the process by which a woman obtains contraception. Although most nonbarrier methods have similar efficacy, the ability to use that method consistently and correctly will determine whether it provides maximal contraception. Oral contraceptives are the most popular method in the US; accordingly, the process by which US women obtain their contraception may not take into account the desire of many women to use nondaily methods. The recent introduction of nondaily methods in the US and elsewhere has provided more choice so that a successful contraceptive decision can be made in the first instance rather than after an adverse clinical outcome or unintended pregnancy with a method not as well suited to that woman's lifestyle. These new methods are not characterized by improved safety or efficacy; rather, they have novel components or delivery systems that may provide important options to women who may not be able to or willing to use existing methods of contraception. The transdermal patch, vaginal ring, and monthly injectable are combination estrogen/progestogen methods characterized by novel delivery systems and compliance regimens. The single rod implant is a facile and well accepted method that has not yet been approved for use in the US but has been an increasingly popular choice elsewhere. The levonorgestrel intrauterine system has been used in Europe for over 10 years and has recently been introduced in the US. This intrauterine contraceptive provides high efficacy and reliability, and may have considerable noncontraceptive benefit with regard to the nonsurgical treatment of uterine bleeding problems and endometrial protection for menopausal hormone therapy. The increasing popularity of these methods can be considered a testament to the desire of women to consider nondaily contraceptives as first-line, mainstream options. It is hoped that increasing use of these methods will lead to a considerable decrease in the rate of unintended pregnancy.

Users' perspectives on implantable contraceptives for women

Users of subdermal contraceptive implants report long duration of use, convenience, and high efficacy as liked features and bleeding irregularities, weight loss/gain, and headaches as disliked effects of these methods. Satisfied users tend to be women who do not experience side effects or women who value positive features and tolerate the side effects. Satisfaction of the users is also closely related to quality of services. Service delivery problems, such as lack of proper pre-insertion counseling, inadequacy in number and imbalance in the geographical distribution of providers who can insert and remove implants, and appropriately manage side effects have been observed in new programs. Insensitivity of some providers to side-effects, such as bleeding irregularities, and to requests for removal have caused user dissatisfaction and serious public concern. Care must be taken to provide implants in a context of high quality of care with adequate numbers and distribution of trained providers and a basic record-keeping and tracking system.

Nonmenstrual adverse events during use of implantable contraceptives for women: data from clinical trials

Contraceptive methods, including implants, do not prevent common symptoms and adverse health events that most people experience. It is difficult, therefore, to decide whether or not the occurrence of symptoms or adverse events that are common can be attributed to use of a contraceptive method or to determine if a given method changes the likelihood of their occurrence. Based on the review of the literature, no apparent differences in the frequency of adverse events are evident between the six-implant or two-rod levonorgestrel systems and the single implant etonogestrel and nomegestrol acetate systems. The most frequent adverse events reported in clinical trials that are probably related to implant use are headaches and acne. Weight gain, dizziness, and mood changes are also frequently mentioned adverse events and are possibly steroid-related. Other possibly related adverse events, although much less frequently reported, are loss of libido, fatigue, hair loss, and other skin conditions. Persistent ovarian follicles that spontaneously disappear are a common event during use of progestin-only contraceptives, and providers should be aware of this condition to avoid unnecessary interventions. Overall, the vast experience reported in the clinical studies reviewed here show that all existing implantable contraceptives are equally safe. This can probably be attributed to the low-hormonal dose delivered by progestin-implant systems.

Nonpalpable ultrasonographically not detectable Implanon rods can be localized by magnetic resonance imaging

Recently, the contraceptive implant Implanon has been introduced in several European countries. In comparison to the six-capsule preparation Norplant, the removal of this single-rod system should be associated with less complications. However, the removal of nonpalpable Implanon rods can be difficult because the implant is not always visible with ultrasound. The aim of this study was to find a radiologic method for the localization of Implanon implants that are nonpalpable and can not be detected by ultrasound. X-ray, ultrasound, computed tomography, and magnetic resonance imaging (MRI) were investigated as methods to localize Implanon in a pig chest preparation and in a woman with a nonpalpable implant. The implant in the woman could be localized unequivocally only by MRI. We conclude that MRI is the best method for the unequivocal localization of nonpalpable, ultrasonographically not detectable Implanon rods. To avoid unnecessary scar tissue formation, it may be appropriate to defer surgery for the removal until definitive localization.

Implanon: a critical review

OBJECTIVE

To evaluate clinical information on Implanon as a long-term method of contraception and, specifically, to review the efficacy and adverse effect profile of Implanon.

DATA SOURCES

A MEDLINE search (from 1966 through June 1999) was performed to retrieve primary and review articles. The search was limited to data on human subjects. Some references were identified through secondary sources.

STUDY SELECTION AND DATA EXTRACTION

Pharmacokinetic and pharmacodynamic studies, and clinical trials assessing the efficacy and safety of desogestrel implants were reviewed. Relevancy and consistency of information was assessed for each trial.

DATA SYNTHESIS

Implanon is the newest contraceptive implant system that has completed worldwide Phase III clinical trials. It is a single rod that contains a core of 68 mg of 3-keto-desogestrel with a membrane of ethylene vinyl acetate. Inhibition of ovulation occurs within one day of implantation, and effective contraception lasts for three years. Fertility returns within one month after implant removal. Insertion and removal by trained medical professionals is simple, and only minor complications have been documented. Adverse effects are mild and primarily consist of abnormal bleeding, weight gain, acne, breast pain, and headache.

CONCLUSIONS

The data on Implanon indicate that it provides effective long-term contraception with limited adverse effects. It appears to be a good addition to the currently available contraceptives.

Implantable contraception

Although levonorgestrel contraceptive implants have been available for over 15 years, innovations have only recently led to a wider choice. These new implants offer easier insertion and removal and other advantages depending on the type of progestin. Implants prevent pregnancy by several mechanisms, including inhibition of ovulation and luteal function and alteration of cervical mucus and the endometrium. The high efficacy and ease of maintenance make implants an ideal contraceptive for many women, including adolescents, a population that uses implants infrequently but reports high satisfaction. Implants are appropriate for women who are breastfeeding, who have contraindications to estrogen, or who have diseases such as diabetes, hypertension, sickle cell anemia, or an HIV infection because implants have few metabolic or hematologic effects. Long-term use has not been associated with a decrease in BMD and generally leads to increased blood levels and iron stores. Women who wish to space their pregnancies appreciate the nearly immediate onset of action with insertion and the rapid termination of all effects with removal. All types of implants lead to menstrual changes and other side effects in some women. Adverse effects that occur in implant users more than the general population include headaches and acne. Women must be thoroughly counseled regarding the potential for menstrual alteration, side effects, and sexually transmitted infections if they do not use condoms. Despite their initial high cost, implants are a cost-effective method over several years, even when discontinued before the life of the implant.

Acceptability of Norplant at a well-woman clinic in Turkey

OBJECTIVE

To make an assessment of the acceptability and cost of subdermal implants, a new method in Turkey, in a free-choice environment.

METHODS

The records of women attending a university well-woman clinic in Istanbul, Turkey, were analyzed retrospectively. Among other contraceptives registered in the country, the women were offered subdermal contraceptive implants (Norplant) during counselling sessions. The women who chose implants were invited to attend for follow-up three times during the first 12 months and were advised to return annually thereafter. An estimation of cost was performed for Norplant, using the government price of the implant and the wage rates of public-sector staff. An estimation of cost was also performed for oral contraceptives.

RESULTS

Among the 5650 women who applied to the Clinic for contraception between 1 January 1995 and 31 December 1998, 274 women decided to use implants, giving an initial acceptance rate of 5.1%. Continuation rates were 91.8%, 71.6% and 42.5% at 12 months, 24 months and 36 months, respectively. There were no pregnancies within the study period. The only demographic characteristic that was positively related to the acceptability of Norplant was younger age. The cost of contraception with Norplant was found to be lower than that for oral contraceptives.

CONCLUSION

The high initial acceptance and continuation rates, combined with its high efficacy, make Norplant a valuable tool for Turkey's National Family Planning Program. Contraception with Norplant is also a cost-effective method, at least for the public sector.

The effects of Implanon on lipid metabolism in comparison with Norplant

This open, randomized study was intended to assess the effects of the new single-rod contraceptive implant (Implanon) containing etonogestrel on lipid metabolism in Indonesian women, in comparison with the six-rod implant Norplant, containing levonorgestrel. The effects of both products were compared with a control group using an intrauterine device (IUD) over a 3-year period. A total of 135 healthy volunteers of childbearing potential, aged 22 to 41 years, were enrolled in Jakarta, Indonesia. Ninety volunteers were randomized to use Implanon (n = 45) or Norplant (n = 45), and a nonrandomized group of 45 Multiload Cu 250 IUD users served as a control. Serum concentrations of total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, apolipoprotein AI, apolipoprotein AII, and apolipoprotein B were measured. The ratios of HDL cholesterol to total cholesterol, of HDL to LDL cholesterol, and of apolipoprotein AI to apolipoprotein B were determined. Lipid and lipoprotein determinations were done at screening and after 3, 6, 12, 18, 24 and 36 months. Contraceptive efficacy and insertion and removal times were also recorded. Mean changes from baseline in the lipid and apolipoprotein parameters, although occasionally statistically significant, were small in all groups (less than 1 standard deviation of the mean concentration at baseline) and clinically not significant. Statistically significant differences between the Implanon and Norplant groups were only occasionally observed. In both implant groups, total mean cholesterol, LDL cholesterol, and apolipoprotein AI concentrations tended to decrease during the study, but statistically significant changes from baseline were only occasionally observed, suggesting that drug-related factors are not involved. The mean ratios of HDL/total cholesterol and the HDL/LDL cholesterol showed very little change over time in both implant groups; slight and statistically nonsignificant increases were noted at most time points. Similar changes were seen in the group of IUD users. It can be concluded that changes from baseline in the lipid and apolipoprotein parameters tested were generally small and did not differ between Implanon and Norplant.

A randomized multicenter study comparing the efficacy and bleeding pattern of a single-rod (Implanon) and a six-capsule (Norplant) hormonal contraceptive implant

To compare the contraceptive efficacy, tolerability, and bleeding patterns, 200 healthy female volunteers received, in an open, comparative, randomized, multicenter study in China, either a single-rod (Implanon) or a six-capsule (Norplant) contraceptive implant for 2 years with an optional extension of up to 4 years. Women were exposed to Implanon for 341.6 woman-years and Norplant for 329.1 woman-years. There were no pregnancies during the study. Per 90-day reference period, the median number of bleeding/spotting days with Implanon decreased from 33.5 in the first period to 19.0-21.5 days in the last year. Similarly, with Norplant, the median number of bleeding/spotting days decreased from 34.5 to 18.0-23.0 days, respectively. The number of bleeding/spotting episodes during year 1 was 2.0 per 90-day reference period with Implanon and 3.0 per period with Norplant (p < 0.05 for periods 1-4). For the remaining 90-day periods, there was no statistical difference between the two groups. In general, there was less frequent bleeding with Implanon compared with Norplant, whereas the incidences of amenorrhea and infrequent bleeding were higher with Implanon than with Norplant. The mean overall incidence of prolonged bleeding fell markedly during the study, from 66.0% in reference period 1 to 27.3% in period 16 with Implanon and from 69.0% to 21.7% with Norplant, respectively. The most common adverse events were related to disturbed bleeding patterns, which were also the major reasons for discontinuation (Implanon n = 8; Norplant n = 14). Normal menses returned in almost all subjects within 3 months after removal of the implants. Implanon was inserted in a mean time of 0.61 min and Norplant in 3.90 min (p < 0.001). Similarly, the mean time required to remove the implant was significantly shorter for Implanon than for Norplant (2.18 min vs 11.25 min, p < 0.001). The maximum time required for removal of the implant was 10 min for the Implanon group and 60 min for the Norplant group. In both groups, blood pressure and hemoglobin were not affected, whereas body weight tended to increase. It can be concluded that both contraceptive systems demonstrated excellent contraceptive efficacy and were well tolerated. Compared with Norplant, there was less frequent bleeding with Implanon, whereas the incidence of infrequent bleeding and amenorrhea was higher. Implanon was significantly quicker to insert and to remove than was the multiple capsule system.

A long-term study of the efficacy and acceptability of a single-rod hormonal contraceptive implant (Implanon) in healthy women in China

OBJECTIVE

To investigate the contraceptive efficacy, cycle control and acceptability of Implanon, a new single-rod, progestogen-only contraceptive implant.

METHODS

In a non-comparative, open, multicenter study, a contraceptive implant containing the progestogen etonogestrel was inserted into 200 healthy women. The study duration was 2 years, with an optional extension up to 4 years.

RESULTS

Women were exposed to Implanon for 644.6 woman-years. There were no pregnancies during the study. Per 90-day reference period, the median number of bleeding-spotting days ranged between 18 and 21 and the median number of bleeding-spotting episodes was two. The mean overall incidence of prolonged bleeding fell markedly during the study, from 69% in the first reference period to 26% in the 16th period. The most common adverse events were related to disturbed bleeding pattern and amenorrhea. Heavy or prolonged bleeding caused 18 subjects to withdraw from the study. Only a few subjects discontinued the study early due to irregular bleeding (2%) or amenorrhea (2%). A slight increase in mean body weight was observed. The implant was removed in an average time of 2.9 min.

CONCLUSIONS

Implanon demonstrated excellent contraceptive efficacy for 4 years of use and was well tolerated. The incidences of prolonged bleeding and amenorrhea both fell markedly with continued implant use. Because of its single-rod design, Implanon was quickly removed with few complications and proved to be a highly acceptable method of contraception.

An integrated analysis of nonmenstrual adverse events with Implanon

This integrated analysis evaluates nonmenstrual adverse events, blood pressure, and body weight changes during the use of the single-rod etonogestrel-containing contraceptive implant, Implanon; these aspects are compared for Implanon and Norplant, the six-capsule implant containing levonorgestrel. Overall, 47% of Implanon users had drug-related adverse events, whereas in the comparative studies the figure for those using Implanon (61%) was slightly lower than that for Norplant users (69%). In all Implanon studies, 12 of 1716 women (0.7%) were affected by serious adverse events that were considered drug related. In comparative studies three of the 689 Implanon users (0.4%) and one of 689 Norplant users (0.1%) had such experiences. The most frequently reported drug-related adverse events were acne, breast pain, headache and weight gain. The adverse events that most often caused discontinuation of Implanon were weight gain and acne. The development or aggravation of acne was a frequent adverse event (in 18.5% of Implanon and 22.3% of Norplant users in the comparative studies) but individual studies indicated that there were also many subjects whose acne improved during implant use. There were gradual increases in body weight over time but these may be only partly attributable to implant use and partly attributable to normal increases over time.