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

Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Acceptability of telemedicine for follow up after contraceptive implant initiation at an obstetrics and gynecologic training center

BACKGROUND

During the COVID-19 pandemic, telemedicine has become a popular adjunct to in-person visits, including for family planning services. This study determined the proportion of clients participated in telemedicine services and the association between sociodemographic factors and telemedicine participation during the COVID-19 pandemic. The adverse effects within the first seven days post-insertion were also reported.

METHODS

This retrospective cohort study considered data from all women initiating contraceptive implantation between June 2020 and August 2021 at King Chulalongkorn Memorial Hospital. Clients were offered the following two options for follow-up visits: in-person or communication via an online LINE® Official Account (LINE® OA), a free chat application widely used among the Thais. Logistic regression analyses were used to assess the association between socio-demographic factors and telehealth usage.

RESULTS

In total, 574 of 947 (60.6%) clients participated in telemedicine follow-up services during the period considered. A significant association between telemedicine usage and the following were observed: the peak of second wave COVID-19 outbreak in Thailand, using the period preceding the second wave as a reference [adjusted odds ratio (aOR) = 1.47 (95% confidence interval [CI]: 1.12-1.96)]; participants receiving governmental benefits for contraceptive implant payment (aOR: 3.23, 95% CI: 1.86-5.60), and timing of contraceptive implant(s) initiation, using interval insertion as a reference for which aORs of postpartum and immediate postpartum insertions were 0.62 (95% CI: 0.43-0.90) and 0.35 (95% CI: 0.24-0.52), respectively. Significant ecchymosis at the insertion site was observed in 13.1% of participants.

CONCLUSION

This study emphasizes the significance of telemedicine during the COVID-19 epidemic, particularly in facilitating contraceptive implant initiation. Our data show a significant increase in the uptake and utilization of telemedicine during the pandemic's peak. The data also shows that during the period of Thailand's second COVID-19 epidemic, government benefits for contraceptive implant payment, and the timing of contraceptive implant initiation, are significantly associated with telemedicine use. This finding supports the continued use of telemedicine in healthcare, particularly for services like family planning, where remote follow-ups can provide safe, efficient, and timely care.

Contraceptive Implant-Associated Bleeding in Adolescent/Young Adult Clinical Practice: Associated Factors, Management, and Rates of Discontinuation

PURPOSE

To identify factors associated with bothersome implant-associated uterine bleeding, and to evaluate the impact of bleeding management on implant discontinuation.

METHODS

We analyzed a quality improvement database of implant insertions (n = 825) at three adolescent/young adult programs and described individuals with and without reported bothersome bleeding. We utilized logistic regression to assess for factors associated with bleeding.

RESULTS

Implant recipient mean age was 18.9 ± 2.6 years, and 27% reported having subsequent bothersome uterine bleeding. Recipients had increased odds of reporting such bleeding if they had previously irregular menses (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.11-1.68 irregular and infrequent, OR = 1.41; 95% CI: 1.07-1.86 irregular and frequent) or sought the implant for menstrual management purposes exclusively (OR = 1.67; 95% CI 1.42-1.96) or in combination with contraceptive need (OR 1.65; 95%: CI 1.57-1.72). Prior use of the progestin injection or implant was associated with lower odds of subsequent bleeding report (OR = 0.63; 95% CI: 0.54-0.73; OR = 0.54; 95% CI: 0.39-0.75, respectively). Medication management of bleeding was associated with the likelihood of implant discontinuation at 1 year compared to those with untreated bleeding (hazard ratio 1.98 times, 95% CI: 1.39-2.81). The implant was continued for 3 years in over 50% of recipients with ever-managed bothersome bleeding.

DISCUSSION

Individuals with historically irregular menses and those seeking the implant for menstrual management more often reported bothersome bleeding. Treating such bleeding with medication was associated with higher 1-year discontinuation rates, although many continued implant use for 3 years. Such findings may influence implant preinsertion counseling and/or postinsertion bleeding management.

Continuation Rates of the Etonogestrel Implant and Factors Associated With Early Discontinuation

BACKGROUND

The etonogestrel implant is generally considered an effective, three-year, long-acting reversible contraceptive device. Previous research, such as the landmark CHOICE study, has reported a one-year continuation rate of 72% to 84%, however, in a real-world setting these rates may be significantly lower.

OBJECTIVE

To study etonogestrel implant continuation rates and factors associated with early discontinuation in a specific clinical setting.

STUDY DESIGN

Single-center, retrospective cohort study of patients who received the etonogestrel implant between January 1, 2015, and December 31, 2017, at several practices at an academic community hospital network. Records were reviewed up to three years after implant insertion to determine continuation rates (one to three years), early discontinuation rates (≤12 months), and reasons for early discontinuation. A sample size calculation was performed to guide a subanalysis of side effects.

RESULTS

A total of 774 patients underwent etonogestrel insertion during the study period. The one-year continuation rate was lower than that of the CHOICE study (62% vs. 83%, P <0.001). A subanalysis (n=216) revealed that a majority (82%, n=177) of patients reported side effects. Side effects were more common in patients with early discontinuation compared with patients who continued use longer than one year (93% vs. 71%, P <0.001). The most common side effect, abnormal uterine bleeding, was not significantly associated with early discontinuation. A significant association (P=0.02) was found between early discontinuation and neurologic/psychiatric complaints.

CONCLUSIONS

The one-year continuation rate of the etonogestrel implant in our population is significantly lower than the value reported by CHOICE. Implant side effects are common and significantly affect rates of discontinuation. Our data suggest there is an opportunity for education and counseling for individuals opting for this method of long-acting contraception.

One-year follow-up of immediate postpartum contraceptive implant insertion in adolescents

PURPOSE

Our study aimed to evaluate the acceptability, adverse effects and continuation rates among adolescents who accepted the etonogestrel (ENG) subdermal implant and compared to adolescents who chose other methods during the immediate postpartum period before hospital discharge, with one year follow-up up.

MATERIALS AND METHODS

We conducted a cohort non-randomised study at the Women's Hospital, University of Campinas. All women up to 19 years of age, who gave birth at the hospital between July 2019 and April 2020, were invited to participate and were offered the ENG-implant or the routine contraceptive methods. They were followed for one year postpartum.

RESULTS

We included 100 teenagers and 72 accepted the ENG-implant. Students are more likely to accept the ENG-implant than non-students (PR: 1.25 [95%CI 0.99-1.59]). Up to one year of follow-up, survival analysis showed that the time of adherence to the method was longer for the ENG-implant users (p = 0.0049). More than 90% of the adolescents were satisfied with the implant; however, five requested early removal due to menstrual irregularity and local discomfort.

CONCLUSION

Provision ENG-implant for adolescents in the immediate postpartum demonstrated high acceptance and ensured effective contraception. After one year, most of them were satisfied, with a high continuation rate and without unplanned pregnancies.

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.

A systematic review on clinical effectiveness, side-effect profile and meta-analysis on continuation rate of etonogestrel contraceptive implant

Background

Unintended pregnancies (UIP) have a significant impact on health of women and the health budget of countries. Contraception is an effective way to prevent UIPs. The study objective was to collate evidence on clinical effectiveness of etonogestrel subdermal implant (ESI), continuation rate and side effect profile among eligible women of reproductive age group, as compared to levonorgestrel intrauterine system (LNG-IUS), copper intrauterine device (Cu-IUD) and depot medroxy progesterone acetate injections; other types of contraceptive implants were excluded as comparators.

Methods

The protocol of the systematic review was registered in Prospero (registration number: CRD42018116580). MEDLINE via PubMed, Cochrane library and web of science were the electronic databases searched. A search strategy was formulated and studies from 1998 to 2019 were included. Clinical trial registries and grey literature search was done. Critical assessment of included studies was done using appropriate tools. A qualitative synthesis of included studies was done and a meta-analysis was conducted in RevMan software for continuation rates of ESI as compared to other long acting reversible contraceptives (LARC) e.g. LNG IUS and Cu-IUD.

Results

The search yielded 23,545 studies. After excluding 467 duplicates, 23,078 titles were screened and 51 studies were included for the review. Eight of the 15 studies reporting clinical effectiveness reported 100% effectiveness and overall pearl index ranged from 0 to 1.4. One-year continuation rates ranged from 57–97%; 44–95% at the end of second year and 25–78% by 3 years of use. Abnormal menstruation was the most commonly reported side effect. There was no significant difference in bone mineral density at 1 year follow-up. The meta-analyses showed that odds ratio (OR) of 1-year continuation rate was 1.55 (1.36, 1.76) for LNG-IUS vs. ESI and 1.34 (1.13, 1.58) for copper-IUD vs. ESI; showing that continuation rates at the end of one-year were higher in LNG-IUS and copper-IUD as compared to ESI.

Conclusion

ESI is clinically effective and safe contraceptive method to use, yet 1-year continuation rates are lower as compared to LNG-IUS and copper-IUD, mostly attributed to the disturbances in the menstruation.

Best Practices for Counseling Adolescents about the Etonogestrel Implant

Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.

Long-acting reversible contraception side effect management

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects.

RECENT FINDINGS

Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up.

SUMMARY

Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Quality of life of women using the etonogestrel long-acting reversible contraceptive implant after abortion for unplanned pregnancy

OBJECTIVES

The aims of the study were to investigate the effect of a subcutaneous etonogestrel-containing contraceptive implant on the quality of life (QoL) and sexual function of women who had undergone termination of an unplanned pregnancy.

METHODS

At pregnancy termination 140 women received contraceptive counselling on the etonogestrel implant. The Short Form-36 questionnaire, the Female Sexual Function Index and the Female Sexual Distress Scale were used to investigate, respectively, the QoL, sexual function and sexual distress of the women at baseline and at 6, 12, 24 and 36 months of follow-up.

RESULTS

The study group comprised 86 (61.4%) women who chose to use the contraceptive implant. The control group comprised 28 (20.0%) women who chose to use short-acting reversible contraception (SARC) and 26 (18.6%) women who chose not to use hormonal contraception. In the women not using hormonal contraception there were 23 (88.5%) unintended pregnancies before the end of the 3 year study period. QoL, sexual function and sexual distress improved in the study group from the 6 months follow-up until the end of the study (p < 0.001). QoL (p < 0.02) and sexuality (p < 0.001) gradually improved in the control group after 24 and 12 months of follow-up, respectively. None of the women using the etonogestrel implant became pregnant during the study. Inter-group analysis showed better improvement in QoL, sexual function and sexual distress in the study group than in the control group from 6 months (p < 0.004) until the end of the study (p < 0.001).

CONCLUSION

Compared with SARC and non-hormonal contraception, the contraceptive implant promoted better QoL and sexuality in users and reduced the incidence of unplanned pregnancy. However, the women who opted for SARC or non-hormonal contraception did so because of the lower cost compared with that of the contraceptive implant.