Complications of Subcutaneous Contraception: A Review

Experiences of women on the use of Implanon NXT in Gauteng province, South Africa: A qualitative study

Background

Maternal-related illnesses and pregnancy-related deaths could be averted using contraceptives, particularly long-acting methods because they improve overall access to family planning because of their benefits, such as fewer visits to the healthcare facility, higher effectiveness and value for money. The introduction of Implanon NXT in the South African health system raised great concern about the number of women who returned to healthcare facilities for its early removal within a few months of insertion.

Aim

This article focussed on exploring the experiences of women regarding early removal of Implanon NXT insertion.

Setting

The study was conducted in four selected clinics in Region E sub-district, city of Johannesburg.

Methods

A qualitative exploratory approach was followed using semi-structured individual interviews to collect data. Data were analysed using the content analysis method.

Results

The most cited reasons for its discontinuity were that women experienced unpleasant side effects such as amenorrhoea, excessive bleeding and headaches, whilst other women found it to be reliable and convenient.

Conclusion

Contraceptive methods empower women to take control of their lives and to decide on the right time for them to have children. It is, therefore, important to equip women with relevant information about the contraceptive methods so that they can make informed decisions and choices.

Contribution

The study calls for health promoters to periodically conduct information sessions with women as guided by the National Contraception Policy Guidelines to ensure up-to-date practice.

Early removal of the etonogestrel contraceptive implant in Spanish women: a prospective cohort study

Purpose

To know the discontinuation rate and characterize predictors and reasons of contraceptive implant removal within 12 months of insertion in our community setting.

Methods

This prospective cohort study included women receiving the etonogestrel contraceptive implant at sexual and reproductive health centers between September 2019 and September 2020. The variables collected were implanted insertion timing, reproductive and demographic characteristics, medical conditions, sexual activity and counseling. Our primary outcome was implant discontinuation. Kaplan-Meier survival curves were used to show the cumulative discontinuation rate of implants contraceptive within the first year of insertion. We also identified factors that increased the risk of implant removal using the log-rank test and the Cox regression model. Reasons for discontinuation were documented.

Results

199 women were followed up. Implant discontinuation was documented in 17.1% of implant users prior to 12 months. Factors that increase the risk of implant removal are living with a partner, being aged 25-34 years and not receiving comprehensive and structured counseling from the midwife. The main reason for removal was unsatisfactory bleeding (97.1%), but this was combined with other reasons such as cessation of sexual intercourse (58.8%), worsening mood (58.8%), weight gain (55.9%) or decreased libido (50.0%).

Conclusion

The rate of discontinuous implant uses in the first year is relevant in relation to cost-effectiveness, there is room for improvement that should not be overlooked. Comprehensive and structured midwife-led counseling can reduce early implant abandonment removal. The development in different countries of the role of midwives in the management of contraceptives can contribute to the economic benefit of health services and the satisfaction of women.

A long-term fulvestrant eluting implant is safe, non-toxic, and reduces the risk of breast cancer in in vivo models

For individuals at high risk of developing breast cancer, interventions to mitigate this risk include surgical removal of their breasts and ovaries or five years treatment with the anti-estrogen tamoxifen or aromatase inhibitors. We hypothesized that a silicone based anti-estrogen-eluting implant placed within the breast would provide the risk reduction benefit of hormonal therapy, but without the adverse effects that limit compliance. To this end, we demonstrate that when placed adjacent to mammary tissue in the DMBA-induced rat breast cancer model a fulvestrant-eluting implant delays breast cancer with minimal systemic exposure. Using adult female sheep, fulvestrant-eluting implants were found to be safe and non-toxic when placed at the base of the udder for directed elution into the mammary tissue. At 30 days of elution, fulvestrant was found to penetrate mammary tissue forming a concentration gradient beyond 15 mm from the implant. Consistent with the small animal rat study, minimal systemic fulvestrant biodistribution was found. Together, these studies provide the proof of principle that a breast indwelling fulvestrant-eluting implant can reduce the risk of breast cancer and limit systemic exposure, while penetrating and distributing through breast tissue.

Localized, on-demand, sustained drug delivery from biopolymer-based materials

INTRODUCTION

Local drug delivery facilitiates higher concentrations of drug molecules at or near the treatment site to enhance treatment efficiency and reduce drug toxicity and other systemic side effects. However, local drug delivery systems face challenges in terms of encapsulation, delivery, and controlled release of therapeutics.

AREAS COVERED

We provide an overview of naturally derived biopolymer-based drug delivery systems for localized, sustained, and on-demand treatment. We introduce the advantages and limitations of these systems for drug encapsulation, delivery, and local release, as well as recent applications.

EXPERT OPINION

Naturally derived biopolymers like cellulose, silk fibroin, chitosan, alginate, hyaluronic acid, and gelatin are good candidates for localized drug delivery because they are readily chemically modified, biocompatible, biodegradable (with the generation of metabolically compatible degradation products), and can be processed in aqueous and ambient environments to maintain the bioactivity of various therapeutics. The tradeoff between the effective treatment dosage and the response by local healthy tissue should be balanced during the design of these delivery systems. Future directions will be focused on strategies to design tunable and controlled biodegradation rates, as well as to explore commercial utility in substituting biopolymer-based systems for currently utilized synthetic polymers for implants for drug delivery.

Implants with Sensing Capabilities

Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.

Recent progress in advanced biomaterials for long-acting reversible contraception

Unintended pregnancy is a global issue with serious ramifications for women, their families, and society, including abortion, infertility, and maternal death. Although existing contraceptive strategies have been widely used in people's lives, there have not been satisfactory feedbacks due to low contraceptive efficacy and related side effects (e.g., decreased sexuality, menstrual cycle disorder, and even lifelong infertility). In recent years, biomaterials-based long-acting reversible contraception has received increasing attention from the viewpoint of fundamental research and practical applications mainly owing to improved delivery routes and controlled drug delivery. This review summarizes recent progress in advanced biomaterials for long-acting reversible contraception via various delivery routes, including subcutaneous implant, transdermal patch, oral administration, vaginal ring, intrauterine device, fallopian tube occlusion, vas deferens contraception, and Intravenous administration. In addition, biomaterials, especially nanomaterials, still need to be improved and prospects for the future in contraception are mentioned.

Implantable Drug Delivery Systems and Foreign Body Reaction: Traversing the Current Clinical Landscape

Precise delivery of therapeutics to the target structures is essential for treatment efficiency and safety. Drug administration via conventional routes requires overcoming multiple transport barriers to achieve and maintain the local drug concentration and commonly results in unwanted off-target effects. Patients’ compliance with the treatment schedule remains another challenge. Implantable drug delivery systems (IDDSs) provide a way to solve these problems. IDDSs are bioengineering devices surgically placed inside the patient’s tissues to avoid first-pass metabolism and reduce the systemic toxicity of the drug by eluting the therapeutic payload in the vicinity of the target tissues. IDDSs present an impressive example of successful translation of the research and engineering findings to the patient’s bedside. It is envisaged that the IDDS technologies will grow exponentially in the coming years. However, to pave the way for this progress, it is essential to learn lessons from the past and present of IDDSs clinical applications. The efficiency and safety of the drug-eluting implants depend on the interactions between the device and the hosting tissues. In this review, we address this need and analyze the clinical landscape of the FDA-approved IDDSs applications in the context of the foreign body reaction, a key aspect of implant–tissue integration.

Safety and pharmacokinetics of islatravir subdermal implant for HIV-1 pre-exposure prophylaxis: a randomized, placebo-controlled phase 1 trial

Islatravir (MK-8591) is a highly potent type 1 human immunodeficiency virus (HIV-1) nucleoside reverse transcriptase translocation inhibitor with a long intracellular half-life that is in development for the prevention and treatment of HIV-1. We conducted a randomized, double-blind, placebo-controlled, phase 1 trial in adults without HIV-1 infection. Participants received islatravir or placebo subdermal implants for 12 weeks and were monitored throughout this period and after implant removal. The co-primary end points were safety and tolerability of the islatravir implant and pharmacokinetics, including concentration at day 85, of islatravir triphosphate in peripheral blood mononuclear cells (PBMCs). Secondary end points included additional pharmacokinetic parameters for islatravir triphosphate in PBMCs and the plasma pharmacokinetic profile of islatravir. Based on preclinical data, two doses were assessed: 54 mg (n = 8, two placebo) and 62 mg (n = 8, two placebo). The most frequently reported adverse events were mild-to-moderate implant-site reactions (induration, hematoma, pain). Throughout the 12-week trial, geometric mean islatravir triphosphate concentrations were above a pharmacokinetic threshold of 0.05 pmol per 10⁶ PBMCs, which was estimated to provide therapeutic reverse transcriptase inhibition (concentration at day 85 (percentage of geometric coefficient of variation): 54 mg, 0.135 pmol per 10⁶ cells (27.3); 62 mg, 0.272 pmol per 10⁶ cells (45.2)). Islatravir implants at both doses were safe and resulted in mean concentrations above the pharmacokinetic threshold through 12 weeks, warranting further investigation of islatravir implants as a potential HIV prevention strategy.

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.

Nexplanon failure in a woman with HIV infection in rural Ghana: A case report

Although Nexplanon is one of the most effective and most utilized long-acting reversible contraceptives in Ghana. We report a rare event of Nexplanon failure in a woman with human immunodeficiency virus (HIV) infection in rural Ghana.

Phase 3 Trial of a Small-volume Subcutaneous 6-Month Duration Leuprolide Acetate Treatment for Central Precocious Puberty

CONTEXT

Gonadotropin-releasing hormone agonists (GnRHas) are standard of care for central precocious puberty (CPP). A 6-month subcutaneous injection has recently been approved by the Food and Drug Administration.

OBJECTIVE

Determine efficacy, pharmacokinetics, and safety of 6-month 45-mg subcutaneous leuprolide acetate for CPP.

DESIGN

Phase 3 multicenter, open-label, single-arm study.

SETTING

25 sites in 6 countries.

SUBJECTS

64 GnRHa-naïve children with CPP (age: 7.5 ± 0.1 years) received study drug: 59 completed the study.

INTERVENTION(S)

2 doses of 45-mg subcutaneous leuprolide acetate (0.375 mL) at 0 and 24 weeks; children were followed for 48 weeks.

MAIN OUTCOME MEASURE(S)

Percentage of children with serum luteinizing hormone (LH) <4 IU/L 30 minutes following GnRHa stimulation at week 24.

RESULTS

54/62 (87%) children achieved poststimulation LH <4 IU/L at week 24; 49/56 (88%) girls and 1/2 boys maintained peak LH <4 IU/L at week 48. Mean growth velocity decreased from 8.9 cm/year at week 4 to 6.0 cm/year at week 48. Mean bone age was advanced 3.0 years beyond chronological age at screening and 2.7 years at week 48. Breast pubertal stage regressed or was stable in 97% of girls and external genitalia development regressed in both boys. Adverse events were mild and did not cause treatment discontinuation.

CONCLUSIONS

A small volume of 45-mg subcutaneous leuprolide acetate administered at a 6-month interval effectively suppressed pubertal hormones and stopped or caused regression of pubertal progression. This long-acting GnRHa preparation of leuprolide acetate is a new, effective, and well-tolerated therapy for children with CPP.

Testosterone synthesis in the female songbird brain

Decades of work have established the brain as a source of steroid hormones, termed 'neurosteroids'. The neurosteroid neuroestradiol is produced in discrete brain areas and influences cognition, sensory processing, reproduction, neurotransmission, and disease. A prevailing research focus on neuroestradiol has essentially ignored whether its immediate synthesis precursor - the androgen testosterone - is also dynamically regulated within the brain. Testosterone itself can rapidly influence neurophysiology and behavior, and there is indirect evidence that the female brain may synthesize significant quantities of testosterone to regulate cognition, reproduction, and behavior. In songbirds, acoustic communication is regulated by neuroestrogens. Neuroestrogens are rapidly synthetized in the caudomedial nidopallium (NCM) of the auditory cortex of zebra finches in response to song and can influence auditory processing and song discrimination. Here, we examined the in vivo dynamics of NCM levels of the neuroestrogen synthesis precursor, testosterone. Unlike estradiol, testosterone did not appear to fluctuate in the female NCM during song exposure. However, a substantial song-induced elevation of testosterone was revealed in the left hemisphere NCM of females when local aromatization (i.e., conversion to estrogens) was locally blocked. This elevation was eliminated when local androgen synthesis was concomitantly blocked. Further, no parallel elevation was observed in the circulation in response to song playback, consistent with a local, neural origin of testosterone synthesis. To our knowledge, this study provides the first direct demonstration that testosterone fluctuates rapidly in the brain in response to socially-relevant environmental stimuli. Our findings suggest therefore that locally-derived 'neuroandrogens' can dynamically influence brain function and behavior. SIGNIFICANCE STATEMENT: This study demonstrates that androgen synthesis occurs rapidly in vivo in the brain in response to social cues, in a lateralized manner. Specifically, testosterone synthesis occurs within the left secondary auditory cortex when female zebra finches hear male song. Therefore, testosterone could act as a neuromodulator to rapidly shape sensory processing. Androgens have been linked to functions such as the control of female libido, and many steroidal drugs used for contraception, anti-cancer treatments, and sexual dysfunction likely influence the brain synthesis and action of testosterone. The current findings therefore establish a clear role for androgen synthesis in the female brain with implications for understanding neural circuit function and behavior in animals, including humans.