Altered bleeding patterns

Altered bleeding patterns occur in all users of the etonogestrel implant. Blood loss overall is less than menstruation, and amenorrhoea occurs in 20% of users. Frequent bleeding occurs in 7% of users, and prolonged bleeding occurs in 18% of users. Altered bleeding patterns may settle as the serum etonogestrel concentration drops during the first 3 months of use.

Consider other causes of bleeding, such as pregnancy, sexually transmitted infections (eg chlamydia), drugs that induce liver enzymes, and vaginal, cervical or uterine pathology. If no other cause of bleeding is suspected, reassure the user that bleeding can be expected and is not harmful.

Many users wish to continue the implant and have medical management for frequent or prolonged bleeding. Evidence for medical management is limited; options include adding:

• a combined hormonal contraceptive, taken continuously or cyclically for up to 3 months (or longer on a case-by-case basis, although this has not been studied and data on effectiveness and risks are lacking)
• a 5-day course of a nonsteroidal anti-inflammatory drug (NSAID) or (if bleeding is heavy) tranexamic acid; see Heavy menstrual bleeding for dosages.

Other options (with low-level, anecdotal or conflicting evidence) include adding oral norethisterone (see Heavy menstrual bleeding for dosage), a levonorgestrel progestogen-only pill (twice daily for 20 days), or replacing the implant.