Implant

Question 1

Who is the implant NOT suitable for?

Answer 1

• anyone taking liver enzyme inducing drugs
• previous hormone dependent cancer in last 5 years
• severe decompensating liver disease or liver tumours
• sensitivity to any of the components of the implant
• development of IHD/stoke with implant in
• unexplained vaginal bleeding

Question 2

What is the mechanism of action of the implant?

Answer 2

• MAIN: inhibits ovulation by suppressing LH (though up to 5% of patients may ovulate in the 3rd year of use)
• also thickens cervical mucus, induces endometrial atrophy and can modify sperm function and motility

Question 3

What medications may interact with the implant?

Answer 3

• liver enzyme inducers: certain ARVs, antibiotics (rifampicin), anti-epileptics (carbamazepine, phenytonin, topiramate, lamotrigine), st john’s wort

Question 4

What are the advantages of the implant?

Answer 4

• long lasting, effective and immediately reversible
• can be used in women with previous ectopic
• no effect on future fertility
• no adverse risk to foetus if does get pregnant
• no oestrogen effects
• high user acceptability - first year continuation >70%
• requires little medical attention
• may reduce ovulation pain and dysmenorrhoea
• reduced total menstrual loss
• no evidence of bone mineral density reduction
• no increased risk of VTE, MI or stroke

Question 5

What are the disadvantages of the implant?

Answer 5

• unpredictable and irregular bleeding patterns
• can cause enlarged ovarian follicles (and these patients are more likely to experience prolonged bleeding)
• progestogen side effects: headache, weight gain, acne, loss of libido, mood changes
• risk of fat atrophy at site of implant
• requires minor operative procedure with local anaesthetic
• risk of non-palpable implants can cause damage to neurovascular bundle
• mild discomfort and bruising following insertion/removal
• risk of infection, irritation, breakage of implant, local fibrosis, migration of implant and scarring
• discontinuation not under the patient’s control
• lack of studies re: risk of breast ca or gynaecological ca

Question 6

What should be advised for women who cannot feel their implant?

Answer 6

• abstain from sex or use another method of contraception
• do not attempt removal
• arrange an x ray of the arm - if visible, then it is effective as contraception. if it cannot be seen, a CXR should be taken
• if removal is requested, refer to regional centre providing deep implant removals - high res USS is used to locate the implant
• if the implant cannot be found, the manufacturer can arrange an etonogestrel assay

Question 7

What to do for late implant removals?

Answer 7

• if >3yrs has passed, risk of pregnancy is small. PT should be performed and if negative, implant cane be changed and patient should use condoms for 7 days
• repeat PT in 3 weeks
• Unlikely necessary to need EC if implant inserted <4 yrs ago

Question 8

How long is the delay in return to fertility?

Answer 8

There is no delay - most women ovulate within 3 weeks of removal

Question 9

What is the name and dose of the implant

Answer 9

Etonergestrel 68mg