Tools for Practice


#315 The LARC (long-acting reversible contraception) Song: Is the etonogestrel implant a hit?


CLINICAL QUESTION
How does the etonogestrel implant (Nexplanon®) compare to other long-acting reversible contraception?

BOTTOM LINE
Etonogestrel implant (Nexplanon®) is effective with 0-0.34 pregnancies per 100 women per year. In one randomized controlled trial (RCT), the implant had a higher discontinuation rate (27% versus 20%), more amenorrhea (29% versus 9%) and lower patient satisfaction (66% versus 80%) than a low-dose levonorgestrel intrauterine device.


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EVIDENCE
  • No statistical analysis unless mentioned.
  • One systematic review, 51 studies, only one RCT looking at etonogestrel implant versus other contraception.1 68mg etonogestrel implant (Nexplanon®) versus 13.5mg levonorgestrel intrauterine device (IUD) (Jaydess®) over 12 months (766 women).2
    • Pregnancies: 0 versus 3 (IUD).
    • Discontinuation: 27% versus 20% (IUD) (statistically different), mostly due to adverse events [examples increased bleeding 11% versus 3% (IUD), acne 5% versus 3% (IUD)].
    • Patient satisfaction: 66% versus 80% (IUD) (statistically different).
    • Amenorrhea: 29% versus 9% (IUD).
    • Prolonged bleeding: 16% versus 5% (IUD).
    • “Normal bleeding pattern”: 4% versus 31% (IUD).
    • Limitations:
      • IUD manufacturer funded.
      • Available IUDs in Canada are higher dose.
  • Integrated analysis, 11 non-controlled trials assessed bioequivalent etonogestrel implant (Implanon®) over 2-4 years (942 women, 18-40 years old).3
    • Pregnancy in six women, conception presumed to be following implant extraction (0.34 pregnancies per 100 women per year).
    • Adverse events leading to discontinuation: Bleeding irregularities (11%), emotional lability (2%), weight gain (2%), headache (2%), acne (1%), and depression (1%).
    • Insertion and removal complications 1% and 2%, respectively.
    • Limitations: Industry funded, not a systematic review.
  • Non-comparative trial of etonogestrel implant (Nexplanon®) for 3 years (301 women, mean age 28) found similar efficacy and adverse events.4
    • Average weight gain 1.4kg at 36 months.
  • Similar efficacy5 and insertion/removal complications6 in observational studies.
Context
  • Nexplanon® is a subcutaneous, radio-opaque, matchstick-sized flexible rod that lasts 3 years.7,8
    • Costs ~$310 versus ~$370 for hormonal IUDs which last 5 years.7
  • Training required for insertion and removal.8
  • Cases of pulmonary migration, infections, barium allergic reactions, and insertion-related neuropathies have been reported.9 No effect observed on bone mineral density.10,11

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Author(s):

  • Jessica Kirkwood MD CCFP (AM)
  • Nicolas Dugré PharmD MSc BCPAC
  • Nidhi Choksi BScPharm

1. Moray KV, Chaurasia H, Sachin O, et al. Reprod Health. 2021; 18(1):4.

2. Apter D, Briggs P, Tuppurainen M, et al. Fertil Steril. 2016; 106(1):151-157.e5.

3. Darney P, Patel A, Rosen K, et al. Fertil Steril. 2009; 91(5):1646-53.

4. Mommers E, Blum GF, Gent TG, et al. Am J Obstet Gynecol. 2012; 207(5): 388.e1-6.

5. Winner B, Peipert JF, Zhao Q, et al. N Engl J Med. 2012; 366(21):1998-2007.

6. Reed S, Do Minh T, Lange JA, et al. Contraception. 2019; 100(1):31-36.

7. Be Ready to Answer Questions About Nexplanon Contraceptive Implant. Pharmacist's Letter Canada. October 2020, No. 361018. https://ca-pharmacist.therapeuticresearch.com/Content/Articles/PLC/2020/Oct/Be-Ready-to-Answer-Questions-About-Nexplanon-Contraceptive-Implant (Accessed Feb 17, 2022).

8. Organon Canada. Product monograph: Nexplanon. April 2021. https://www.merck.ca/static/pdf/NEXPLANON-PM_E.pdf (Accessed Feb 17, 2022).

9. Rocca ML, Palumbo AR, Visconti F, et al. Pharmaceuticals (basel). 2021; 14(6):548.

10. Beerthuizen R, van Beek A, Massai R, et al. Human Reproduction. 2000; 15(1):118-22.

11. Modesto W, Dal Ava N, Monteiro I, et al. Arch Gynecol Obstet. 2015; 292(6):1387-91.

Authors do not have any conflicts of interest to declare.