This month’s JFPRHC had a short but useful article on the management of irregular bleeding with etonorgestrel implants. The authors sensibly pointed out that it’s wise to be fairly proactive in management – a ‘wait and see’ attitude can have the unwanted consequence of using up the woman’s patience before any treatment has been tried and leading to a request for implant removal. Recommended treatments are:
- For women who are eligible for oestrogen, the COC (for three months initially, but can be given throughout the duration of implant use if symptoms persist). Progestagenic pills such as Microgynon are advisable, although the article didn’t explain why.
- For women not eligible for oestrogen, try an NSAID such as mefenamic acid.
- If short-term arrest of bleeding is required, high-dose progestogens such as norethisterone 5 mg tds can be used.
Comments on other treatments:
- Desogestrel, which is often recommended, may be useful if bleeding which has been stable then becomes troublesome further into implant use, but can actually worsen initial irregular bleeding by contributing to the endometrial instability.
- There are theoretical reasons to think doxycycline might be helpful, but the only RCT done found the benefits not to be significant.
- Tranexamic acid has no role in treatment of irregular bleeding.
(Dickson, Hoggart and Newton. Unanticipated bleeding wtih the etonorgestrel implant: advice and therapeutic interventions. J Fam Plann Reprod Health Care 2014; 40: 158 – 160.)