The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
Which women are eligible to use progestogen-only implants?
- Health professionals should be familiar with the United Kingdom Medical Eligibility Criteria (UKMEC) for progestogen-only implant use (Good Practice Point).
Table: Definitions of UK Medical Eligibility Criteria for Contraceptive Use Categories
| UKMEC Definition of Category |
| Category |
|
| UKMEC 1 |
A condition for which there is no restriction for the use of the contraceptive method. |
| UKMEC 2 |
A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. |
| UKMEC 3 |
A condition where the theoretical or proven risks usually outweigh the advantages of using the method.a |
| UKMEC 4 |
A condition which represents an unacceptable health risk if the contraceptive method is used. |
aThe provision of a method to a woman with a condition given a UKMEC Category 3 requires expert clinical judgement and/or referral to a specialist contraceptive provider since use of the method is not usually recommended unless other methods are not available or not acceptable.
What should a clinician assess when considering use of a progestogen-only implant?
- A medical history (including sexual history) together with consideration of the recommendations in the UKMEC should be used to assess the appropriateness of the progestogen-only implant (Good Practice Point).
What information should be given to a woman when counseling her about a progestogen-only implant?
Mode of Action
- Women should be informed that the primary mode of action of the progestogen-only implant is prevention of ovulation (Grade B).
Duration of Use
- Women can be advised that the duration of use for the progestogen-only implant is 3 years (Grade C).
Contraceptive Efficacy
- Women should be advised that the pregnancy rate associated with use of a progestogen-only implant is very low (<1 in 1000 over 3 years) (Grade B).
- Women should be advised that the overall risk of ectopic pregnancy is reduced when using progestogen-only implants when compared to using no contraception (Grade B).
- Women with a body mass index (BMI) >30 kg/m2; can use a progestogen-only implant without restriction and without a reduction in contraceptive efficacy for the duration of the licensed use (Grade C).
Return of Fertility
- Women should be informed that there is no evidence of a delay in return of fertility following removal of a progestogen-only implant (Grade B).
Side Effects
Bleeding
- Women should be informed about the likely bleeding patterns that may occur with a progestogen-only implant (Grade C).
- Women should be advised that 20% of users will have no bleeding, while almost 50% will have infrequent, frequent or prolonged bleeding and that bleeding patterns are likely to remain irregular (Grade C).
Weight Change, Mood Change, Loss of Libido
- Women should be advised that there is no evidence of a causal association between use of a progestogen-only implant and weight change, mood change or loss of libido (Grade C).
Acne
- Women should be advised that acne may improve, occur or worsen during the use of a progestogen-only implant (Grade C).
Headache
- Women should be advised that there is no evidence of a causal association between use of a progestogen-only implant and headache (Grade C).
- Women of any age with a history of migraine (with or without aura) may use progestogen-only implants (Grade C).
- Women who develop new symptoms of migraine without aura while using progestogen-only implants may continue the method (UKMEC 2) (Grade C).
- Women who develop new symptoms of migraine with aura while using progestogen-only implants should be advised to seek medical advice as investigation may be appropriate. Continued use of progestogen-only implants may be considered (UKMEC 3) (Grade C).
Discontinuation
- Clinicians should be aware that early discontinuation (up to 43% within 3 years) of progestogen-only implants is common (Grade C).
Health Concerns
Venous Thromboembolism
- Women should be informed that evidence suggests there is little or no increase in risk of venous thromboembolism associated with use of a progestogen-only implant (Grade C).
Bone Mineral Density
- Women should be informed that there is no evidence of a clinically significant effect on bone mineral density with use of a progestogen-only implant (Grade B).
Breast Cancer
There are insufficient data to make an evidence-based recommendation concerning the effect of progestogen-only implants on breast cancer risk.
Drug Interactions
- Women using liver enzyme-inducing drugs short term (<3 weeks) may choose to continue with a progestogen-only implant. Additional contraceptive protection, such as condoms, should be used and until 4 weeks after the liver enzyme-inducing drug has been stopped. Information should be given on the use of alternative contraception if liver enzyme-inducing drugs are to be used long term (Good Practice Point).
- Women should be informed that the efficacy of a progestogen-only implant is not reduced by non-liver enzyme-inducing antibiotics and that additional contraceptive protection is not required (Grade C).
When can a progestogen-only implant be safely inserted?
Insertion of Progestogen-only Implants in Special Circumstances
Postpartum
- Progestogen-only implants can safely be used by women who are breastfeeding (Grade C).
- Women can have a progestogen-only implant inserted up to and including Day 21 postpartum with immediate contraceptive protection. If inserted after Day 21 then condoms or abstinence should be advised for 7 days (Grade C).
Following Abortion or Miscarriage
- A progestogen-only implant can be inserted immediately following surgical abortion or (second part of) medical abortion or miscarriage; no additional contraction is required. If inserted >5 days after abortion or miscarriage then condoms or abstinence should be advised for 7 days (Grade C).
Table: Recommendations for Timing of Insertion of a Progestogen-only Implant as Long-term Contraception
| Circumstances when progestogen-only implant is to be inserted |
Recommendations for timing of insertion |
| General Insertion |
Ideally, an implant should be inserted between Days 1 and 5 (inclusive) of a normal menstrual cycle. No additional contraception is required.
- An implant can be inserted at any other time in the menstrual cycle if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. Additional contraception (barrier method or abstinence) should be advised for 7 days after insertion.
- If the woman is amenorrhoeic, the clinician must be reasonably certain that the woman is not pregnant and that there is no risk of conception; additional contraception should be used for 7 days.
|
| Postpartum |
An implant can be inserted up to Day 21 postpartum with immediate contraceptive cover. If inserted after Day 21, then condoms or abstinence should be advised for 7 days. Insertion can be prior to Day 21 but bleeding may be a problem (unlicensed use). |
| Following miscarriage or abortion |
Insert on day of surgical or second part of medical abortion or immediately following miscarriage: no additional method required. If started >5 days after abortion or miscarriage additional contraception is required for 7 days (as for general insertion). |
| Switching from another method of contraception |
| Combined hormonal contraception (CHC) |
| Progestogen-only pill (POP) |
| Progestogen-only implant |
| Progestogen-only injectable |
| Levonorgestrel-releasing intrauterine system (LNG-IUS) |
| Copper-bearing intrauterine device (IUD) |
| Barrier method (i.e. male condom, female condom, cap or diaphragm) |
|
| |
| Can be inserted immediately if CHC has been used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. No additional contraception is required. |
| Can be inserted immediately if POP has been used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. No additional contraception is required. |
| Can be inserted immediately if previous implant was used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. No additional contraception is required. |
| Should be inserted when the repeat injection was due (or up to 14 weeks since last injection). No additional contraception is required. |
| Can be inserted immediately if LNG-IUS was used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant. If it is more than 5 days after the start of menstrual bleeding the LNG-IUS should be retained until the time of the woman's next menstrual period or if the woman is amenorrhoeic the LNG-IUS can be removed 7 days or more after insertion of the implant. |
| Can be inserted immediately if IUD was used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant. If it is more than 5 days after the start of menstrual bleeding the IUD should be retained until the time of the woman's next menstrual period. |
| Can be inserted immediately if barrier method has been used consistently and correctly or if the clinician is reasonably certain that the woman is not pregnant and that there is no risk of conception. If the woman is amenorrhoeic or it has been more than 5 days since menstrual bleeding started, additional contraception should be continued for 7 days. |
|
Implant Insertion
Training Requirements
- Health professionals who insert (and remove) progestogen-only implants should be appropriately trained, maintain competence and attend regular updates (Grade C).
Emergency Services for Insertions and Removals
- Emergency equipment must be available in all settings where subdermal contraception is inserted/removed and local referral protocols must be in place for women who require further medical input (Grade C).
Note: See Table 3 in the original guideline document "Emergencies and insertion of subdermal implants: resuscitation measures and contents of an emergency pack".
Practical Procedures for Implants
Insertion Site
Implanon should be inserted at the inner side of the upper arm (non-dominant arm) about 6–8 cm above the elbow crease in the groove between the biceps and the triceps (sulcus bicipitalis medialis).
Aseptic Precautions and Sterile Gloves
- An aseptic technique should be used for the insertion and removal of a progestogen-only implant (Good Practice Point).
Local Anaesthesia
- Appropriate anaesthesia should be injected prior to insertion and removal of a progestogen-only implant (Good Practice Point).
Antibiotic Prophylaxis for Implant Procedures
- Use of prophylactic antibiotics to prevent endocarditis is not recommended for progestogen-only implant insertion or removal (Good Practice Point).
Documentation
Recommendations from the Faculty of Sexual and Reproductive Healthcare (FSRH) for record keeping specific to progestogen-only implant insertion are summarised in Box 1 of the original guideline document.
What information should be given to implant users about continuation and follow-up?
Follow-up
- Women using implants should be advised that no routine follow-up is required, but that they can return at any time to discuss problems or if that want to change their contraceptive method (Grade C).
Signs and Symptoms Requiring Medical Attention
- Women using a progestogen-only implant should be advised to return if: they cannot feel their implant or it appears to have changed shape; they notice any change to the skin or pain around the site of the implant; they become pregnant; or they develop any condition which may contraindicate continuation of the method (Good Practice Point).
Reducing the Risk of Sexually Transmitted Infections (STIs)
- If a woman chooses a progestogen-only implant and is at higher risk of STIs (aged <25 years, or > 25 years with a new sexual partner, or more than one partner in the last year) she should be advised to use condoms in addition (Grade C).
Managing Problems Associated with Progestogen-only Implant Use
Problematic Bleeding
- Women who experience problematic bleeding while using a progestogen-only implant should have a sexual history taken to establish STI risk and/or be investigated for gynaecological pathology if clinically indicated (Grade C).
- Women who experience problematic bleeding while using a progestogen-only implant and who have had gynaecological pathology excluded may be offered mefenamic acid or ethinylestradiol (alone or as an oral contraceptive) for treatment (Grade C).
Pregnancy
- There is no evidence of a teratogenic effect of a progestogen-only implant, but if a user becomes pregnant and continues with the pregnancy then the implant should be removed (Grade C).
Implant Removal and Replacement
- Women should be advised that fertility may return immediately after progestogen-only implant removal and effective contraception is required if pregnancy is not desired (Grade B).
- Women who do not wish to have a pregnancy can be reassured that abstinence, additional contraceptive protection or emergency contraception is not necessary prior to implant removal as long as they return within 3 years, have immediate replacement or immediately start another method of contraception (Good Practice Point).
Complications with Removal
- If difficulty arises with progestogen-only implant removal (due to deep insertion, failed insertion or migration) it should be localised by ultrasound before being removed. Deeply inserted implants often need to be removed by an expert (Good Practice Point).
Definitions:
Grades of Recommendations
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the multidisciplinary group
