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Add subdermal implant to options for teens
By Anita Brakman, MS
Director of Education, Research & Training
Physicians for Reproductive Choice and Health
New York City and
Melanie Gold, DO, FAAP, FACOP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
Most adolescents who use contraception rely on combination oral contraceptive pills.1 Unfortunately, this method poses challenges in daily maintenance. Both the transdermal patch and vaginal ring entail less maintenance, yet still require patients to remember when to remove the method and replace it on the skin or in the vagina on a weekly or monthly basis, respectively. Therefore, long-acting reversible contraceptive (LARC) methods that are provider-inserted and require less user maintenance may be especially useful to adolescent patients who are looking to postpone childbearing for several years.
As reported in this issue of Contraceptive Technology Update, the American Congress of Obstetricians and Gynecologists (ACOG) recently released a practice bulletin on LARC methods focusing on intrauterine devices and implants.2 In addition, much has been written about the benefits of intrauterine contraception for teens and other nulliparous women.3-5
Less has been written, however, about the contraceptive implant. Use of this method is not even tracked by the National Survey of Family Growth, the major data source on contraceptive use in the United States, which makes it difficult to assess how well the method is being utilized by adolescents and older women.
The only contraceptive implant available in the United States is Implanon (Merck & Co., Kenilworth, NJ), a single-rod device approved by the Food and Drug Administration in 2006. Implanon is placed as an outpatient procedure subdermally in the upper arm, releases 68 mg of etonorgestrel over time, and prevents pregnancy for up to three years. The implant is 99% effective at preventing pregnancy, and this rate is the same for perfect and typical use, as there is no room for user error once the device is inserted. The mechanisms of action include inhibiting ovulation, as well as thickening cervical mucus.6
Check the advantages
Implants have few contraindications and might be especially appropriate for women who have medical conditions that contraindicate using estrogen-based methods.7 The method's discreet nature might benefit some adolescents who wish to keep their contraceptive use private from parents, partners, or others. The implant is not visible; however it is palpable in the upper arm, and hyperpigmentation of the skin over the rod has been reported.
The initial cost of insertion is $400-$800, which might be prohibitive for many teens or any women with low income or no insurance coverage. Nevertheless, over time the method costs less than short-term hormonal methods that require ongoing refills or injections.
In addition to their contraceptive benefits, implants might decrease acne. A two-year study investigating contraceptive efficacy and tolerability of Implanon among women ages 18-40 noted 61% of those with acne at insertion reported improvement over the two years. However, 14% of participants who reported no acne at baseline reported having acne at the end of the two-year study. The severity of these changes was not reported.8
Counsel on bleeding
One side effect of implants that adolescents might find difficult to deal with is irregular menstrual bleeding. This irregularity can include more or less frequent bleeding, bleeding for longer or shorter duration, or amenorrhea.
A small chart review of 12-24 year old implant users revealed 22% of participants experienced bleeding problems leading to removal.9 Other rare adverse events reported in trials include effects similar to other hormonal methods.10
Adolescents also might be particularly concerned about weight gain occurring after implant insertion, similar to their concern of weight gain with other methods. Participants in clinical trials reported a mean weight gain of 2.8 pounds at the end of the first year and 3.7 pounds at the end of the second year of implant use.10 In a more recent study, weight gain was reported by 12.7% of participants over two years. In 95% of these cases, gains were considered to be related to the implant.8 However, no study of the method's effect on weight has included a control group for comparison.
While little research has focused on this method in the wider adolescent population, several articles have assessed and found the method to be a safe and effective for adolescent mothers.11-12
The most important aspect of counseling female adolescents about this option it to discuss the likelihood, extent, and tolerability of potential bleeding irregularities, because these irregularities are a major reason for implant discontinuation among adult women.13 Ask adolescent women how they will cope with bleeding changes and how much abnormal bleeding they can tolerate. The implant does not protect against sexually transmitted infections, so counseling should include ways to facilitate condom use.
The implant might be a particularly good choice for female adolescents who wish to delay childbearing for three years. If this time frame fits with an adolescent's childbearing plans, and she is comfortable with the idea of an implant and possible bleeding irregularities, this option might be a better choice than shorter-acting or intrauterine methods.