Follow up, removal, and management of problems

• Advise additional contraception for seven days if necessary.
• Give wound care instructions at time of insertion.
• Advise to take simple analgesia if required.
• Routine post-insertion follow up is not necessary. Women should be advised to return at any time to discuss problems or if they want to change their contraceptive method.
• Advise women to return if they:
• cannot feel the implant
• notice any change in shape or changes to the skin around the site of the implant
• experience any pain
• become pregnant or develop any condition that would contraindicate its use.

Timing of removal

Implants work by preventing ovulation. Contraceptive cover is present until the device is removed, irrespective of when last sexual intercourse occurred. Any sexual intercourse after removal must be covered by an alternative method of contraception if pregnancy is to be avoided.

Timing of change

If an implant is removed prior to its licence limit (3 years) and another implant reinserted immediately, there is no need for additional contraceptive precautions.

An implant that has been in situ between 3 and 4 years can be changed if a pregnancy test is negative. If there has been UPSI in the past 3 weeks a repeat pregnancy test should be considered 21 days after the UPSI.

Management of bleeding problems with progesterone implants

• A sexual history should be taken from women who experience unacceptable bleeding while using the implant to establish STI risk.
• Investigation for gynaecological pathology may be clinically indicated, i.e., inspection of the cervix is recommended to exclude local causes.
• Only perform a cervical smear test if it is due.
• There is very little evidence supporting the use of any particular drug regimen in the management of persistent unacceptable bleeding patterns with implant use. Women who are eligible may be offered a COC cyclically or continuously for 3 months (outwith the product Licence).

If other pathology is excluded or treated, the client can be reassured that irregular bleeding patterns is an expected side effect of an implant, but she should report any further changes.

Deep implant/Lost implant

Women with an impalpable implant should be advised to use additional precautions or avoid intercourse until presence of the implant is confirmed.

If the implant is impalpable, no attempt should be made to remove it. The client should be referred for ultrasound location.

High frequency linear ultrasound remains the recommended first line imaging technique for locating a non palpable or deep implant. Nexplanon is radio-opaque and can be seen on X-ray.

Deeply inserted implants may need to be removed by an expert and should be referred to the local expert removal centre.

If after imaging the implant cannot be located then advice from a Senior Clinician should be sought to see whether blood levels for etonorgestrel need performed.