While use of long-acting reversible contraceptive (LARC) methods is growing, the contraceptive implant (Nexplanon, Merck & Co., Whitehouse Station, NJ) is still underused, say family planning experts. Look at the most recent national figures: In 2009, 8.5% of women using contraceptives relied on LARC methods, rising from 5.5% in 2007 and 2.4% in 2002. However, most of these women (nearly 8%) use intrauterine devices (IUDs), compared to less than 1% who use the implant.1
About one-third of participants (32.3%) in the 2014 Contraceptive Technology Update Contraception Survey reported more than 25 implant insertions in the past year. In 2013, about 75% of survey respondents said their facility offered or planned to offer the implant, which is a 10% jump from 2012.
“It is really shocking that more than a decade after the introduction of this enormously effective, extraordinarily safe, and conspicuously convenient method, we are pleased that only one-third of clinicians dedicated to family planning [participants in the CTU survey] place at least one implant every other week,” says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department, David Geffen School of Medicine, University of California, Los Angeles. “Imagine how underutilized the implants are by primary care providers.”
What will increase usage?
What will it take to change what Nelson terms “this tragic picture of underutilization”? One move might be to increase clinician education and training on implant insertion and usage of the method.
According to a survey of fellows in the American College of Obstetricians and Gynecologists, most providers generally offer IUDs, but fewer offer the contraceptive implant.2 Almost all (92%) reported residency training on IUDs, while about 51% reported residency training on implants.2
A total of 59.6% of providers surveyed said they had received continuing education on at least one LARC method in the past two years. Recent continuing education was most strongly associated with implant insertion, and 31.7% of those responding to the survey listed lack of insertion training as a barrier.2
Nelson, who presented information on the implant at the 2014 Contraceptive Technology conference in Atlanta, points to the leading benefits of the device:
* unsurpassed contraceptive efficacy;
* rare medical contraindications;
* rapid reversibility.3
In international trials of the device, zero pregnancies were recorded in 58,900 cycles, Nelson notes.4 The device is labeled for three years of effective use; however data indicate its effectiveness might be longer than that.5
Numbers may improve
Nexplanon usage at El Paso County Department of Health and Environment in Colorado Springs was implemented with private donor funding to Title X, says Ingrid Silva, ANP, clinical manager at the facility. The funding is part of the Colorado Family Planning Initiative. Made by a confidential private donor, it is distributed through the Colorado Department of Public Health and Environment’s Title X Family Planning Program. The Initiative has addressed barriers to LARC methods by training providers, financing method provision at Title X-funded clinics, and increasing patient caseload. Research indicates the Initiative has been successful. In two years, caseloads increased by 23%, and LARC use among 15- to 24-year-olds grew from 5% to 19%. Cumulatively, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008. Compared with expected fertility rates in 2011, observed rates were 29% lower among low-income 15- to 19-year-olds and 14% lower among similar 20- to 24-year-olds, data suggests.6
Silva credits the popularity of implant in the younger woman who does not want a cycle; young peers getting the implant, who in turn influence other teens to get the device; and teens who like the idea of the device being implanted in the arm versus anything placed in the vagina or uterus.
“Some other clinics learn we have the grant for LARC methods and send their patients to us for the IUD or implant,” notes Silva.
Counsel on bleeding
One of the downsides of implant use is irregular bleeding. Patients at El Paso County Department of Health and Environment either love the implant or want it out because they don’t like their bleeding profile, reports Silva.
According to a fact sheet issued by the Association of Reproductive Health Professionals, some women might have heavy and/or longer periods, while other women have periods that are lighter and occur less often. Some women stop getting their period all together. (Download a free patient sheet on the implant, in English and Spanish, at http://bit.ly/1eSUbxO)
Counsel women on what to expect with implant bleeding patterns, says Nelson. “Irregular bleeding improves with time for the majority of women,” she notes.
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Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007-2009. Fertil Steril 2012; 98(4):893-897.
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Luchowski AT, Anderson BL, Power ML, et al. Obstetrician-gynecologists and contraception: long-acting reversible contraception practices and education. Contraception 2014; 89(6):578-583.
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Nelson AL. Focus on the contraceptive implant: easy and effective, but underutilized? Presented at the Contraceptive Technology conference. Atlanta; October 2014.
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Darney P, Patel A, Rosen K, et al. Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials. Fertil Steril 2009; 91(5):1646-1653.
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Raymond EG. Contraceptive implants. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
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Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014; 46(3):125-
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