	Implants: Tools for Providers
October 2007 Issue No. 15	The INFO Project • Johns Hopkins Bloomberg School of Public Health • Center for Communication Programs • 111 Market Place, Suite 310 • Baltimore, Maryland 21202, USA • 410-659-6300 • 410-659-6266 (fax) • www.infoforhealth.org • infoproject@jhuccp.org

Questions and Answers About Implants

The New Implants

1. What are the main differences among the different implants?
The main differences are the number of capsules or rods, the type of progestin that each releases, and how long they can be used before replacement.
Implanon: 1 rod containing 68 mg of etonogestrel. Labeled for 3 years of use.
Sino-Implant (II): 2 rods, each containing 75 mg of levonorgestrel. Labeled for 4 years of use.
Jadelle: 2 rods, each containing 75 mg of levonorgestrel. Labeled for 5 years of use.
Norplant: 6 capsules, each containing 36 mg of levonorgestrel. Labeled for 5 years of use. (Large studies have found it is effective for 7 years.)

2. When will Norplant implants no longer be available?
The manufacturer intends to produce Norplant implants until 2008 and then expects programs to replace Norplant with the newer product, Jadelle. Jadelle is already registered in over 50 countries.

Providing Implants

3. Can young women and older women use implants?
Yes. There is no minimum or maximum age limit. Implants should be removed after menopause has occurred—12 months after a woman’s last monthly bleeding. Implants, like all other hormonal methods, affect bleeding, and so it may be difficult to know if a woman using them has reached menopause. After stopping a hormonal method, a woman can use a nonhormonal method. She no longer needs contraception once she has had no bleeding for 12 months in a row.

Tip: Counselors in Indonesia have explained to their clients: “All women, even those who are old, young, or don’t have children, can use implants safely and effectively. Implants will not cause negative effects to the body, and your fertility will return as soon as they are removed.”

After Insertion

4. Can a woman work soon after having implants inserted?
Yes, a woman can do her usual work immediately after leaving the clinic, as long as she tries not to bump the insertion site or get it wet for 4 days.

5. What can be done about pain or soreness at the insertion or removal site?

Check that the bandage or gauze on her arm is not too tight.
Put a new bandage on the arm and advise her to avoid pressing on the site for a few days.
Give her aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.

6. Do users of implants need to make follow-up visits?
No. Implant users do not need to make any routine follow-up visits. Annual visits may be helpful for other preventive care, but they are not required for use of implants. Of course, women should be invited to return at any time if they have questions or problems.

7. Can implants be left permanently in a woman’s arm?
Leaving the implants in place beyond their effective lifespan is generally not recommended if the woman continues to be at risk of pregnancy. The implants themselves are not dangerous, but, as the hormone levels in the implants drop, they become less and less effective and should no longer be relied on to prevent pregnancy.

Effectiveness

8. How effective are implants compared with other family planning methods?
Implants are among the most effective contraceptive methods—as effective as the IUD, female sterilization, and vasectomy. During the first year of implant use, less than one pregnancy is expected per 100 women using implants (5 pregnancies per 10,000 users). This means that 9,995 of every 10,000 women using implants will not become pregnant in the first year. A small risk of pregnancy remains for as long as a woman continues to use implants.

9. Should heavy women avoid implants?
No, heavier women can use implants, and the implants will be highly effective. These women should know, however, that the effectiveness of Jadelle or Norplant implants may start to drop off sooner than for other women. For example, in studies of Norplant implants, the pregnancy rate among women who weighed 70 to 79 kg was 2 per 100 women in the sixth year of use. Women who want to maintain maximum contraceptive effectiveness should consider having their implants replaced or removed at five years after insertion. Among women who used Norplant or Jadelle implants and who weighed 80 kg or more, the pregnancy rate was 6 per 100 in the fifth year of use. These women can consider having their implants replaced at four years after insertion, especially if they are less than 30 years of age. Keeping the implants in after four years will still offer these women better protection from pregnancy than many other methods. No studies of Implanon have found that effectiveness declines among heavier women within the 3-year lifespan approved for this type of implant.

Side Effects

10. What should be done if bleeding changes are bothering a user of implants?
In the first few months of use, explain that the changes probably will lessen with time. If the bleeding changes continue to bother the client, or if at any time a client asks, offer available treatments such as ibuprofen, mefenamic acid, or oral contraceptives, which may provide some short-term relief from the bleeding changes (see “Counseling About Changes in Monthly Bleeding”). At any time a client finds bleeding changes unacceptable, help her choose a method that better suits her.

Tip: Providers in Egypt counsel their clients by explaining, “The most frequent side effect is disruption of the menstrual cycle, including spotting between periods, amenorrhea, and prolonged bleeding. But, in general, the total monthly blood loss is less than in a normal menstrual period.”

11. What should be done if an implant user has an ovarian cyst?
The great majority of cysts are not true cysts but actually fluid-filled structures (follicles) in the ovary that continue to grow beyond the usual size in a normal menstrual cycle. They may cause some mild abdominal pain, but they require treatment only if they grow abnormally large, twist, or rupture (burst). Usually, these follicles go away without treatment.

Health Issues

12. Do implants cause cancer?
No. Studies have shown no increased risk of any cancer with use of implants when compared with women not using any contraception.

13. Can implants move around within a woman’s body or come out of her arm?
Implants do not move around in a woman’s body. The implants remain where they are inserted until they are removed. Rarely, a rod may start to come out through the insertion site, most often in the first four months after insertion. When this happens, it is usually because the implants were not inserted well or because of an infection where they were inserted. In these cases the woman will see the implants coming out. Also, some women may have a sudden change in bleeding pattern, which could indicate that a rod has come out. If a woman notices a rod coming out, she should start using a backup contraceptive method and return to the clinic as soon as possible.

Tip: Counselors in Indonesia use this message to counsel clients: “Implants will be inserted under the skin on your arm and will not travel to other parts of your body because your skin tissues will keep them in place. Implants contain progesterone hormones that will influence your reproductive organs and therefore they do not cripple your arm or reduce the strength of your hand.”

14. Do implants increase the risk of ectopic pregnancy?
No. On the contrary, implants greatly reduce the risk of ectopic pregnancy. Ectopic pregnancies are extremely rare among implant users. The rate of ectopic pregnancy among women with implants is 6 per 100,000 women per year. By comparison, the rate of ectopic pregnancy among women in the United States using no contraceptive method is 650 per 100,000 women per year.

On the very rare occasions that implants fail and pregnancy occurs, 10 to 17 of every 100 of these pregnancies are ectopic. Thus, the great majority of pregnancies after implants fail are not ectopic. Still, ectopic pregnancy can be lifethreatening, so a provider should be aware that ectopic pregnancy is possible if implants fail.

15. Do implants cause birth defects? Will the fetus be harmed if a woman accidentally becomes pregnant with
implants in place?
No. There is good evidence to show that implants will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using implants or she accidentally has implants inserted when she is already pregnant.

Adapted from: World Health Organization and Johns Hopkins Bloomberg School of Public Health, 2007 (17)

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Implants: Tools for Providers