On this page
Referral and warning signs
When to refer
Refer to trained provider for insertion/removal. Refer if: Contraindications identified, Complications occur (infection, expulsion, difficult removal), Severe/unacceptable side effects, Need for alternative method due to drug interactions.
Red flags
- Signs of infection at insertion site (pus, spreading redness, persistent pain)
- Partial or complete expulsion of implant
- Signs of nerve injury after insertion (persistent numbness, tingling, weakness distal to site)
- Suspected pregnancy
Signs and symptoms
- Common Side Effects: Changes in bleeding pattern (irregular bleeding, spotting, infrequent bleeding, amenorrhoea - very common, unpredictable), Headaches, Weight changes (gain or loss), Acne, Breast tenderness, Mood changes, Dizziness.
- Local reactions: Pain, bruising, swelling, itching at insertion site (usually mild/transient). Infection or expulsion (rare).
- Warning signs: Signs of infection at insertion site (pus, increasing redness/pain), Implant expulsion, Severe persistent headaches, Signs of VTE (very rare).
Risk factors
- Contraindications (MEC Category 4): Current Breast Cancer.
- Relative Contraindications (MEC Category 3): Past breast cancer >5yrs ago, Severe liver disease (active/tumour), Unexplained vaginal bleeding (initiation concern), History IHD/Stroke (initiation concern), SLE with positive antiphospholipid antibodies, Certain drug interactions (Rifampicin, some anticonvulsants reduce efficacy).
Diagnosis
Clinical assessment
Eligibility assessment based on medical history and MEC guidelines. Suitable for women desiring highly effective, long-term, reversible contraception.
Investigations
- Rule out pregnancy before insertion.
- Assess for contraindications via history.
Diagnostic criteria
Client meets medical eligibility criteria for implant use.
Management
Non-pharmacological management
- Counseling: Explain mechanism, high effectiveness, duration (3 or 5 years), insertion/removal procedure, common side effects (esp. unpredictable bleeding), lack of STI protection.
- Skilled Insertion: Requires trained provider using aseptic technique.
- Skilled Removal: Requires trained provider, may be difficult if inserted deeply.
Pharmacological treatment
- Insertion: Subdermal placement in non-dominant upper arm after local anaesthetic.
- Timing: Can insert any time if reasonably sure not pregnant. If >5 days after LMP start, use backup for 7 days.
- Management of Side Effects:
- - Irregular Bleeding/Spotting/Amenorrhoea: Reassurance is key (common, not harmful). Rule out pregnancy/pathology if significant change. NSAIDs (Ibuprofen) or short course COC/estrogen may be tried for troublesome bleeding (specialist advice), but often ineffective long-term. Removal may be requested if unacceptable.
- - Headache/Mood changes/Weight gain etc: Manage symptomatically. Reassure often unrelated or transient. Consider removal if severe/persistent.
- - Insertion Site Infection: Clean area, oral antibiotics (cover Staph aureus). Do NOT remove implant initially unless severe infection/abscess/expulsion. Refer if no improvement.
- Drug Interactions: Reduced effectiveness with enzyme inducers (Rifampicin, some anticonvulsants). May need alternative method.
Monitoring
Check insertion site after 1-2 weeks. Routine follow-up annually or as needed for concerns/side effects. Check removal date.
Complications
- Irregular bleeding patterns (most common reason for discontinuation).
- Insertion/removal difficulties (deep placement, fibrosis, broken rod).
- Infection at insertion site (rare).
- Expulsion of implant (rare).
- Nerve or vessel injury during insertion/removal (rare).
Prevention
- Proper insertion technique by trained provider.
- Aseptic technique.
- Appropriate screening using MEC.
Patient education
- High effectiveness and duration.
- How it works, insertion/removal process.
- Expect changes in bleeding pattern (unpredictable).
- Other potential side effects.
- Does not protect against STIs/HIV.
- When implant needs removal/replacement.
- How to check implant presence.
- Warning signs to report.
Uganda-specific notes
Increasingly popular LARC method. Implanon NXT (3-year, single rod) and Jadelle (5-year, two rods) commonly used. Requires specific training for insertion and removal. Counseling about bleeding changes is crucial for acceptance and continuation.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15, Section 15.2.6