Progestin Subcutaneous Implant

Aka: Progestin Subcutaneous Implant, Implanon, Nexplanon, Etonogestrel Drug Implant, Progesterone Implant, Contraceptive Implant

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II. Definitions

  1. Progesterone Implant
    1. Subcutaneous inserted Progestin containing rod

III. Precautions

  1. FDA Black Box Warning in 2026 regarding improper insertion or removal
    1. Has been associated with nerve and vascular injury when inserted too deeply
  2. REMS Program is required for insertion or removal in U.S. as of August 23, 2026
    1. REMS Program mandates immediate reporting of complications from insertion or removal
    2. Certification lapses after 3 years from last Nexplanon insertion

IV. Background

  1. Duration: Continuous Contraception for 5 years (previously 3 years)
  2. Progestin: Etonogestrel
  3. Release rate
    1. Initial: 60-70 mcg/day
    2. Tapers to 30 mcg/day
  4. Rod dimensions: (Lenth: 40 mm, Diameter 2 mm)

V. Efficacy

  1. Nexplanon Failure rate: 1 per 2000 users
    1. Failure rate may be higher if >130% of Ideal Weight
    2. Several medications lower efficacy (see below)
    3. Implanon had a higher failure rate (1 in 1000) attributed to insertion technique

VI. Drug Interactions: Medications that lower efficacy

  1. Phenobarbital and other Barbiturates
  2. Phenytoin, Fosphenytoin and other Hydantoins
  3. Carbamazepine
  4. Griseofulvin
  5. Protease Inhibitors
  6. Primidone

VII. Safety

  1. Safe in Lactation
  2. Ovulation resumes within 3 weeks of removal

VIII. Adverse Effects

  1. Weight gain
  2. Acne Vulgaris
  3. Depression or Emotional lability
  4. Irregular Menstrual Bleeding
    1. Amenorrhea most common
    2. Frequent or prolonged bleeding occurs in 23% of patients (unlike IUD, often persists)
    3. Menorrhagia
      1. Bleeding 50% less with Doxycycline 100 twice daily for 5 days
      2. Weisberg (2006) Human Reproduction 21:295-302 [PubMed]
    4. Management
      1. See Depo Provera (DMPA)
  5. Too Deep Insertion
    1. Tissue injury (nerve, vascular)
    2. May require surgical excision
  6. Implant site Skin Infection
    1. Observe for redness, swelling and other infection signs after implant
  7. Traumatic Injury to implant
    1. Implant may break or bend with direct blow to region (e.g. Contact Sports)

IX. Procedure: Insertion (<5 minutes)

  1. No incision needed
  2. Nexplanon comes inn Preloaded applicator
  3. Inserted into subcutaneous skin of arm
  4. Both patient and physician must palpate rod post-insert

X. Procedure: Removal (<10 minutes)

  1. Infiltrate Local Anesthetic under Implanon
  2. Incision of 2-3 mm at distal tip of Implanon
  3. Nexplanon pushed from proximal end into incision
    1. Consider scraping with scalpel
  4. Make incision through fibrous sheeth around Implanon
  5. Remove by grasping Nexplanon rod with forceps
  6. Pearls for difficult removal
    1. Ultrasound if device cannot be palpated
    2. Middle of implant the only palpable part
      1. Make incision over palpable rod and grasp with vas clamp or curved hemostat

XI. Protocol: Switching between contraceptives

  1. Starting Nexplanon
    1. Use pill, patch, ring, or barrier protection for the first 4 days after Implanon insertion
    2. Switch may be made before the scheduled end of use of the prior contraceptive

XII. References

  1. (2026) Presc Lett 33(5): 7-8
  2. Welsh (2006) New Contraceptives, Lecture, Wyoming, MN
  3. Funk (2005) Contraception 71:319-26 [PubMed]
  4. Prine (2018) Am Fam Physician 98(5): 304-9 [PubMed]

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