Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting

doi:10.1016/j.contraception.2016.02.030

Contraception

Volume 94, Issue 1, July 2016, Pages 81-86

https://doi.org/10.1016/j.contraception.2016.02.030 Get rights and content

Abstract

Objective

The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation.

Study design

A retrospective chart review identified adolescent females aged 12 to 22 years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12 months) and ENG continuers (continued for ≥ 12 months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ²/Fisher's Exact Tests and backwards stepwise logistic regression.

Results

Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12 months of use. The mean length of implant use for those who discontinued was 7.5 months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥ 1 medical visit for implant concerns (not including removal) were independently predictive (p < .01) of method discontinuation.

Conclusion

The vast majority of adolescents continued the ENG implant at 12 months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers.

Implications

The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Introduction

Despite recent declines, the United States leads the developed world in teen births [1], [2], [3]. US adolescents have unacceptably high rates of pregnancy (~ 4/5 unintended) and birth [4], [5]. Low use of highly effective contraceptive methods contributes to high teenage pregnancy rates [6], [7]. In 2013, only 25.3% of sexually active high school students reported use of a hormonal contraceptive or intrauterine device (IUD) at last intercourse [8]. American teens who do use contraceptives predominantly rely on pills and condoms, which are relatively less effective but more commonly prescribed [6], [9], [10]. Only a small minority of teens use long-acting reversible contraceptives (LARCs), the most effective methods available. In 2011–2013, approximately 5% of adolescent and young adult women aged 15–24 using birth control chose a LARC method [11].

LARC methods demonstrate first-year failure rates of 0.8%, 0.2% and 0.05% for the levonorgestrel intrauterine system, copper IUD and etonogestrel (ENG) implant, respectively [9]. Prior studies have established the superior effectiveness, safety and acceptability of IUDs and the ENG implant for adolescent females [12], [13], [14]. The Institute of Medicine and the Centers for Disease Control and Prevention identify reducing unintended and teen pregnancy as a national priority and call for increased utilization of LARCs [15], [16]. In September 2014, the American Academy of Pediatrics recommended that LARCs be first-line contraceptive choices for adolescents [17].

Improving adolescents' access to LARCs in the primary care pediatric office setting could increase uptake of LARC methods by adolescents and lead to significant reductions in teen pregnancy [18], [19]. The ENG implant (Nexplanon®) may appeal to pediatricians due to ease and simplicity of placement, perceived noninvasiveness and lack of need for pelvic examination. However, pediatrician concern about appropriateness of LARCs for adolescents may limit adoption of new contraceptive practices. Few large studies have evaluated adolescents' experiences with the ENG implant, leaving pediatricians and adolescent health care providers in need of more adolescent-specific evidence.

The objectives of this study were to (a) determine 12-month discontinuation and (b) characterize risk factors for discontinuation of the ENG implant in a sample of adolescents seen in a variety of outpatient clinical settings at an urban children's hospital.

Section snippets

Participants and setting

The Nationwide Children's Hospital (NCH) Institutional Review Board approved the study protocol. A retrospective chart review was conducted of all adolescent females ages 12–22 who received the ENG implant between January 1, 2011, and April 15, 2014, at any outpatient clinic within the NCH system. Eligible patients were identified via International Classification of Diseases, Ninth Revision, codes (V25.5, V25.43), Current Procedural Terminology codes (11981, 11983) and medication orders for ENG

Results

Of the 750 patients who had an ENG implant inserted during the study period, 77 (10.3%) had the device removed prior to 12 months. Mean age was approximately 1 year older (p < .001) for those who discontinued as compared to those who continued the method (Table 1). ENG discontinuers were significantly more likely to have had a prior pregnancy (p = .004) and to have used one or more contraceptive methods in the preceding 2 years (p = .048). Postplacement, ENG discontinuers were more likely to contact

Discussion

ENG implant discontinuation prior to 12 months was low among adolescents in an outpatient clinical setting. Problematic bleeding was the most common reason for removal. Younger age at placement was not a risk factor for early discontinuation, whereas prior pregnancy was associated with removal prior to 12 months. To our knowledge, ours represents the largest study of adolescent ENG users in a pediatric office setting to date.

Our finding of 10.3% discontinuation at 12 months is within the range of

Acknowledgments

The authors would like to acknowledge Hannah L.H. Lange, MPH, for her thoughtful input and edits of the manuscript.

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Cited by (32)

Amenorrhea in adolescents using the etonogestrel contraceptive implant
2024, Contraception
Clinical factors related to development of amenorrhea in adolescents with the etonogestrel contraceptive implant are not well-understood. The purpose of this study is to describe what baseline clinical characteristics are associated with amenorrhea in adolescents with a contraceptive implant 12 months after placement.
This retrospective cohort study included 252 post-menarchal individuals aged 12–22 years with a contraceptive implant placed between 2016–2020. Data abstracted at insertion, three months post-insertion, and 12 months post-insertion included demographics, baseline bleeding pattern, prior contraception use, post-insertion bleeding pattern, and method discontinuation. We assessed possible predictive characteristics of our outcomes using bivariate and multivariable logistic regression analyses.
Twenty nine percent of patients were amenorrheic 12 months after placement. Patients who were amenorrheic at 12 months were more likely to be obese (41.1% vs 24.6%, p = 0.01), to have been amenorrheic prior to implant insertion (16.9% vs 5.4%, p < 0.01, to have used hormonal contraception immediately prior to insertion (42.5% vs 26.3%, p = 0.01), to have had the most recent contraceptive method being another implant (12.3% vs 3.6%, p = 0.02), and to have developed amenorrhea within three months after placement (22.2% vs 12.6%, p < 0.01). After multivariable regression analysis, only obesity (adjusted odds ratio [aOR] 2.2 95% CI 1.1–4.2) and amenorrhea at three months (aOR 3.6, CI 1.1–11.5) were associated with amenorrhea at 12 months.
Obesity and early amenorrhea were associated with 12-month amenorrhea in adolescents using the etonogestrel subdermal implant. Understanding this can help with contraceptive method selection and counseling for patients and providers.
Obesity and early amenorrhea with the etonogestrel contraceptive implant are associated with longer-term amenorrhea in adolescents using this method. These findings can aid providers with method selection and pre-insertion decision-making for adolescents considering contraceptive implant use, as well as continued counseling after placement.
Contraceptive Implant-Associated Bleeding in Adolescent/Young Adult Clinical Practice: Associated Factors, Management, and Rates of Discontinuation
2023, Journal of Adolescent Health
To identify factors associated with bothersome implant-associated uterine bleeding, and to evaluate the impact of bleeding management on implant discontinuation.
We analyzed a quality improvement database of implant insertions (n = 825) at three adolescent/young adult programs and described individuals with and without reported bothersome bleeding. We utilized logistic regression to assess for factors associated with bleeding.
Implant recipient mean age was 18.9 ± 2.6 years, and 27% reported having subsequent bothersome uterine bleeding. Recipients had increased odds of reporting such bleeding if they had previously irregular menses (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.11–1.68 irregular and infrequent, OR = 1.41; 95% CI: 1.07–1.86 irregular and frequent) or sought the implant for menstrual management purposes exclusively (OR = 1.67; 95% CI 1.42–1.96) or in combination with contraceptive need (OR 1.65; 95%: CI 1.57–1.72). Prior use of the progestin injection or implant was associated with lower odds of subsequent bleeding report (OR = 0.63; 95% CI: 0.54–0.73; OR = 0.54; 95% CI: 0.39–0.75, respectively). Medication management of bleeding was associated with the likelihood of implant discontinuation at 1 year compared to those with untreated bleeding (hazard ratio 1.98 times, 95% CI: 1.39–2.81). The implant was continued for 3 years in over 50% of recipients with ever-managed bothersome bleeding.
Individuals with historically irregular menses and those seeking the implant for menstrual management more often reported bothersome bleeding. Treating such bleeding with medication was associated with higher 1-year discontinuation rates, although many continued implant use for 3 years. Such findings may influence implant preinsertion counseling and/or postinsertion bleeding management.
Tamoxifen for the Treatment of Etonogestrel Implant-Associated Bleeding in an Adolescent Gynecology Practice
2022, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
Additionally, all of the patients included in our study received medication management, which could indicate that our cohort was experiencing either more severe or more bothersome bleeding. A retrospective study of 750 adolescents found that 61% of patients cited “bleeding problems” as their reason for ENG implant removal, with only 6.6% of implant continuers and 20.8% of discontinuers trialing temporizing measures including NSAIDs and hormonal medications prior to discontinuation.6 There are limited published papers investigating therapeutic options to address bothersome bleeding among implant users.
To describe clinical outcomes in a cohort of adolescent female patients using tamoxifen for the treatment of bothersome etonogestrel (ENG) implant-associated bleeding.
Retrospective chart review
A tertiary children's hospital
Adolescent female patients ages 12–21 seen between August 2016 and August 2019 with an ENG implant in place who received a tamoxifen prescription for the indication of implant-associated bleeding.
None
Main outcome measures were implant continuation rates, average time to implant discontinuation after tamoxifen prescription, reasons for implant removal, number of doses and timing of tamoxifen use, bleeding patterns, and adverse effects.
A total of 67 patients met the inclusion criteria. The mean age of patients was 16.7 years old. Of the patients with available follow-up data, 49 out of 60 (81.7%) were still using the implant at 12 months, 29 out of 53 (54.7%) at 24 months, and 9 out of 40 (22.5%) at 36 months. The average time from tamoxifen prescription to implant removal was 12.1 months. Bothersome bleeding was the primary reason for ENG implant discontinuation (68.6%). No side effects from tamoxifen use were reported.
Tamoxifen was well-tolerated among this cohort of patients and can be considered a treatment option to manage bothersome implant bleeding in adolescents.
Does Obesity Influence Body Mass Index Changes in Nulliparous Adolescent Users of Long-Acting Reversible Contraceptives?
2021, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
However, use of LARCs compared to short-acting contraceptive methods is still low, despite LARCs being recommended by national medical societies as first-line contraceptive options for adolescents.2,3 Although adolescents discontinue LARCs at much lower rates than short-acting contraceptive methods, they nevertheless are discontinued at rates of up to 17% within 1 year.4-7 Perceived weight gain is a common reason given by both adolescents and adults for discontinuation of progestin-releasing LARCs such as the etonogestrel subdermal implant (ENG-implant) and the levonorgestrel intrauterine device (LNG-IUD), whereas weight gain has not been identified as a reason for discontinuation of the copper intrauterine device (Cu-IUD).8,9
To compare body mass index (BMI) changes in adolescents using long-acting reversible contraceptives (LARCs), specifically, the etonogestrel subdermal implant (ENG-implant), levonorgestrel intrauterine device (LNG-IUD), and copper IUD (Cu-IUD), by initial BMI category from the time of LARC insertion to within 6-18 months after insertion.
This was a single-center retrospective cohort study.
We reviewed electronic health records from our large health system to identify and follow a cohort of 196 adolescents aged 14-19 years with LARCs inserted from 2010 to 2016. We excluded adolescents with conditions or medications affecting weight, including childbirth.
BMI change from LARC insertion to first BMI documented after 6-18 months
Mean age was 17.2 ± 0.2 years; 59% of the cohort was Hispanic and 29% Black. Mean BMI was 26.4 ± 7.1 kg/m². Of the total cohort of adolescents, 51% were underweight/normal, 24% overweight, and 25% obese. Mean time to first BMI documented after LARC insertion was 10.1 ± 3.2 months. Mean BMI change for the total cohort was +0.73 ± 1.8 kg/m², indicating weight gain. Mean BMI change for the ENG-implant + LNG-IUD users (n = 127) was larger than for Cu-IUD users (n = 69) (+0.92 ± 1.9 kg/m² vs +0.37 ± 1.6 kg/m², respectively, P < .05). Two-way analysis of variance showed that both initial BMI category (P = .001) and type of LARC (P = .011) had an independent significant main effect on BMI change. A significant interaction effect (P = .017) showed that obese adolescents had a larger increase in BMI when they were using a progestin-releasing LARC, either ENG-implant or LNG-IUD, as compared to a Cu-IUD (P < .05).
Adolescents using progestin-releasing LARCs had a larger increase in BMI within 6-18 months after device insertion than those using Cu-IUDs. The disproportionate increase in BMI with progestin-releasing LARCs was primarily contributed by obese users.
The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion
2021, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
In our study of a diverse, primarily nulligravid and nulliparous AYA population, 12-month implant continuation was high. The 80% continuation rate in our study is consistent with those in other studies of AYA implant users, reporting rates ranging from 78% to 91%.3-9 In all, 22% of our patients reported bothersome bleeding within the first year after insertion.
Temporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation.
Retrospective chart review.
The research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents.
A chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016.
The primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding.
Younger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001).
Some patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.
Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome
2021, Journal of Pediatric and Adolescent Gynecology
Citation Excerpt :
Reasons for ENG implant discontinuation before 1 year of use in this population of adolescents with PCOS were also similar to those in other studies. Problematic bleeding was the most commonly cited reason (41%) for discontinuation, which is consistent with other research in youths.12 A total of 23% reported concerns about weight gain as the reason for ENG implant discontinuation, and these individuals did indeed gain weight.
To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation.
Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up.
Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared.
A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m²). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue.
The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

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^☆: Funding: This work was supported by Research Data & Computing Services at Nationwide Children's Hospital and the Center for Clinical and Translational Science at The Ohio State University (CTSA grant UL1TR001070) and by the OSU College of Medicine Bennett Research Scholarship awarded to Ms. Mizraji.

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Original research articleTwelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting☆

Abstract

Objective

Study design

Results

Conclusion

Implications

Introduction

Section snippets

Participants and setting

Results

Discussion

Acknowledgments

J Adolesc Health

Contraception

Contraception

J Pediatr Adolesc Gynecol

J Biomed Inform

Contraception

Contraception

Why is the teen birth rate in the United States so high and why does it matter?

J Econ Perspect

Births: final data for 2013

Natl Vital Stat Rep

Healthy People 2020

Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006–2010 national survey of family growth

Vital Health Stat

Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use

Fam Plan Perspect

Youth risk behavior surveillance—United States, 2013

MMWR Surveill Summ

Original research article
Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting☆