A 16-year-old woman attends your clinic complaining of irregular vaginal bleeding with the progestogen-only implant. She had this inserted 2 months ago. Prior to insertion she was not using any contraception and had attended the clinic for emergency contraception on several occasions. She is ‘fed up’ and asks to have the device removed. She does not have any other symptoms. She has a ‘new’ boyfriend and relies on the implant for contraception.
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1. What are the possible causes of the bleeding?
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Correct answer: The most likely cause is a side effect of the progestogen-only implant; however, other pathology should be excluded, e.g. STIs. It is also important to confirm that pregnancy was excluded when the implant was inserted, and that the device is palpable in her arm. Most pregnancies which have occurred with the progestogen-only implant have been due to the women already being pregnant when the device was inserted rather than actual method failure
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2. Do you need to perform a vaginal examination?
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Correct answer: No. She does not have any other symptoms and is within the first 3 months of starting this method. Unscheduled bleeding with hormonal contraception is common during the first 3–6 months.
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3. What investigations would you offer?
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Correct answer: I would recommend an STI screen. As a vaginal examination is not indicated, a self-taken vaginal swab can be sent for chlamydia and gonorrhoea NAAT testing. A urine-βHCG may be indicated depending on the implant insertion history and whether the device is palpable.
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4. Her STI screen is negative, the device is in situ and she is not pregnant. You determine that the bleeding is associated with the progestogen-only implant. How do you manage this case?
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Correct answer: Offer reassurance that irregular bleeding during the first few months of hormonal contraceptive use is common and that it does not reduce the efficacy of the method. The first option would be to persevere as the bleeding may settle without intervention. Alternatively the COC can be offered for up to 3 months either continuously or cyclically (both unlicensed).
The advantages of this LARC method in terms of efficacy may outweigh the disadvantages. If the bleeding does not settle however, an alternative method may have to be considered and the implant removed.
