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Etonogestrel

Pronunciation

(e toe noe JES trel)

Index Terms

  • 3-Keto-desogestrel
  • ENG
  • Implanon

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Implant, Subcutaneous:

Implanon: 68 mg (1 ea [DSC])

Nexplanon: 68 mg (1 ea) [latex free]

Brand Names: U.S.

  • Implanon [DSC]
  • Nexplanon

Pharmacologic Category

  • Contraceptive
  • Progestin

Pharmacology

Etonogestrel is the active metabolite of desogestrel. It prevents pregnancy by suppressing ovulation, increasing the viscosity of cervical mucous, and inhibiting endometrial proliferation.

Distribution

Vd: ~201 L

Metabolism

Hepatic via CYP3A4; forms metabolites (activity not known)

Excretion

Urine (primarily); feces

Duration of Action

Each implant maintains etonogestrel levels sufficient to inhibit ovulation for 3 years

Half-Life Elimination

~25 hours

Protein Binding

Albumin (66%) and sex hormone binding globulin (~32%)

Use: Labeled Indications

Contraception: Prevention of pregnancy

Contraindications

Allergic reaction to etonogestrel or any component of the formulation; breast cancer or other estrogen- or progestin-dependent neoplasms (current or a history of); hepatic tumors or disease; pregnancy; thrombosis or thromboembolic disorders (current or history of); undiagnosed abnormal genital bleeding.

Documentation of allergenic cross-reactivity for progestins is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Contraception (females): Subdermal: Insert 1 implant in the inner side of the upper, nondominant arm. Remove no later than 3 years after the date of insertion; may be replaced with a new implant at the time of removal if continued contraceptive protection is desired. After ruling out pregnancy, timing of insertion is based on the patient's contraceptive history:

No hormonal contraceptives within the past month: Insert between days 1 through 5 of menstruation, even if woman is still bleeding

Switching from combination hormonal contraceptive:

Oral tablet: Insert on the day after the last active tablet (at the latest, insert on the day following the usual tablet-free or placebo interval)

Transdermal system or vaginal ring: Insert on the day of the removal of the transdermal system or vaginal ring (at the latest, insert on the day following the transdermal-free or ring-free interval)

Switching from a progestin-only contraceptive:

Oral tablet: Any day during the month; do not skip days between the last tablet and implant insertion

Implant or intrauterine device (IUD): Insert on same day as removal of implant or IUD

Injection: Insert on day next injection is due

First trimester abortion or miscarriage: Insert within first 5 days following first trimester abortion or miscarriage.

Second trimester abortion or miscarriage: Insert between 21 and 28 days following second trimester abortion or miscarriage.

Postpartum: If not breast-feeding, insert between 21 to 28 days postpartum. If breast-feeding, insert after the fourth postpartum week and use a second nonhormonal form of contraception for the first 7 days of insertion.

Note: If following any of the above insertion schedules, no back-up contraception needed (except in postpartum women who are breast-feeding). If deviating, use a back-up nonhormonal contraceptive method for 7 days postinsertion. If intercourse has already occurred, pregnancy should be excluded.

Additional dosing considerations (CDC 2013):

Initiation of therapy: May be started at any time in the menstrual cycle once it is determined that the woman is not pregnant. Back-up contraception is not needed if started within 5 days of onset of menstruation. If started >5 days after the onset of menstruation or at any time in a woman experiencing amenorrhea (not postpartum), back-up contraception should be used for 7 days.

Switching from a different contraceptive to an implant: May be started at any time if it is determined that the woman is not pregnant. Unless the woman abstains from sexual intercourse, a back-up method of contraception is needed if it has been >5 days since menstrual bleeding has begun. When an additional method of contraception is needed, consider continuing the woman’s previous method for 7 days after inserting the implant.

Switching from an IUD to an implant: Continue the IUD for at least 7 days after the implant is inserted or advise the woman to abstain from sexual intercourse or use a barrier contraceptive for 7 days before removing the IUD. Alternately, an emergency contraceptive may be used at the time of IUD removal.

Dosing: Geriatric

Not indicated for use in postmenopausal women.

Dosing: Pediatric

Contraception: Adolescents (females): Refer to adult dosing. Not for use prior to menarche.

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Dosing: Hepatic Impairment

Use is contraindicated in patients with hepatic impairment.

Reconstitution

Hazardous agent; use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Refer to the manufacturer's product labeling for preparation instructions.

Administration

Subdermal: For subdermal insertion by health care providers trained in the insertion and removal procedure. Insert implant subdermally at the inner side of the nondominant upper arm ~8 to 10 cm (3 to 4 inches) above the medial epicondyle of the humerus just under the skin. Implant must be palpable after insertion. X-ray, CT scan, ultrasound scanning, or MRI may also be used to confirm the location of the implant if it is not palpable. Use of a nonhormonal contraceptive (eg, condom) is required until the presence of the implant can be verified.

When removing the implant, confirm that the entire implant has been removed by measuring its length (4 cm). Remove all pieces if implant has broken. A new implant may be inserted in the same arm through the same incision.

Refer to the manufacturer's product labeling for complete administration, removal, and reinsertion instructions. A User Card (to give to the patient), consent form (to keep on file), and patient product information are provided with the device. Materials related to the insertion and removal of etonogestrel implant are available from the manufacturer (877-467-5266).

Hazardous agent; use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Storage

Store at 25°C (77°F); excursions are permitted between 15°C and 30˚C (59˚F and 86˚F).

Drug Interactions

Acitretin: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Given the potential for progestin-only preparations to fail to prevent pregnancy during acitretin therapy, such products should not be relied upon. Alternative, nonhormonal forms of contraception must be employed during acitretin therapy. Consider therapy modification

Anticoagulants: Progestins may diminish the therapeutic effect of Anticoagulants. More specifically, the potential prothrombotic effects of some progestins and progestin-estrogen combinations may counteract anticoagulant effects. Management: Carefully weigh the prospective benefits of progestins against the potential increased risk of procoagulant effects and thromboembolism. Use is considered contraindicated under some circumstances. Refer to related guidelines for specific recommendations. Consider therapy modification

Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Monitor therapy

Aprepitant: May decrease the serum concentration of Contraceptives (Progestins). Management: Alternative or additional methods of contraception should be used both during treatment with aprepitant or fosaprepitant and for at least one month following the last aprepitant/fosaprepitant dose. Consider therapy modification

Artemether: May decrease the serum concentration of Contraceptives (Progestins). Management: Consider the use of an alternative (i.e., non-hormonal) means of contraception in all women of childbearing potential who are using artemether. Consider therapy modification

Atazanavir: May increase the serum concentration of Contraceptives (Progestins). Management: Consider an alternative or additional method of contraception, particularly with combined estrogen/progestin products. Depot medroxyprogesterone acetate may be used without a need for additional contraception. Consider therapy modification

Barbiturates: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Use of alternative, nonhormonal contraceptives is recommended. Consider therapy modification

Bexarotene (Systemic): May decrease the serum concentration of Contraceptives (Progestins). Management: Women of childbearing potential receiving bexarotene should use two reliable forms of contraception (including at least one nonhormonal form). Consider therapy modification

Bile Acid Sequestrants: May decrease the serum concentration of Contraceptives (Progestins). Management: Administer oral progestin-containing contraceptives at least 1-4 hours prior to or 4-6 hours after administration of a bile acid sequestrant. Consider therapy modification

Boceprevir: May increase the serum concentration of Contraceptives (Progestins). This has been seen specifically with norethindrone. Boceprevir may increase the serum concentration of Contraceptives (Progestins). This has been seen specifically with drospirenone. Management: Patients receiving boceprevir, ribavirin, and peginterferon alfa should use two reliable forms of contraception. Norethindrone/ethinyl estradiol may be used for one of these when norethindrone dose is at least 1 mg/day. Avoid drospirenone. Consider therapy modification

Bosentan: May decrease the serum concentration of Contraceptives (Progestins). Management: Use an alternative (i.e., non-hormonal) means of contraception for all women of childbearing potential who are using bosentan, and do not rely on hormonal contraceptives alone. Consider therapy modification

C1 inhibitors: Progestins may enhance the thrombogenic effect of C1 inhibitors. Monitor therapy

CarBAMazepine: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Use of alternative, nonhormonal contraceptives is recommended. Consider therapy modification

Carfilzomib: May enhance the thrombogenic effect of Contraceptives (Progestins). Management: Consider alternative, non-hormonal methods of contraception in patients requiring therapy with carfilzomib. Consider therapy modification

CloBAZam: May decrease the serum concentration of Contraceptives (Progestins). Consider therapy modification

Cobicistat: May increase the serum concentration of Contraceptives (Progestins). Management: Consider an alternative, non-hormone-based contraceptive in patients receiving cobicistat-containing products. Consider therapy modification

Dabrafenib: May decrease the serum concentration of Contraceptives (Progestins). Management: Females of reproductive potential should use an alternative, highly effective, non-hormonal means of contraception during and at least 2 weeks (dabrafenib alone) or 4 months (dabrafenib + trametinib) after discontinuation of dabrafenib treatment. Consider therapy modification

Darunavir: May decrease the serum concentration of Contraceptives (Progestins). Management: Consider using an alternative or additional means of contraception. Injected depot medroxyprogesterone acetate may be used without a need for additional contraception. Consider therapy modification

Efavirenz: May diminish the therapeutic effect of Etonogestrel. Management: Use a reliable barrier contraceptive if efavirenz is used in combination with etonogestrel. Continue using barrier contraception for 12 weeks after discontinuation of efavirenz. Consider therapy modification

Eslicarbazepine: May decrease the serum concentration of Contraceptives (Progestins). Management: Alternative, non-hormonal means of birth control should be considered for women of child-bearing potential. Consider therapy modification

Exenatide: May decrease the serum concentration of Oral Contraceptive (Progestins). Management: Administer oral contraceptives at least one hour prior to exenatide. Consider therapy modification

Felbamate: May decrease the serum concentration of Contraceptives (Progestins). Management: Contraceptive failure is possible. Use of an alternative, nonhormonal method of contraception is recommended. Consider therapy modification

Flibanserin: Contraceptives (Progestins) may increase the serum concentration of Flibanserin. Monitor therapy

Fosamprenavir: Contraceptives (Progestins) may decrease serum concentrations of the active metabolite(s) of Fosamprenavir. Fosamprenavir may decrease the serum concentration of Contraceptives (Progestins). Management: Consider using an alternative or additional means of contraception. Injected depot medroxyprogesterone acetate may be used without a need for additional contraception. Consider therapy modification

Fosaprepitant: May decrease the serum concentration of Contraceptives (Progestins). The active metabolite aprepitant is likely responsible for this effect. Management: Alternative or additional methods of contraception should be used both during treatment with aprepitant or fosaprepitant and for at least one month following the last aprepitant/fosaprepitant dose. Consider therapy modification

Fosphenytoin: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Contraceptive failure is possible. Use of an alternative, nonhormonal contraceptive is recommended. Consider therapy modification

Griseofulvin: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Avoid combination

Herbs (Progestogenic Properties) (eg, Bloodroot, Yucca): May enhance the adverse/toxic effect of Progestins. Monitor therapy

LamoTRIgine: May decrease the serum concentration of Contraceptives (Progestins). Management: Women using progestin-only “minipill” products may be at risk for contraceptive failure; it is unclear if other progestin-containing products would be significantly impacted. Alternative, non-hormonal, means of contraception are recommended. Consider therapy modification

Lesinurad: May decrease the serum concentration of Contraceptives (Progestins). Management: Use of an additional, nonhormonal contraceptive is recommended in patients being treated with lesinurad who desire effective contraception. Consider therapy modification

Lopinavir: May decrease the serum concentration of Contraceptives (Progestins). Lopinavir may increase the serum concentration of Contraceptives (Progestins). Management: Consider using an alternative or additional means of contraception. Injected depot medroxyprogesterone acetate and etonogestrel implants may be used without a need for additional contraception. Consider therapy modification

Lumacaftor: May decrease the serum concentration of Contraceptives (Progestins). Management: Do not rely on hormone-based contraceptives with concurrent use of lumacaftor/ivacaftor; an alternative, non-hormonal, method of contraception should be used if this combination is required. Consider therapy modification

Metreleptin: May decrease the serum concentration of Contraceptives (Progestins). Metreleptin may increase the serum concentration of Contraceptives (Progestins). Monitor therapy

Mifepristone: May diminish the therapeutic effect of Contraceptives (Progestins). Mifepristone may increase the serum concentration of Contraceptives (Progestins). Management: Women of childbearing potential should use an effective, nonhormonal means of contraception during and 4 weeks following mifepristone treatment. Consider therapy modification

Mycophenolate: May decrease the serum concentration of Contraceptives (Progestins). Management: Use of an additional or alternative (nonhormonal) method of contraception should be considered. Consider therapy modification

Nelfinavir: May decrease the serum concentration of Contraceptives (Progestins). Management: Use an alternative or additional method of contraception due to possibly decreased contraceptive effectiveness. Injected depot medroxyprogesterone acetate does not appear to participate in this interaction. Consider therapy modification

Nevirapine: May decrease the serum concentration of Contraceptives (Progestins). Management: Instruct patients receiving nevirapine to use an alternative or additional nonhormonal contraceptive. Nevirapine product labeling however suggests that depo-medroxyprogesterone acetate may be used as a sole method of contraception. Consider therapy modification

OXcarbazepine: May decrease the serum concentration of Contraceptives (Progestins). Management: Contraceptive failure is possible. Use of an additional or alternative, nonhormonal method of contraception is recommended. Consider therapy modification

Perampanel: May decrease the serum concentration of Contraceptives (Progestins). Management: Patients should use an alternative, non-hormonal based form of contraception for the duration of concurrent perampanel. Both oral and non-oral progestin-based contraceptives are likely to be impacted by this interaction. Consider therapy modification

Phenytoin: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Contraceptive failure is possible. Use of an alternative, nonhormonal contraceptive is recommended. Consider therapy modification

Primidone: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Use of alternative, nonhormonal contraceptives is recommended. Consider therapy modification

Prucalopride: May decrease the serum concentration of Contraceptives (Progestins). Consider therapy modification

Retinoic Acid Derivatives: May diminish the therapeutic effect of Contraceptives (Progestins). Retinoic Acid Derivatives may decrease the serum concentration of Contraceptives (Progestins). Management: Two forms of effective contraception should be used in patients receiving retinoic acid derivatives. Particularly, microdosed progesterone-only preparations may be inadequately effective. Exceptions: Adapalene; Bexarotene (Topical); Tretinoin (Topical). Consider therapy modification

Rifamycin Derivatives: May decrease the serum concentration of Contraceptives (Progestins). Contraceptive failure is possible. Management: Contraceptive failure is possible. Use of an alternative, nonhormonal contraceptive is recommended. Consider therapy modification

Saquinavir: May decrease the serum concentration of Contraceptives (Progestins). Management: Use an alternative or additional method of contraception due to possibly decreased contraceptive effectiveness. Injected depot medroxyprogesterone acetate does not appear to participate in this interaction. Consider therapy modification

Selegiline: Contraceptives (Progestins) may increase the serum concentration of Selegiline. Monitor therapy

St John's Wort: May diminish the therapeutic effect of Contraceptives (Progestins). Contraceptive failure is possible. Management: Consider using a product other than St John's wort. Contraceptive failure is possible. Use of an alternative, nonhormonal contraceptive is recommended. Consider therapy modification

Sugammadex: May decrease the serum concentration of Contraceptives (Progestins). Management: Patients receiving any hormonal contraceptive (oral or non-oral) should use an additional, nonhormonal contraceptive method during and for 7 days following sugammadex treatment. Consider therapy modification

Telaprevir: May decrease the serum concentration of Contraceptives (Progestins). Management: Two different nonhormonal forms of contraception are required for women of childbearing potential taking telaprevir. Hormonal contraceptives may be less effective during concurrent telaprevir and for up to 2 weeks after telaprevir discontinuation. Consider therapy modification

Thalidomide: Contraceptives (Progestins) may enhance the thrombogenic effect of Thalidomide. Monitor therapy

Tipranavir: May increase the serum concentration of Contraceptives (Progestins). Management: Use an alternative or additional method of contraception due to possibly decreased contraceptive effectiveness. Injected depot medroxyprogesterone acetate does not appear to participate in this interaction. Consider therapy modification

Topiramate: May decrease the serum concentration of Contraceptives (Progestins). Management: Caution patients that this combination may be associated with reduced contraceptive effectiveness. Consider adding an additional (non-hormonal) contraceptive method. Consider therapy modification

Tranexamic Acid: Contraceptives (Progestins) may enhance the thrombogenic effect of Tranexamic Acid. Avoid combination

Ulipristal: May diminish the therapeutic effect of Progestins. Progestins may diminish the therapeutic effect of Ulipristal. Management: Ulipristal for uterine fibroids (Canadian indication): avoid progestins within 12 days of stopping ulipristal; as emergency contraceptive (U.S. indication): avoid progestins within 5 days of stopping ulipristal. Avoid combination

Vitamin K Antagonists (eg, warfarin): Contraceptives (Progestins) may diminish the anticoagulant effect of Vitamin K Antagonists. In contrast, enhanced anticoagulant effects have also been noted with some products. Management: When possible, concomitant hormonal contraceptives and coumarin derivatives should be avoided in order to eliminate the risk of thromboembolic disorders. Consider using an alternative, nonhormonal contraceptive. Consider therapy modification

Voriconazole: May increase the serum concentration of Contraceptives (Progestins). Contraceptives (Progestins) may increase the serum concentration of Voriconazole. Monitor therapy

Adverse Reactions

>10%:

Central nervous system: Headache (25%)

Dermatologic: Acne vulgaris (14%)

Endocrine & metabolic: Menstrual disease (<3 episodes/90 days: 34%; prolonged menstrual bleeding lasting >14 days: 18%; >5 episodes/90 days: 7%), amenorrhea (no bleeding in 90 days: 22%), weight gain (14%)

Gastrointestinal: Abdominal pain (11%)

Genitourinary: Vaginitis (15%), mastalgia (13%)

Respiratory: Pharyngitis (11%)

1% to 10%:

Central nervous system: Dizziness (7%), emotional lability (7%), depression (6%), nervousness (6%), pain (6%)

Endocrine & metabolic: Dysmenorrhea (7%)

Gastrointestinal: Nausea (6%)

Genitourinary: Leukorrhea (10%)

Hypersensitivity: Hypersensitivity reaction (5%)

Local: Implant site reactions (4% to 9%), pain at implant site (1% to 5%), hematoma at implant site (≤3%), redness at implant site (≤3%), implant site bruising (2%)

Neuromuscular & skeletal: Back pain (7%)

Respiratory: Flu-like symptoms (8%)

<1% (Limited to important or life-threatening): Alopecia, anaphylaxis, angioedema, cerebrovascular accident, convulsions, hypertension, migraine, myocardial infarction, ovarian cyst, pulmonary embolism, seizure

Warnings/Precautions

Concerns related to adverse effects:

• Breast cancer: Breast cancer is a hormonal sensitive tumor and the prognosis for women with current or a recent history of breast cancer may be worse with progestin only contraceptive use (CDC 2013). Use is contraindicated in women with (or history of) breast cancer.

• Carbohydrate intolerance: May decrease glucose tolerance; use caution in women with diabetes or prediabetes.

• Ectopic pregnancy: Ectopic pregnancy (rare) may occur more commonly than in women using no contraception.

• Ovarian cysts: Follicular development may occur and may continue to increase in size beyond what may occur in a normal cycle; generally, ovarian cysts resolve spontaneously without intervention; however, surgery may rarely be required.

• Retinal vascular thrombosis: Discontinue if unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions occur and immediately evaluate for retinal vein thrombosis.

• Thromboembolism: Combination hormonal contraceptives may increase the risk of thromboembolism and other vascular events (eg, deep vein thrombosis [DVT], myocardial infarction [MI], pulmonary embolism [PE]). Women with inherited thrombophilias (eg, protein C or S deficiency) may have increased risk of venous thromboembolism when using combination hormonal contraceptives (DeSancho, 2010; van Vlijmen, 2011). The risk of DVT/PE is expected to be less with progestin only contraceptives than that observed with combination hormonal contraceptives (CDC 2010). Use of etonogestrel is contraindicated in women with thrombosis or thromboembolic disorders (current or history of).

• Vaginal bleeding: Changes in bleeding patterns are likely to occur. Presentation of undiagnosed, persistent, or recurrent abnormal vaginal bleeding warrants further evaluation to rule out malignancy.

• Weight gain: Use commonly results in an average weight gain of ~2.8 pounds after 1 year and ~3.7 pounds after 2 years of treatment.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with risk factors for cardiovascular disease (eg, hypertension, hypercholesterolemia, morbid obesity, diabetes, women who smoke) (CDC 2010)

• Depression: Use with caution in patients with a history of depression; discontinue if serious depression recurs.

• Diseases exacerbated by fluid retention: Use with caution in patients with diseases that may be exacerbated by fluid retention.

• Gallbladder disease: Use of combination hormonal contraceptives may have an increased risk of developing gallbladder disease; it is not known if this risk increases with progestin only products.

• Hepatic adenomas or carcinomas: Use of combination hormonal contraceptives is associated with hepatic adenomas (rare). The risk with progestin only contraceptives is not known. Etonogestrel is contraindicated with preexisting hepatic tumors.

• Hepatic impairment: May be poorly metabolized in women with hepatic impairment. Discontinue if jaundice develops during therapy or if liver function becomes abnormal. Use is contraindicated with preexisting hepatic disease.

• Hyperlipidemia: Use caution in patients treated for hyperlipidemia; progestins may increase low-density lipoprotein (LDL) concentrations.

• Hypertension: According to the manufacturer, women with a history of hypertension-related diseases should be encouraged to use a nonhormonal form of contraception. In women with hypertension that is well-controlled, use may be considered; monitor blood pressure closely. If sustained hypertension develops during use, or if a significant increase in blood pressure does not respond adequately to antihypertensive therapy, remove the implant. Women with hypertension may use progestin only implants; other risk factors for cardiovascular disease (such as older age, smoking, diabetes) should be considered when prescribing (CDC 2010).

• Renal impairment: Women with renal disease should be encouraged to use a nonhormonal form of contraception.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Contact lens wearers: Any changes with lens tolerance or vision should be evaluated by an ophthalmologist.

• Obese: Use with caution in overweight women (may be less effective, especially in the presence of other risk factors); women >130% of ideal body weight were not included in clinical studies. However, contraceptive failure was not observed in obese women in a prospective study (Xu 2012). Progestin only implants may be used in women with a body mass index (BMI) ≥30 kg/m2 (CDC 2010).

• Pediatric: Not for use prior to menarche.

• Surgical patients: Consider removal during periods of prolonged immobilization due to surgery or illness.

Dosage form specific issues:

• Implant: Broken or bent implants while in the patient's arm have been reported; the release rate of etonogestrel may be slightly increased. Ensure implant is removed in its entirety.

Special handling:

• Hazardous agent: Use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Other warnings/precautions:

• Appropriate use: For use in women who request long-acting (up to 3 years) contraception. Insertion/removal should be done by a trained health care provider and implant must be palpable after insertion. Complications may occur from insertion and removal procedures, or inserting the implant too deep. Treatment should be instituted for infection at the insertion site; if infection persists, the implant should be removed.

Expulsion may occur following incomplete insertion or infection. The implant must be removed by the end of the third year.

• Cervical/Ovarian cancer: The use of combination hormonal contraceptives has been associated with a slight increased risk of cervical cancer; however, studies are not consistent and may be related to additional risk factors (Gierisch 2013). Women awaiting treatment for cervical or ovarian cancer may use progestin only contraceptives (CDC 2013).

• HIV infection protection: Use does not protect against HIV infection or other sexually transmitted diseases (CDC 2010; CDC 2013).

• Laboratory changes: The use of estrogens and/or progestins may change the results of some laboratory tests (eg, coagulation factors, lipids, glucose tolerance, binding proteins). The dose, route, and the specific estrogen/progestin influences these changes. In addition, personal risk factors (eg, cardiovascular disease, smoking, diabetes, age) also contribute to adverse events; use of specific products may be contraindicated in women with certain risk factors.

Monitoring Parameters

Assessment of pregnancy status (prior to therapy); weight (optional; body mass index [BMI] at baseline may be helpful to monitor changes during therapy); assess potential health status changes at routine visits (CDC 2013).

Monitor patient for vision changes; blood pressure; signs and symptoms of thromboembolic disorders; signs or symptoms of depression; glycemic control in patients with diabetes; lipid profiles in patients being treated for hyperlipidemias. Bleeding irregularities including amenorrhea; adequate diagnostic measures should be performed to rule out malignancy in all cases of undiagnosed abnormal vaginal bleeding.

Pregnancy Considerations

Use is contraindicated in pregnant women. Pregnancy status should be evaluated prior to prescribing and implant should be removed if pregnancy occurs. In general, the use of combination hormonal contraceptives, when inadvertently used early in pregnancy, have not been associated with teratogenic effects. There is no evidence that the risk is different with etonogestrel.

Due to the risk of thromboembolism, the manufacturer does not recommend insertion <21 days postpartum. However, progestin only implants may be inserted at any time if it is reasonably certain the woman is not pregnant, including immediately postpartum or post abortion (CDC 2013).

Etonogestrel serum concentrations decrease by 1 week after removal of the implant; pregnancies have been reported as early as 7 to 14 days after removal. Restart contraception immediately after removal if continued contraception is desired.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience weight gain, headache, acne vulgaris, mood changes, vaginal irritation, menstrual irregularities, or vascular diseases (ie, gallbladder disease, thrombosis, myocardial infarction, other blood vessel problems) (rare). Have patient report immediately to prescriber angina, dyspnea, edema of extremities, skin discoloration, painful extremities, signs of depression (ie, suicidal ideation, anxiety, emotional instability, illogical thinking), severe vaginal hemorrhaging, significant dyspepsia, considerable nausea, vision changes, ophthalmalgia, eye irritation, lump in breast, mastalgia, intolerable skin irritation, or pregnancy (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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