Adolescents can benefit from etonogestrel-releasing contraceptive implant: experts

Calgary - The newly approved etonogestrel-releasing contraceptive implant (Nexplanon) could be used in adolescents, experts propose. Health Canada approved the implant in May 2020 but only for people 18 years and older. “As a pediatric and adolescent gynecologist—I feel like frequently, options for contraception and menstrual suppression are only tested/marketed for the over 18 population when in fact they have excellent utility in the adolescent population,” said Dr. Sarah McQuillan, from the department of obstetrics and gynecology at the University of Calgary. Dr. McQuillan and Dr. Margot Rosenthal, from the department of obstetrics, gynecology and reproductive sciences at the University of Manitoba, authored a paper in Pediatrics and Child Health about the implant for teens. READ: New Canadian guidelines for managing labour and delivery in persons with a physical disability Nexplanon is inserted into a patient’s upper arm under local anesthesia by a trained physician. It contains 68 mg etonogestrel, which is continually released for three years. It acts to inhibit ovulation and is an effective method of contraception, with 0.006 pregnancies per 100 women-years when inserted correctly. Dr. McQuillan and Dr. Margot Rosenthal note that a 2018 position statement by the Canadian Pediatric Society recommends long-acting reversible contraception as first-line contraception option for adolescents. This is partly because this form of contraception doesn’t depend on adherence. Previously, the only other options available in Canada were copper or hormonal intrauterine devices (IUDs). Drs. McQuillan and Rosenthal told the Medical Post about other benefits of Nexplanon for adolescents. “The Nexplanon is an excellent option for period suppression and contraception because it doesn't require a pelvic examination and is a progesterone-only option so carries minimal risk of blood clots or estrogen-related side effects,” they wrote in an email. The lack of pelvic exam may be of particular interest to younger women, who may not need a speculum exam until they reach 21, the CADTH clinical review of Nexplanon suggests. The CADTH clinical review was published in December 2020. The clinical trial results reviewed by CADTH show that discontinuation of Nexplanon was high, at 35 to 42%. Most of the discontinuations were due to bleeding irregularities. In their paper, Drs. Rosenthal and McQuillan said that patients should be told to expect changes in bleeding, as 20% of patients have their period stop, 30% will have infrequent bleeding and 7% have frequent bleeding. Drs. Rosenthal and McQuillan said that patients who have unusual bleeding should be tested for pregnancy and STIs. “The most common discomfort reported is spotting which can resolve with time,” they said. The implant can also be inserted postpartum, even while the mother is in the hospital. It doesn’t interfere with breastfeeding. One randomized clinical trial found that 81% of women aged 14 to 24 years offered the implant after delivery used it for a year or more. The drawback to using long-acting contraception in adolescents is the lack of protection against STIs. A 2016 cross-sectional analysis of data from U.S. high school students showed adolescents with long-acting reversible contraception were 60% less likely to use condoms than those on oral contraception. These students were also twice as likely to have more than two sexual partners, putting them at risk for STIs. The study was published in JAMA Pediatrics. While it is new to Canada, Nexplanon has been used in other countries, including Australia and the U.S., for more than a decade. The version approved by Health Canada differs in that it can now be seen using X-ray or other imaging tools and comes with an applicator device designed to improve the insertion procedure to make sure it is in the correct place. The implant costs around $350, although costs may be covered by some provinces. CADTH recommends reimbursement for Nexplanon if it is not more expensive than other long-acting reversible contraception options. Drs. Rosenthal and McQuillan state that despite Health Canada only approving the device for people 18 years old and older, “there is no biologically plausible reason to restrict the device from menstruating adolescents following an informed consent discussion.” There is no data available yet as to how many adolescents in Canada may have received the implant since it was approved. Training for physicians on how to insert the implant has been virtual due to the pandemic. Organon Canada said that more than 2,000 healthcare professionals in Canada have been trained to insert the implant. This includes physicians as well as nurses and nurse practitioners. The majority were trained in British Columbia, Alberta, Ontario, and Quebec.

Adolescents can benefit from etonogestrel-releasing contraceptive implant: experts

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