Irregular or prolonged vaginal bleeding is the most common complaint among users of the hormonal contraceptive implant, such as Nexplanon, often leading to method discontinuation. This unscheduled bleeding is a known side effect of the implant’s hormone profile, but it does not indicate a failure of the device to prevent pregnancy. Temporarily adding a combined oral contraceptive pill (COC) to the regimen is a common, medically supervised method used to resolve this bleeding irregularity. This short-term combination introduces a second hormone that stabilizes the uterine lining, offering a path toward a more manageable bleeding pattern while maintaining the implant’s high efficacy.
Why Hormonal Implants Cause Irregular Bleeding
The contraceptive implant works by steadily releasing only one type of hormone: a synthetic progestin, like etonogestrel, into the bloodstream. This constant hormonal input is highly effective at preventing pregnancy by inhibiting ovulation and thickening cervical mucus. However, the continuous presence of only progestin fundamentally alters the internal environment of the uterus.
Progestin causes the endometrium, the lining of the uterus, to become thin, atrophic, and unstable. In a typical cycle, estrogen helps build and maintain a thick, stable lining, which is then shed during menstruation. Without this balancing effect from estrogen, the progestin-thinned lining becomes fragile and sheds sporadically. This process leads to frequent, unpredictable spotting or prolonged bleeding.
The resulting blood vessels within this fragile lining can also become delicate, contributing to the random nature of the bleeding. The bleeding is not a true period but rather the result of this unopposed progestin causing the uterine lining to break down erratically. This is a direct consequence of the implant’s mechanism and is not an indication that the device is failing to work.
How Adding Oral Contraceptives Stabilizes Bleeding
Adding a birth control pill is a targeted medical strategy to correct the hormonal imbalance that causes the irregular bleeding. The pill used is typically a Combined Oral Contraceptive (COC), containing both a progestin and estrogen. The implant continues to provide progestin for contraception, and the added estrogen acts as the therapeutic agent.
The primary role of the added estrogen is to thicken and stabilize the atrophic uterine lining that the implant’s progestin has made fragile. Estrogen promotes the growth of the endometrium and strengthens its structure, which helps to stop the sporadic shedding. This process creates a more robust lining that is less likely to break down unpredictably, thereby resolving the erratic spotting.
By stabilizing the lining, the combined pill helps establish a predictable pattern. This may include a controlled withdrawal bleed when the placebo pills are taken, or it may lead to no bleeding if taken continuously. In some cases, the bleeding can stop rapidly after starting the combined pill, offering quick relief.
Safety Considerations and Duration of Treatment
Before beginning combined hormonal treatment, a medical consultation is necessary to ensure safety and rule out other causes of bleeding. Combining the implant with a Combined Oral Contraceptive introduces a higher dose of hormones, which carries certain health considerations. The most significant safety concern is a temporary, increased risk of venous thromboembolism (VTE), or blood clots, primarily associated with the estrogen component of the pill.
Healthcare providers must screen for pre-existing risk factors, such as a history of blood clots, certain types of migraines, high blood pressure, or smoking, before prescribing the combined pill. This strategy is not intended for long-term use. The goal is temporary stabilization, and the combined pill is typically prescribed for a short course, often lasting one to three months.
After the short course is completed, the expectation is that the uterine lining will remain stable, and the irregular bleeding will not return. If the bleeding returns after stopping the pill, a healthcare provider may prescribe a second short course or discuss other long-term solutions.
Alternative Strategies for Bleeding Management
If the combined pill is not a suitable option, perhaps due to contraindications like a high risk for blood clots, other methods exist to manage irregular bleeding.
Non-Hormonal Options
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, can offer short-term relief. These medications are taken for a short period and work by reducing local prostaglandin levels in the uterine lining, which can help decrease the amount of bleeding.
Other Hormonal Interventions
Other hormonal interventions may involve a short course of a different, higher-dose progestin-only pill, or an antifibrinolytic medication like tranexamic acid, which helps with blood clotting. These alternatives can be effective in stopping an active bleeding episode and are often used when estrogen is contraindicated. However, these temporary interventions are not proven to alter the long-term bleeding pattern caused by the implant.
Implant Removal
If the bleeding persists despite a trial of the combined pill or alternative treatments, or if the bleeding is heavy or significantly bothersome, implant removal is the final alternative. While the implant remains a highly effective contraceptive, persistent bleeding is a major reason for discontinuation, and patients always have the option to remove the device and choose a different contraceptive method.