The hormonal birth control implant, such as Nexplanon, is a highly effective, long-acting reversible contraceptive (LARC) device. This small, flexible rod is placed discreetly under the skin of the upper arm and works continuously for up to three years. While the implant offers exceptional protection against pregnancy, the most common side effect is a change in the normal menstrual bleeding pattern, often leading to irregular bleeding or spotting. This unpredictable bleeding is the primary reason why about one in ten users choose to have the implant removed early.
Why Irregular Bleeding Occurs
The implant works by continuously releasing a low dose of the synthetic progestin hormone, etonogestrel, into the bloodstream. This constant, non-cyclical hormonal environment directly affects the endometrium, the lining of the uterus. The synthetic progestin causes the endometrium to become thin, fragile, and unstable.
Normally, the uterine lining builds up and sheds predictably during a monthly cycle. With the implant, the steady, low progestin level prevents a stable lining from forming, leading to disorganized shedding. This results in unscheduled bleeding, which can manifest as light spotting, frequent episodes, or prolonged, continuous bleeding. While this irregular pattern is not a sign that the implant is ineffective, it can be bothersome. The side effect frequently lessens over the first six to twelve months of use.
Clinical Strategies for Bleeding Management
For users experiencing bothersome irregular bleeding, healthcare providers can offer several short-term medical interventions to stabilize the uterine lining while the implant remains in place. One common strategy involves the temporary use of non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. These medications are typically prescribed for five to seven days to reduce blood flow and decrease the release of prostaglandins, chemicals that cause uterine muscle contractions and blood vessel dilation. This temporary course of NSAIDs can effectively reduce the amount and duration of bleeding.
If NSAIDs do not provide sufficient relief, a healthcare provider may recommend a short course of estrogen supplementation. This is often delivered by prescribing a combined oral contraceptive pill for seven to fourteen days. The added estrogen temporarily thickens and stabilizes the fragile uterine lining, which helps stop the unscheduled bleeding. Once the course is completed, a planned withdrawal bleed typically occurs, effectively resetting the endometrial lining.
Other hormonal interventions may involve a short course of a different, higher-dose progestin or the use of an anti-fibrinolytic agent like tranexamic acid. Tranexamic acid helps stabilize blood clots and reduce excessive bleeding. The choice of intervention depends on the patient’s overall health and whether any underlying conditions need to be ruled out. These strategies are not intended as long-term solutions but manage acute, bothersome bleeding while the user waits for their body to adjust to the implant.
When to Seek Immediate Medical Evaluation
While irregular bleeding is a known side effect, it is important to know when to seek immediate medical attention to rule out other potential health issues. Any sudden or unusually heavy bleeding requires prompt evaluation. Heavy bleeding is defined as soaking through multiple pads or tampons every hour for several consecutive hours. Unscheduled bleeding can sometimes mask an underlying condition not related to the implant.
Contact a provider immediately if the irregular bleeding is accompanied by severe, new symptoms. These symptoms should be investigated urgently:
- Signs of infection, such as fever, severe abdominal pain, or a foul-smelling vaginal discharge.
- Symptoms suggesting a pregnancy, such as persistent nausea or breast tenderness, as contraception carries a small risk of failure.
- Severe headaches or sudden vision changes.
- Pain in the lower leg that does not go away, which can signal a serious condition.
Long-Term Options and Contraceptive Alternatives
If irregular bleeding persists or remains intolerable despite clinical management, the ultimate option is removal of the implant. The removal procedure is simple and allows the body’s natural hormonal cycle to resume quickly. Fertility typically returns within a few weeks, so a new contraceptive plan must be in place immediately if pregnancy is not desired.
If the user still requires highly effective, long-acting contraception but cannot tolerate the bleeding pattern, alternative LARC methods are available. A levonorgestrel-releasing intrauterine device (IUD), such as Mirena, is a progestin-only option that often significantly reduces bleeding or leads to amenorrhea (no periods). Alternatively, the non-hormonal copper IUD is highly effective and avoids hormonal side effects entirely, although it may increase menstrual bleeding and cramping.
The decision to wait for adjustment or proceed with removal is a personal one that should be discussed with a healthcare provider. While many users see improvement in bleeding patterns after six to twelve months, removal is always an option if the side effect severely impacts quality of life. Exploring alternative methods ensures that highly effective contraception can be maintained.