Source: McIntosh N, A Blouse and L
Schaefer. 1995. Norplant Implants Guidelines for Family Planning Service Programs, 2nd
edition.
How widely have Norplant implants been researched and tested?
They have been studied for over 20 years and have been used by millions of women in 46
countries, including over a million women in the USA. The hormone they contain
(levonorgestrel) has been used for more than 30 years in oral contraceptive pills. The
capsules themselves are made of a medical-grade substance (Silastic tubing) that does not
cause any reaction (allergy) and has been used in various procedures, including heart
surgery, since the 1950s (Population Council 1990).
Can the capsules be seen or felt?
Since the incision is small, insertion does not leave a noticeable scar. The capsules
are not visible in most women but can be felt under the skin. When they are visible, the
outline of the capsules resembles veins underneath the skin. In some women the scar may be
darker (hyperpigmentation). This usually disappears following removal of the capsules.
Will the capsules move or migrate to some other place in the body?
No. The capsules remain where they are inserted until they are removed. They are
flexible and cannot break inside the woman's arm.
After the incision has healed, the skin over the capsules can be touched at any time.
Also, the client does not have to be concerned if the capsules are bumped or if pressure
is put on the area, such as when a child is carried.
How effective are Norplant implants?
No contraceptive is 100% effective; however, Norplant implants are one of the most
effective contraceptives available. For every 100 women who use implants for a year, fewer
than 1 will become pregnant. That is a lower failure rate than for the oral contraceptive
pill and is comparable to voluntary sterilization.
Is the effectiveness affected by a woman's weight?
There is no correlation between effectiveness and a woman's weight. Concerns that
implants are slightly less effective in women weighing 70 kg or more applies only to
capsules made of the older, harder tubing previously used to make the capsules. Currently,
only the new, softer tubing is used. Studies involving this new tubing have not
shown a significant difference in pregnancy rates associated with a woman's weight.
How quickly do Norplant implants become effective?
Implants become effective within 24 hours after insertion. (If they are not
inserted during the first 7 days of the menstrual period, however, a backup contraceptive
method should be used for at least 7 days.)
How long will Norplant implants be effective?
They protect against pregnancy for 5 years, but can be removed earlier. All six capsules
are needed for protection, even if the method is used for less than 5 years.
Can a woman who is breastfeeding use Norplant implants?
A hormonal contraceptive is not considered the method of first choice for breastfeeding
women; however, studies have shown no significant effects on the growth or health of
infants whose mothers used Norplant implants beginning 6 weeks after childbirth. There is
no reported experience with the use of implants earlier than 6 weeks after childbirth in
breastfeeding women.
Do other drugs interact with the hormone in Norplant implants?
Certain drugs increase the ability of the liver to break down the hormone
(levonorgestrel) thereby making the method less effective in preventing pregnancy. Such
drugs include: rifampin, used to treat tuberculosis; and drugs used for epilepsy (seizure
disorders) such as barbiturates (e.g., phenobarbital), phenytoin (e.g., Dilantin) and
carbamazepine (e.g., Tegretol) but not valproic acid (Angle,
Huff and Lea 1991).
Remember: Counsel the woman to tell the health care
worker that she is using Norplant implants whenever a new drug is given. |
How soon after insertion can a couple resume sexual relations?
Couples should wait at least 24 hours before resuming sexual relations unless a backup
contraceptive method (e.g., condoms or spermicide agent) is used.
When should the client return to the clinic?
The followup schedule depends on the clinic or program from which the woman receives
the implants. Some clinics may ask the woman to return for periodic health checkups or to
report on her experience with the implants. She should be encouraged to return to the
clinic if she:
- wants the implants removed for any reason,
- has any problems with the method that worry her,
- wants to have a child,
- is moving away and needs the address of a clinic in her new area that provides implants
services, or
- thinks she might be pregnant.
What is the most common side effect?
It is very important to tell clients about common side effects, so they can be fully
informed when making a decision about whether to choose or continue to use Norplant
implants. This way, if they have any side effects, such as irregular bleeding or a missed
menstrual period, they will not be surprised and will know how to deal with the situation.
Experience shows that providing such information increases the length of use as well as
acceptability of the method (Darney et al 1990).
The most frequently reported side effect is a change in the menstrual bleeding pattern,
such as:
- untimely bleeding or spotting between periods;
- prolonged (greater than 8 days) menstrual bleeding during the first months of use;
- no bleeding at all for several months (amenorrhea) or, for a few women, for a year or
longer; or
- a combination of these changes.
What kind of bleeding pattern a woman will have cannot be predicted. Most women can
expect an altered bleeding pattern to become more regular after 9 to 12 months. Despite
the increased frequency of bleeding in some women, the monthly blood loss is usually less
than with normal menses. In fact, in some studies, hemoglobin levels have been shown to
rise in implants users. A followup visit to the clinic is recommended if a client
experiences prolonged, heavy bleeding.
Sometimes a woman is concerned about amenorrhea (i.e., when she does not have any
menstrual bleeding or spotting at all). There is no harm to the woman's health if she
doesn't get her menstrual period (i.e., there is no "build up" of blood in the
uterus). If a woman's menses have not returned after 1 year, she probably will remain
amenorrheic for as long as she has the capsules. Also, not having menses has no harmful
effect on her future fertility.
| Remember: The more thoroughly a prospective Norplant implants user
is counseled about menstrual bleeding changes, the less likely it is that this side effect
will lead to her becoming unhappy with the method and requesting removal. |
Should the Norplant implants user be given any drugs to control irregular bleeding
or spotting?
At the present time the answer is "no."
Should a woman with prolonged bleeding (with or without anemia) have the Norplant
implants removed?
Not usually. If the woman wants to continue using implants, she should be checked to be
sure there are no other causes for the bleeding. Following this, the first approach
should be counseling and reassurance that prolonged spotting or moderate bleeding
(equivalent to normal menstruation but longer in duration) are common and expected in the
first 3 to 6 months of Norplant implants use. If this is not sufficient for the woman, use
of a low-dose COC or ibuprofen can be tried.
For anemia, give nutritional advice on the need to increase iron intake. Use oral iron
treatment (one tablet daily for 1 to 3 months) if hemoglobin is less than or equal to 9
gm/dl or hematocrit less than or equal to 27.
What are other common reactions?
A small number of women using Norplant implants have complained about the following
conditions, which may be method-related:
- headache (the most frequent complaint after menstrual irregularities),
- nervousness/anxiety,
- lower abdominal pain,
- dizziness,
- depression,
- pimples and/or oily skin (acne),
- change of appetite,
- weight gain,
- breast tenderness (mastalgia),
- increased facial or body hair growth (hirsutism) or hair loss, and
- whitish vaginal discharge (leukorrhea).
Pre-existing acne or excessive growth of body or facial hair also could be worsened.
Occasionally, an infection may occur at the implants site, or there may be a brief period
of pain or itching.
Enlarged ovarian follicles, detectable only during a physical examination, may occur in
implants users. They usually disappear spontaneously within a few months without need for
medical or surgical treatment.
There are a number of other complaints reported by implants users or discovered by
service providers that may or may not be associated with the method:
- breast (nipple) discharge;
- cervicitis (inflammation of the cervix, detected by service provider);
- general weakness (malaise);
- weight loss;
- itching (pruritus); and
- hypertension.
What are the warning signs of problems?
The client should return to the clinic if she has any of the following problems:
- pus or bleeding at the insertion site (this may indicate infection);
- expulsion of a capsule (this rarely occurs with proper insertion);
- delayed menstrual period, especially after a long interval of regular cycles;
- heavy vaginal bleeding (more than 2 pads or cloths per hour);
- prolonged vaginal bleeding (8 days or more);
- severe lower abdominal pain;
- episodes of migraine, repeated bad headaches or blurred vision; or jaundice.
When should Norplant implants be removed?
Norplant implants should be removed at the end of 5 years. The capsules can, however,
be removed before 5 years if the user desires to stop the method, for either a personal or
medical reason. The capsules should be removed by a service provider trained in removal.
If the client wants to continue using Norplant implants, she may receive a new set of
capsules at the same time the old set is removed.
Where should the client go to have the capsules removed?
The client should return to the same clinic where the capsules were inserted, or to
another clinic where the method is provided.
The counselor should be sure that the client knows she has access to removal. If
removals are not done every day, the clinic should post a schedule of the regular days of
the week when removals are performed.
What happens if the Norplant implants are left in longer than 5 years?
The effectiveness of Norplant implants decreases after 5 years so the chance of
becoming pregnant increases. If left in place, capsules will continue to release a small
amount of LNG for many years (some calculations indicate as long as 20 years). Given the
reduced effectiveness, however, capsules should be removed after 5 years and replaced with
a new set if continued contraception with implants is desired.
How long does removal take?
The removal process usually takes from 10 to 20 minutes, but may take longer if some of
the capsules were not inserted correctly or are more difficult to locate.
How soon after removal can a woman become pregnant?
Once the capsules are removed, the contraceptive effect ceases almost immediately.
Return to previous fertility is usually prompt. In a recent study of women who had
implants removed and wished to become pregnant, 20% conceived within 1 month of removal,
more than 50% within 3 months, 63% by 6 months, 86% by 1 year and 93% within 24 months.
These rates of conception are similar to those for women using no contraception (Sivin 1988).
REFERENCES
Angle M, PS Huff and JW Lea. 1991. Interactions between oral
contraceptives and therapeutic drugs. Outlook 9(1): 1-6.
Darney P et al. 1990. Acceptance and perceptions of Norplant
among users in San Francisco, USA. Studies in Family Planning 21(3): 152-160.
The Population
Council. 1990. Norplant Levonorgestrel Implants: A Summary of Scientific Data.
The Population Council: New York.
Sivin I. 1988. International experience with Norplant and
Norplant-2 contraceptives. Studies in Family Planning 19(2): 81-94.
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