Types
Norplant® Implants: Six thin, flexible capsules filled with
levonorgestrel (LNG) which are inserted just under the skin of a woman's upper arm
Mechanisms of Action
- Thicken cervical mucus, preventing sperm penetration
- Change endometrium, making implantation less likely
- Reduce sperm transport in upper genital tract (fallopian tubes)
- Suppress ovulation (PICs)
Benefits
Contraceptive
- Highly effective (0.2-1 pregnancies per 100 women during the first year of use)
- Rapidly effective (< 24 hours)
- Long-term method (up to 5 years protection)
- Pelvic examination not required prior to use
- Do not interfere with intercourse
- Do not affect breastfeeding
- Immediate return of fertility on removal
- Few side effects
- Client needs to return to clinic only if problems
- No supplies needed by client
- Can be provided by trained nonphysician (nurse or midwife)
- Contain no estrogen
Noncontraceptive
- May decrease menstrual cramps
- May decrease menstrual bleeding
- May improve anemia
- Protect against endometrial cancer
- Decrease benign breast disease
- Decrease ectopic pregnancy
- Protect against some causes of PID
Limitations
- Cause changes in menstrual bleeding pattern (irregular bleeding/spotting initially) in
most women
- Some weight gain or loss may occur
- Require trained provider for insertion and removal
- Woman must return to health care provider or clinic for insertion of another set of
capsules or removal
- Woman cannot stop whenever she wants (provider dependent)
- Effectiveness may be lowered when certain drugs for epilepsy (phenytoin and
barbiturates) or tuberculosis (rifampin) are taken
- Cost-effectiveness dependent on length of use
- Do not protect against STDs (e.g., HBV, HIV/AIDS)
Who Can Use Implants
- Women of any reproductive age
- Women of any parity including nulliparous women
- Women who want highly effective, long-term protection against pregnancy
- Women who are breastfeeding (6 weeks or more postpartum) and need contraception
- Women who are postpartum and not breastfeeding
- Women who are postabortion
- Women with desired family size who do not want voluntary sterilization
- Women with histories of ectopic pregnancy
- Women who have blood pressure < 180/110, blood clotting problems or sickle cell
disease
- Women who smoke (any age, any amount)
- Woman who prefer not to or should not use estrogen
- Women who cannot remember to take a pill every day
Conditions Requiring
Precautions
CONDITION |
RECOMMENDATION |
Active liver disease (viral hepatitis)
|
Women with viral hepatitis should
avoid using implants unless other more appropriate methods are not available or
acceptable.
|
Stroke (current) |
Women recovering from a stroke should
avoid using implants unless other more appropriate methods are not available or
acceptable.
|
Taking drugs for epilepsy or
tuberculosis
|
Because of possible decreased
effectiveness, avoid using implants unless other more appropriate methods are not
available or acceptable.
|
Who Should Not Use Implants
- Women who are pregnant (known or suspected)
- Women with unexplained vaginal bleeding (until evaluated)
- Women who cannot tolerate any changes in their menstrual bleeding pattern
- Women with current or past history of breast cancer
When To Start
- Anytime during the menstrual cycle when you can be reasonably sure the client is not
pregnant
- Days 1 to 7 of the menstrual cycle
- Postpartum:
- after 6 months if using LAM
- after 6 weeks if breastfeeding but not using LAM
- immediately or within 6 weeks if not breastfeeding
- Postabortion (immediately or within the first 7 days)
Management of Common
Side Effects and Other Problems
SIDE EFFECT/PROBLEM |
MANAGEMENT |
Amenorrhea (absence of vaginal
bleeding or spotting)
|
Check for pregnancy. If
not pregnant, no treatment is required except reassurance. Explain that blood does
not build up inside the uterus or body with amenorrhea. The continued action of small
amounts of the progestin (LNG) shrinks the endometrium, leading to decreased menstrual
bleeding and, in some women, no bleeding at all. Finally, advise client to return to
clinic if amenorrhea continues to be a concern.
If intrauterine pregnancy confirmed, counsel client regarding options.
Remove implants if pregnancy will be continued and assure her that the small dose of
progestin (LNG) will have no harmful effect on the fetus.
If ectopic pregnancy suspected, refer at once for complete evaluation.
Do not give hormonal treatment (COCs) to induce withdrawal bleeding. It
is not necessary and usually is not successful unless 2 or 3 cycles of COCs are
given.
|
Vaginal bleeding/ Spotting
|
If no problem found and client not pregnant, counsel client that
bleeding/spotting is not serious and usually does not require treatment. Most women can
expect the altered bleeding pattern to become more regular after 6 to 12 months. If
the client is not satisfied after counseling and reassurance, but wants to continue using
implants, two treatment options are recommended:
- a cycle of COCs (30-35 µg EE), or
- ibuprofen (up to 800 mg 3 times daily for 5 days) or other NSAID.
Be sure to tell the client to expect bleeding during the week after completing
the COCs (21-pill pack) or during the last 7 pills if 28-pill pack.
For heavy bleeding give 2 COC pills per day for remainder of cycle (at
least 3 to 7 days) followed by 1 cycle of COCs or switch to 50 µg of estrogen (EE) or
1.25 mg conjugated estrogen for 14-21 days.
|
Capsule coming out
|
Remove partially expelled capsule(s). Check to
determine if remaining capsules are in place. If area of insertion is
not infected (no pain, heat and redness), replace capsule(s).
If area of insertion is infected:
- remove remaining capsules and insert a new set in the other arm, or
- help the client choose another method.
|
Infection at insertion site |
If infection (not abscess), wash area (with soap and water) and
give appropriate oral antibiotic for 7 days. Do not remove
capsules. Ask client to return after 1 week. If no improvement, remove capsules and insert
a new set in the other arm or help client choose another method.
|
Weight gain or loss
(change in appetite)
|
Counsel client that fluctuations of 1-2 kg (2-4 lbs) are common
with use of implants. Review diet if weight change is more than 2 kg. If
weight gain (or loss) is unacceptable, even after counseling, stop use and help client
choose another method.
|
Client Instructions
Postoperative Care at Home
- Keep the area dry and clean for at least 48 hours. The incision could become infected if
the area gets wet while bathing.
- Leave the gauze pressure bandage in place for 48 hours and the bandaid in place until
the incision heals (about 3 to 5 days).
- There will be bruising, swelling or tenderness at the insertion site for a few days.
This is normal.
- Routine work can be done immediately. Avoid bumping the area, carrying heavy loads or
applying unusual pressure to the site.
- After healing, the area can be touched and washed with normal pressure.
General Information
- The contraceptive effect of implants begins once the capsules are inserted and continues
until removal (up to 5 years from insertion).
- Changes in menstrual bleeding patterns are common, especially during the first 6 to 12
months following insertion. These changes rarely are a risk to health.
- Certain drugs (rifampin and most anti-epilepsy drugs) may reduce the effectiveness of
implants. For this reason, the client should tell her health care provider if she starts
any new drugs.
- Other minor side effects may include weight gain, mild headaches and breast tenderness.
These symptoms are not dangerous and gradually disappear.
- Removal of the capsules is necessary 5 years after insertion, but may be done sooner if
the client wishes.
| Caution: If removal is delayed beyond
5 years, the chance of becoming pregnant is progressively higher and the risk of ectopic
pregnancy increased significantly. |
- Give the client a card stating the date the implants were inserted and the name of the
clinic.
- Implants do not provide protection against STDs, including the AIDS virus. If either
partner is at risk, they should use condoms as well as implants.
Return Visit
There is no medical reason for a return visit before 5 years unless there is a problem
or the client wants the implants removed. All clients, however, are encouraged to return
for routine reproductive health care, including provision of condoms as necessary.
WARNING SIGNS FOR IMPLANTS
USERS
- Delayed menstrual period after several months of regular cycles (may be a sign of
pregnancy)
- Severe lower abdominal pain (may be a symptom of ectopic pregnancy)
- Heavy bleeding (twice as long or twice as much as normal) or prolonged bleeding
(more than 8 days duration)
- Pus or bleeding at the insertion site
- Expulsion of a capsule
- Migraine (vascular) headaches, repeated very painful headaches or blurred vision
Contact health care provider or clinic if you develop any of the
above problems.
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Who Can Provide
- Physicians
- Nurses, Midwives, Paramedics
Where They Can Be Provided
- Hospitals
- Clinics
- Health Posts
- Private Offices
 
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