Female Contraception

Description

Alternative Names

Implant Contraception

Progestin implant contraception uses rods that are inserted under the skin and continuously release tiny amounts of progestin into the bloodstream.

The standard implant has been the Norplant system, which uses the hormone levonorgestrel. This implant contraception consists of six flexible plastic rods, each about the size of a cardboard match. The Norplant system can generally remain in the arm for five years or be removed earlier if the recipient wishes. It is currently off the market.

Newer systems (Norplant II, Jadelle, Implanon) use fewer implants. The Norplant II and Jadelle system uses two rods and Implanon uses only one. All are proving to be safe and effective. A 2000 study on Implanon, which uses the progestin ketodesogestrel, reported that it was less costly than oral contraceptives, injected progestins (Depo-Provera), and Norplant. It was also more effective than Depo-Provera in preventing pregnancy.

Insertion of Implants. To ensure that a potential Norplant recipient is not pregnant at the time of insertion, the implants are usually inserted during the first seven days of her period. The typical procedure is as follows:

• The rods are inserted by a specially trained health care provider under the skin of the upper inside part of the non-dominant arm.
• After injecting the insertion site with a local anesthetic, the health care provider makes a small incision in the arm and places the implants under the skin with a trocar, a sharp-tipped instrument that resembles a large ballpoint pen. There are no stitches.
• A bandage is then placed over the wound and remains there for a few days to allow the site to heal.
• The entire procedure takes about 10 minutes and is painless, except for any discomfort caused by the anesthetic injection.
• For a few days afterward the recipient may also experience bruising, swelling, and discomfort at the insertion site.
• The implants begin to work within eight to 24 hours of the procedure, but the woman should use additional contraceptive protection for a week or two, depending on the physicians recommendation.

Implants do not require maintenance of any kind and do not affect the use of the arm once the insertion site has healed. They can be felt if the insertion site is touched, and their outline may be visible in thin arms. A return visit to the health care provider within three months of insertion, followed by yearly check-ups, allows the recipients progress to be monitored.

Removing the Implant. When the time comes to remove the implants, the insertion site is again anesthetized and a small incision is made in the arm. Removal can be uncomfortable and is more difficult than the original procedure if scar tissue has formed over the implants. Removal usually takes 15 to 20 minutes, but may require more than one visit. (New implants with fewer rods appear to be much easier and faster to remove.) The implants contraceptive action wears off a few hours after removal. Fertility is restored within a couple of weeks. If the user wishes, new implants can be inserted as soon as the old ones are removed.

Candidacy for Levonorgestrel Implants

Levonorgestrel implants are comparable to tubal ligation in effectiveness. They are good choices for women who want to delay pregnancy for several years but hope to bear children later on. Although failure is rare, pregnancies do occur and are more likely in heavier and younger women.

Women should absolutely not use Norplant if they are pregnant or have the following conditions, or history of them:

• Breast cancer.
• Acute liver disease or tumors.
• Blood clots.
• Undiagnosed vaginal bleeding.

Those who should consider other methods first include the following:

• Women who are breastfeeding. They should wait for six weeks after delivery to receive the implants. (One study suggested the newer Implanon system has no adverse affect on breast milk and so may be a safe option for breast-feeding mothers.)
• Women at risk for breast cancer, blood clots, heart disease, diabetes, high blood pressure, liver disease, or stroke.
• Women at risk for osteoporosis because of a link between bone calcium loss and progestin-contraceptives. (One study, however, reported that young girls who used the Norplant implants experienced increased bone density.)

Implants do not provide protection against sexually transmitted diseases, so women at risk for infection should also use a barrier contraceptive, or as an alternative to the implants.

Advantages of Levonorgestrel Implants

A study of women attending four family planning clinics reported that 92% of users of the implants were satisfied with the Norplant system. Another reported that the continuation rate after a year was better than that of combined oral contraceptive use. In general, studies indicate that at the end of five years, between 40% and 70% of recipients still used implants.

The advantages of the implants are as follows:

• Levonorgestrel implants prevent pregnancy for up to five years.
• They are easily reversible.
• Like the IUD, the implants allow users to enjoy sex without worrying about taking a birth control pill every day, or inserting a diaphragm or cervical cap before sex begins.
• Progestins may protect against uterine and ovarian cancer.

Disadvantages and Complications of Levonorgestrel Implants

The disadvantages of the implants are as follows:

• They have the same side effects as any device containing progestins. In many cases these problems subside as time passes, or can be substantially reduced using other therapies.
• Some studies have reported an association between depression and Norplant use. One study revealed that after two years, many Norplant users who reported severe depression at the beginning showed improvement.
• About 3% of users suffer a reaction to the local anesthetic, experience tissue or nerve damage due to poorly placed implants, or experience problems in removal.
• Certain medications interfere with Norplant, including antiseizure drugs and rifampin (rifampicin), an antibiotic used to treat tuberculosis. A physician must always be informed of any medications the patient is taking, even if they are unrelated to gynecologic problems.

There have been some reports of strokes, unexpected pressure in the brain, and clotting abnormalities in women using implants, but a major 2001 five-year study reported that there were no major health complications and that the implant was an effective, safe method of contraception.