etonogestrel (Rx)

Brand and Other Names:Implanon, Nexplanon
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Dosing & Uses


Dosage Forms & Strengths


  • 68mg


Insert 1 implant subdermally

No preceding hormonal contraceptive use in past month: Insert between Days 1 through 5

Switch from combination other contraceptive

  • OCP: Within 7 days after last active pill
  • Vaginal ring: During 7-day ring-free period etonogestrel/ethinylestradiol
  • Transdermal patch: During 7-day patch-free period of a transdermal contraceptive system

Switch from progestin-only contraceptive

  • Any day of the month when switching from pill; do not skip any days between last pill and insertion
  • On the same day as contraceptive implant removal
  • On the same day as removal of a progestin-containing IUD
  • On the day when next contraceptive injection would be due


For detailed info regarding use following delivery/abortion/miscarriage, see manufacturer's package insert

May be used for up to 3 years and then requires replacement

Insertion procedure and technique differs between brands

Nexplanon: Radiopaque; may use X-ray, CT, ultrasound, or MRI to locate once implanted

Implanon: Nonradiopaque; may use ultrasound or MRI to locate once implanted

Confirm that the entire implant, which is 4 cm long, has been removed by measuring its length

When an implant is broken or bent, in situ, the release rate of etonogestrel may be slightly increased; important to remove in its entirety

Not recommended



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            Adverse Effects


            Oligomenorrhea (34%)

            Headache (25%)

            Vaginitis (24.5%)

            Amenorrhea (22%)

            Menorrhagia (18%)

            Weight gain (14%)

            Acne (13.5%)

            Breast pain (13%)

            Upper resp tract infection (13%)

            Pharyngitis (11%)

            Leucorrhea (10.5%)


            Back pain (7%)

            Depression (6%)

            Dizziness (7%)

            Dysmenorrhea (7%)

            Emotional lability (7%)

            Flu-like symptoms (8%)

            Insertion-site pain (9%)

            Nausea (6%)

            Nervousness (6%)

            Pain (6%)

            Postmarketing Reports

            Gastrointestinal disorders: Constipation, diarrhea, flatulence, vomiting

            General disorders and administration site conditions: Edema, fatigue, implant site reaction, pyrexia

            Immune system disorders: Anaphylactic reactions

            Infections and infestations: rhinitis, urinary tract infection

            Investigations: Clinically relevant rise in blood pressure, weight decreased

            Metabolism and nutrition disorders: Increased appetite

            Musculoskeletal and connective tissue disorders: Arthralgia, musculoskeletal pain, myalgia

            Nervous system disorders: Convulsions, migraine, somnolence

            Pregnancy, puerperium and perinatal conditions: Ectopic pregnancy

            Psychiatric disorders: Anxiety, insomnia, libido decreased

            Renal and urinary disorders: Dysuria

            Reproductive system and breast disorders: Breast discharge, breast enlargement, ovarian cyst, pruritus genital, vulvovaginal discomfort

            Skin and subcutaneous tissue disorders: Angioedema, aggravation of angioedema and/or aggravation of hereditary angioedema, alopecia, chloasma, hypertrichosis, pruritus, rash, seborrhea, urticaria

            Vascular disorders: Hot flush; chest pain and/or respiratory disorders (such as dyspnea, cough, or hemoptysis when implants found within pulmonary artery)




            Documented hypersensitivity

            Known or suspected breast cancer, personal history of breast cancer, or other progestin-sensitive cancer, now or in the past

            Liver tumors, benign or malignant, or active liver disease

            Undiagnosed abnormal vaginal bleeding

            Hypersensitivity to etonogestrel or component of the formulation

            Current/history of thrombophlebitis, thromboembolic disorders


            Caution in family history of DVT/PE, current/history of depression, endometriosis, DM, HTN, bone mineral density changes, renal/hepatic impairment, bone metabolic disease, SLE; conditions exacerbated by fluid retention (eg, migraine, asthma, epilepsy)

            Women with family history of breast cancer or who develop breast nodules should be carefully monitored

            Due to risk of thromboembolism associated with pregnancy and immediately following delivery, drug should not be used prior to 21 days postpartum; women with history of thromboembolic disorders should be made aware of possibility of recurrence

            Discontinue if the following develop jaundice, visual problems (may cause contact lens intolerance), any signs of VTE, migraine with unusual severity, severe depression, increased risk of thromboembolic complications after surgery

            Contact lens wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist

            Evaluate for retinal vein thrombosis immediately if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions

            Discontinue 4 week before major surgery or prolonged immobilization

            Use caution in patients on warfarin, oral anticoagulants (increase in anticoagulant dose may be warranted)

            Some studies link OCP use with increased risk of breast cancer, whereas other studies have not shown a change in risk; woman's risk depends on conditions where naturally high hormone levels persist for long periods of time including early onset menstruation before age 12, late onset menopause, after age 55, first child after age 30, nulliparity

            Increased risk of cervical cancer with OCP use, however HPV remains as main risk factor for this cancer; evidence suggests long-term use of OCPs, 5 or more years, may be associated with increased risk

            Hormonal contraceptives may cause some degree of fluid retention; prescribe with caution, and only with careful monitoring, in patients with conditions which might be aggravated by fluid retention; unknown if drug causes fluid retention

            Disturbances of liver function may necessitate discontinuation of hormonal contraceptive use until markers of liver function return to normal; remove treatment if jaundice develops; progestin may be poorly metabolized in women with liver impairment; increased risk of liver cancer with OCP use; risk increases with longer duration of OCP use

            A pregnancy that occurs in a woman may be more likely to be ectopic than a pregnancy occurring in a woman using no contraception; be alert to possibility of ectopic pregnancy in women receiving therapy who become pregnant or complain of lower abdominal pain

            After starting therapy, women are likely to have a change from their normal menstrual bleeding pattern; these may include changes in bleeding frequency (absent, less, more frequent or continuous), intensity (reduced or increased) or duration; evaluate abnormal bleeding as needed to exclude pathologic conditions or pregnancy

            Implant should be removed in the event of a thrombosis

            Discourage women with history of hypertension-related diseases or renal disease from using hormonal contraception; women with well-controlled hypertension, use can be considered; women with hypertension receiving therapy should be closely monitored; if sustained hypertension develops during therapy, or if a significant increase in blood pressure does not respond adequately to antihypertensive therapy, remove implant

            Patient receiving therapy should have a yearly visit with healthcare provider for a blood pressure check and for other indicated health care

            Implant should be removed if blood pressure rises significantly and becomes uncontrolled

            When implant broken or bent, may increase release rate of etonogestrel; when implant removed, remove it in its entirety

            Small increased relative risk of developing gallbladder disease among combination hormonal contraceptive users reported; not known whether a similar risk exists with progestin-only methods

            Monitor prediabetic and diabetic women receiving therapy; may induce mild insulin resistance and small changes in glucose concentrations of unknown clinical significance; carefully monitor prediabetic and diabetic women receiving therapy

            Follow closely women being treated for hyperlipidemia, if they elect to receive treatment; some progestins may elevate LDL levels and may render control of hyperlipidemia more difficult

            If follicular development occurs, atresia of follicle is sometimes delayed, and follicle may continue to grow beyond size it would attain in normal cycle; generally, enlarged follicles disappear spontaneously; on rare occasion, surgery may be required

            Sex hormone-binding globulin concentrations may be decreased for first six months after implant insertion followed by gradual recovery; thyroxine concentrations may initially be slightly decreased followed by gradual recovery to baseline

            Re-start contraception immediately after removal of implant if continued contraceptive protection is desired

            Complications of Insertion

            • Implant removal may be difficult or impossible if implant not inserted correctly, inserted too deeply, not palpable, encased in fibrous tissue, or has migrated
            • Exploratory surgery without knowledge of exact location of implant is strongly discouraged
            • Migration of implant within arm from insertion site, which may be related to deep insertion, reported; in cases where implant has migrated to pulmonary artery, chest pain and/or respiratory disorders (such as dyspnea, cough, or hemoptysis) reportred; others were asymptomatic; endovascular or surgical procedures may be needed for removal
            • If at any time implant cannot be palpated, it should be localized; removal is recommended
            • If inserted deeply (intramuscular or in fascia), neural or vascular injury may occur; to help reduce risk of neural or vascular injury insert product subdermally just under skin at inner side of non-dominant upper arm overlying the triceps muscle about 8-10 cm (3-4 inches) from medial epicondyle of humerus and 3-5 cm (1.25-2 inches) posterior to sulcus (groove) between biceps and triceps muscles; this location avoids large blood vessels and nerves lying within and surrounding the sulcus

            Pregnancy & Lactation


            Contraindicated during pregnancy because there is no need for pregnancy prevention in woman who is already pregnant; epidemiologic studies and meta-analyses have not shown an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb-reduction defects) following maternal exposure to low dose CHCs prior to conception or during early pregnancy


            Small amounts of contraceptive steroids and/or metabolites, including etonogestrel are present in human milk; no significant adverse effects observed in production or quality of breast milk, or on physical and psychomotor development of breastfed infants

            Hormonal contraceptives, including etonogestrel, can reduce milk production in breastfeeding mothers; this is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women; when possible, advise nursing mother about both hormonal and non-hormonal contraceptive options, as steroids may not be initial choice for these patients; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for hormonal contraceptive and any potential adverse effects on breastfed child from hormonal contraceptive or from underlying maternal condition

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.



            Mechanism of Action

            Progestin; inhibits secretion of gonadotropins from pituitary gland; prevents follicular maturation and ovulation, increases viscosity of cervical mucous, and stimulates growth of mammary tissues


            Bioavailability: 100%

            Release Rate

            • Week 5-6: 60-70 mcg/day
            • After 1 yr: 35-45 mcg/day
            • After 2 yr: 30-40 mcg/day
            • After 3 yr: 25-30 mcg/day


            Protein Bound: 98% (32% SHBG; 66% albumin)

            Vd: 201 L


            Hepatic CYP3A4


            Half-Life: 25 hr

            Excretion: Urine (primarily), feces





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            Tier Description
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