Etonogestrel implant in postpartum adolescents: bleeding pattern, efficacy and discontinuation rate

Tamoxifen for the Treatment of Etonogestrel Implant-Associated Bleeding in an Adolescent Gynecology Practice

OBJECTIVE

To describe clinical outcomes in a cohort of adolescent female patients using tamoxifen for the treatment of bothersome etonogestrel (ENG) implant-associated bleeding.

DESIGN

Retrospective chart review SETTING: A tertiary children's hospital PARTICIPANTS: Adolescent female patients ages 12-21 seen between August 2016 and August 2019 with an ENG implant in place who received a tamoxifen prescription for the indication of implant-associated bleeding.

INTERVENTIONS

None MAIN OUTCOME MEASURES: Main outcome measures were implant continuation rates, average time to implant discontinuation after tamoxifen prescription, reasons for implant removal, number of doses and timing of tamoxifen use, bleeding patterns, and adverse effects.

RESULTS

A total of 67 patients met the inclusion criteria. The mean age of patients was 16.7 years old. Of the patients with available follow-up data, 49 out of 60 (81.7%) were still using the implant at 12 months, 29 out of 53 (54.7%) at 24 months, and 9 out of 40 (22.5%) at 36 months. The average time from tamoxifen prescription to implant removal was 12.1 months. Bothersome bleeding was the primary reason for ENG implant discontinuation (68.6%). No side effects from tamoxifen use were reported.

CONCLUSION

Tamoxifen was well-tolerated among this cohort of patients and can be considered a treatment option to manage bothersome implant bleeding in adolescents.

Feasibility, acceptability and sustainability of postpartum contraceptive implant provision by midwives in NSW public hospitals

BACKGROUND

Repeat pregnancy in the first year after a birth is common. Many of these conceptions are unintended and may be prevented by providing access to contraception in the immediate postpartum period. Midwives in the hospital setting could potentially play a greater role in improving postnatal contraception information and provision.

AIM

We sought to implement and examine the success of a program training hospital-based midwives in immediate postpartum implant insertion.

METHODS

This mixed methods study in two hospitals in New South Wales sought to explore the feasibility, acceptability and sustainability of a program that provided competency-based implant insertion training for midwives. The study documented training completion, implant insertion numbers and experience, and conducted end of study interviews with midwives and stakeholders.

FINDINGS

Twenty-seven midwives undertook training and inserted 265 implants during the study period. Interviews with 13 midwives and 11 stakeholders concluded the program to be feasible and acceptable with midwives reporting high satisfaction from their involvement. All interviewees felt that midwives were well placed to insert implants, and reported that challenges around workload and opportunities for practice were generally manageable. It was recognised that sustainability of the program would require supportive policy and regular insertion opportunities.

CONCLUSIONS

Midwives successfully upskilled in implant insertions and there was widespread support for the program with expectations it would be sustained. Provision of contraceptive information and implant insertion by midwives in the immediate postpartum period is likely to increase contraceptive choice and access for women and contribute to reducing rapid repeat pregnancies.

The cost of improving care: a multisite economic analysis of hospital resource use for implementing recommended postpartum contraception programmes

BACKGROUND

The costs of quality improvement efforts in real-world settings are often unquantified. Better understanding could guide appropriate resource utilisation and drive efficiency. Immediate postpartum contraceptive care (ie, placement of an intrauterine device or contraceptive implant during hospitalisation for childbirth) represents an excellent case study for examining costs, because recommended services are largely unavailable and adoption requires significant effort. We therefore evaluated the cost of implementing immediate postpartum contraceptive services at four academic centres and one private hospital in USA.

METHODS

In this mixed-methods cost analysis, implementation activities were retrospectively identified using standardised data collection. Activities were categorised as preimplementation activities (infrastructure building, tool creation and stakeholder engagement) or execution activities (workforce training and process refinement). Costs were assigned based on national median salaries for the roles of individuals involved. Cross-case comparison and rapid qualitative analysis guided by the Consolidated Framework for Implementation Research were used to identify factors driving cost variation observed across sites.

RESULTS

On average, implementation activities required 204 hours (range 119-368), with this time costing $14 433.94 (range $9955.61-$23 690.49), and involving 9 (range 7-11) key team members per site. Preimplementation activities required more resources than execution activities (preimplementation: average 173 hours, $11 573.25; execution: average 31 hours, $2860.67). Sites that used lower-cost employees (eg, shifting tasks from a physician to a project manager) observed lower costs per hour for implementation activities. Implementation activities and costs were associated with local contextual factors, including stakeholder acceptance, integration of employees and infrastructure readiness for the change effort.

CONCLUSIONS

Our findings provide the first estimates of health system costs for adopting recommended contraceptive care in maternity units in USA. More broadly, our findings suggest that the budget impact of improvement efforts may vary widely depending on local context.

Etonogestrel-Releasing Contraceptive Implant for Postpartum Adolescents: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women.

DESIGN

Non-blinded, randomized controlled trial.

SETTING AND PARTICIPANTS

Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina.

INTERVENTIONS

Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit.

MAIN OUTCOME MEASURES

Contraceptive implant use at 12 months postpartum.

RESULTS

Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02).

CONCLUSION

Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.

Long-acting reversible contraception in adolescents: a systematic review and meta-analysis

BACKGROUND

Among adolescent pregnancies, 75% are unintended. Greater use of highly-effective contraception can reduce unintended pregnancy. Although multiple studies discuss adolescent contraceptive use, there is no consensus regarding the use of long-acting reversible contraception as a first-line contraception option.

OBJECTIVE

We performed a systematic review of the medical literature to assess the continuation of long-acting reversible contraceptives among adolescents.

STUDY DESIGN

Ovid-MEDLINE, Cochrane databases, and Embase databases were searched using key words relevant to the provision of long-acting contraception to adolescents. Articles published from January 2002 through August 2016 were selected for inclusion based on specific key word searches and detailed review of bibliographies. For inclusion, articles must have provided data on method continuation, effectiveness, or satisfaction of at least 1 long-acting reversible contraceptive method in participants <25 years of age. Duration of follow-up had to be ≥6 months. Long-acting reversible contraceptive methods included intrauterine devices and the etonogestrel implant. Only studies in the English language were included. Guidelines, systematic reviews, and clinical reviews were examined for additional citations and relevant points for discussion. Of 1677 articles initially identified, 90 were selected for full review. Of these, 12 articles met criteria for inclusion. All studies selected for full review were extracted by multiple reviewers; inclusion was determined by consensus among authors. For studies with similar outcomes, forest plots of combined effect estimates were created using the random effects model. The meta-analysis of observational studies in epidemiology guidelines were followed. Primary outcomes measured were continuation of method at 12 months, and expulsion rates for intrauterine devices.

RESULTS

This review included 12 studies, including 6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial. The 12 studies included 4886 women age <25 years: 4131 intrauterine device users and 755 implant users. The 12-month continuation of any long-acting reversible contraceptive device was 84.0% (95% confidence interval, 79.0-89.0%). Intrauterine device continuation was 74.0% (95% confidence interval, 61.0-87.0%) and implant continuation was 84% (95% confidence interval, 77.0-91.0%). Among postpartum adolescents, the 12-month long-acting reversible contraceptive continuation rate was 84.0% (95% confidence interval, 71.0-97.0%). The pooled intrauterine device expulsion rate was 8.0% (95% confidence interval, 4.0-11.0%).

CONCLUSION

Adolescents and young women have high 12-month continuation of long-acting reversible contraceptive methods. Intrauterine devices and implants should be offered to all adolescents as first-line contraceptive options.

Medicaid Administrator Experiences with the Implementation of Immediate Postpartum Long-Acting Reversible Contraception

OBJECTIVE

This study sought to understand state Medicaid agencies' experiences with implementing payment for long-acting reversible contraception devices inserted immediately postpartum.

METHODS

We conducted semistructured telephone interviews with Medicaid representatives from 15 agencies that have specific payment methodology for immediate postpartum long-acting reversible contraception (IPLARC). Interviews investigated agency experiences with IPLARC policy implementation. Interviews were audio-recorded and professionally transcribed. We analyzed data thematically using qualitative content analysis principles.

RESULTS

Described implementation experiences fell into three major categories: 1) payer preparedness regarding payment challenges, 2) health care system awareness, attitudes, and readiness to implement IPLARC policy in clinical settings, and 3) ongoing practice improvement. Within the category of payer preparedness, major emergent themes included Medicaid's need to ensure efficient claims processing, maintain appropriate reimbursement rates, and alleviate perceived provider mistrust about payment. With respect to health care systems, themes emerged around raising clinician awareness of IPLARC coverage, managing provider misconceptions about IPLARC, and addressing gaps in provider IPLARC insertion expertise. Regarding practice improvement, a salient theme emerged around the limitations of Medicaid to engage in ongoing clinical implementation and evaluation efforts.

CONCLUSIONS

These findings suggest a multistakeholder implementation framework that can guide the growing number of Medicaid agencies newly implementing IPLARC policy. As more Medicaid programs remove reimbursement barriers to IPLARC, clinicians and hospital administrators have a crucial opportunity to address clinical barriers to IPLARC and ensure real-time access among beneficiaries who desire this safe and effective approach to contraception.

Characterization of Medicaid policy for immediate postpartum contraception

OBJECTIVE

Long-acting reversible contraception (LARC) is safe, effective and cost-saving when provided immediately postpartum but currently underutilized due to nonreimbursement by Medicaid and other insurers. The objectives of this study were to (a) determine which state Medicaid agencies provide specific reimbursement for immediate postpartum LARC and (b) identify modifiable policy-level barriers and facilitators of immediate postpartum LARC access.

STUDY DESIGN

We conducted semistructured telephone interviews with representatives of 40 Medicaid agencies to characterize payment methodology for immediate postpartum LARC. We coded transcripts using grounded theory and content analysis principles.

RESULTS

Three categories of immediate postpartum LARC payment methodology emerged: state Medicaid agency (a) provides separate or increased bundled payment (n=15), (b) is considering providing enhanced payment (n=9) or (c) is not considering enhanced payment (n=16). Two major themes emerged related to Medicaid decision-making about immediate postpartum LARC coverage: (a) Health effects: States with payment for immediate postpartum LARC frequently cited improved maternal/child health outcomes as motivating their reimbursements. Conversely, states without payment expressed misinformation about LARC's clinical effects and lack of advocacy from local providers about clinical need for this service. (b) Financial implications: States providing payment emphasized overall cost savings. Conversely, states without reimbursement expressed concern about immediate budget constraints and potential adverse impact on existing global payment methodology for inpatient care.

CONCLUSIONS

Many states have recently provided Medicaid coverage of immediate postpartum LARC, and several other states are considering such coverage. Addressing misinformation about clinical effects and concerns about cost-effectiveness of immediate postpartum LARC may promote adoption of immediate postpartum LARC reimbursement in Medicaid agencies currently without it.

IMPLICATIONS

Medicaid policy for reimbursement of immediate postpartum LARC is evolving rapidly across the US. Our findings suggest several concrete strategies to remove policy-level barriers and promote facilitators of immediate postpartum LARC.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective?

OBJECTIVE

The objective of the study was to determine the cost-effectiveness of a hypothetical state-funded program offering immediate postpartum implant (IPI) insertion for adolescent mothers.

STUDY DESIGN

Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, n = 171) vs standard contraceptive initiation (comparison group, n = 225). Implant discontinuation, repeat pregnancies and pregnancy outcomes were determined. We compared the anticipated public expenditures for IPI recipients and comparisons at 6, 12, 24, and 36 months postpartum using the actual outcomes of this cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1000 adolescents in each arm and included 1 year of well-baby care for delivered pregnancies.

RESULTS

At 6 months, the expenditures of the IPI group exceed the comparison group by $73,000. However, at 12, 24, and 36 months, publicly funded IPIs would result in a savings of more than $550,000, $2.5 million, and $4.5 million, respectively. For every dollar spent on the IPI program, $0.79, $3.54, and $6.50 would be saved at 12, 24, and 36 months. Expenditures between the IPI and comparison groups would be equal if the comparison group pregnancy rate was 13.8%, 18.6%, and 30.5% at 12, 24, and 36 months. Actual rates were 20.1%, 46.5%, and 83.7%.

CONCLUSION

Offering IPIs to adolescent mothers is cost effective. Payors that do not currently cover IPI should integrate these data into policy considerations.

Immediate postpartum etonogestrel implant: a contraception option with long-term continuation

OBJECTIVE

To determine 3-year continuation rates of the etonogestrel contraceptive implant when inserted immediately postpartum and to identify factors associated with discontinuation.

STUDY DESIGN

A retrospective cohort of 262 women who had the contraceptive implant inserted immediately postpartum between January 2008 and March 2009 was collected from electronic medical records. Continuation rates at 1, 2 and 3 years were estimated. Adverse effects leading to removal of the implant were recorded. Multivariable Cox proportional hazard models were performed to determine factors associated with early discontinuation.

RESULTS

Large subsets of the study patients were adolescent (28.2%) and multigravid (71.8%) and presented for fewer than six prenatal visits (38.5%). Follow-up rates were over 70% at each of the 3 years. Adolescents and women with fewer than six prenatal visits had the highest continuation rates at 1 year, 94.5% and 94.1%, respectively. The cumulative implant continuation rate after 3 years was 66.3%. Multivariable analysis indicated that having six or more prenatal care visits was the only independent predictor of early discontinuation, with a hazard ratio of 3.1 (p=0.04) and 1.8 (p=<0.01) at 1 and 3 years, respectively. The most commonly reported reasons for early removal were abnormal bleeding (41.2%) and weight gain (19.1%).

CONCLUSION

The contraceptive implant has high continuation over its 3-year lifespan when inserted immediately postpartum. Continuation rates were highest among populations most vulnerable to rapid repeat and unintended pregnancies.

IMPLICATIONS

The etonogestrel implant, when placed immediately postpartum for contraception, can have high continuation rates of use for up to 3 years duration.

Metabolic effects of the contraceptive skin patch and subdermal contraceptive implant in Mexican women: a prospective study

Background

The contraceptive skin patch (CSP) accepted by the U.S. FDA in 2001 includes ethinylestradiol and norelgestromine, whereas the subdermal contraceptive implant (SCI) has etonogestrel and is also approved by the FDA. In Mexico, both are now widely used for contraception but their effects on Mexican population are unknown. The objective of the study was to evaluate if these treatments induce metabolic changes in a sample of indigenous and mestizo Mexican women.

Methods

An observational, prospective, longitudinal, non-randomized study of women between 18 and 35 years of age assigned to CSP or SCI. We performed several laboratory tests: clinical chemistry, lipid profile, and liver and thyroid function tests. Also, serum levels of insulin, C-peptide, IGF-1, leptin, adiponectin, and C reactive protein were assayed.

Results

Sixty-two women were enrolled, 25 used CSP (0 indigenous; 25 mestizos) and 37 used SCI (18 indigenous; 19 mestizos). Clinical symptoms were relatively more frequent in the SCI group. Thirty-four contraceptive users gained weight without other clinical significant changes. After 4 months of treatment, significant changes were found in some biochemical parameters in both treatment groups. Most were clinically irrelevant. Interestingly, the percentage of users with an abnormal atherogenic index diminished from 75% to 41.6% after follow-up.

Conclusions

The CSP slightly modified the metabolic variables. Most changes were nonsignificant, whereas for SCI users changes were more evident and perhaps beneficial. Results of this attempt to evaluate the effects of contraceptives in mestizo and native-American populations show that clinical symptoms are frequent in Mexican users of CSP and SCI. Although these medications may affect some metabolic variables, these changes seem clinically irrelevant. Induction of abnormalities in other physiological pathways cannot be ruled out.

Myths and misconceptions about long-acting reversible contraception (LARC)

PURPOSE

To discuss common myths and misconceptions about long-acting reversible contraception (LARC) among patients and health care providers.

METHODS

We address some of these common myths in an effort to provide clinicians with accurate information to discuss options with patients, parents, and referring providers. The list of myths was created through an informal survey of an online listserv of 200 family planning experts and from the experiences of the authors.

RESULTS

When presented with information about LARC, adolescents are more likely to request LARC and are satisfied with LARC. Clinicians have an important role in counseling about and providing LARC to their adolescent patients as well as supporting them in managing associated side effects.

CONCLUSIONS

This review article can be used as a resource for contraceptive counseling visits and for the continuing education of health professionals providing adolescent reproductive health care.

The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review

Repeat pregnancy within 2 years of a previous birth or abortion occurs in approximately 35% of recently pregnant female adolescents. The majority of these pregnancies are classified as unintended with about half ending in births and the remainder in abortions. Rapid repeat pregnancy (RRP) is associated with increased maternal and neonatal morbidity and continues a cycle of economic deprivation for young women and their families. Immediately following a pregnancy, most young women report an intention to avoid pregnancy in the near future, but many change their minds or become ambivalent within months. Lack of contraceptive use is more common among those teens that resume sexual intercourse earlier, live with a male partner, had a preterm delivery, or had an intended teen pregnancy. Adolescents who do not initiate a long-acting reversible contraceptive (LARC) method (intrauterine device or contraceptive implant) have up to a 35 times increased risk of RRP compared with their peers using LARC. Risk of RRP is decreased when LARC methods are initiated earlier after an abortion or within the postpartum period. This review will focus on the prevalence of RRP, the risk factors for RRP, and the effectiveness of strategies to reduce unintended RRP including counseling and early initiation of long-acting contraceptive methods.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider

PURPOSE OF REVIEW

This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population.

RECENT FINDINGS

Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates.

SUMMARY

The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE

The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion.

STUDY DESIGN

Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined.

RESULTS

Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03).

CONCLUSION

IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.