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IMPLANON®
(etonogestrel) Implant
IMPLANON (etonogestrel implant) is a progestin-only, soft, flexible implant preloaded in a sterile, disposable applicator for subdermal use. The implant is off-white, non-biodegradable and 4 cm in length with a diameter of 2 mm (see Figure 22). Each implant consists of an ethylene vinylacetate (EVA) copolymer core, containing 68 mg of the synthetic progestin etonogestrel, surrounded by an EVA copolymer skin. Once inserted subdermally, the release rate is 60 to 70 mcg/day in Week 5 to 6 and decreases to approximately 35 to 45 mcg/day at the end of the first year, to approximately 30 to 40 mcg/day at the end of the second year, and then to approximately 25 to 30 mcg/day at the end of the third year. IMPLANON is a progestin-only contraceptive and does not contain estrogen. IMPLANON does not contain latex and is not radio-opaque.
Figure 22 (Not to scale)
 |
Etonogestrel [13-Ethyl-17-hydroxy-11-methylene-18,19-dinor-17α-pregn-4-en-20-yn-3-one], structurally derived from 19-nortestosterone, is the synthetic biologically active metabolite of the synthetic progestin desogestrel. It has a molecular weight of 324.46 and the following structural formula (Figure 23).
Figure 23
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IMPLANON® is indicated for use by women to prevent pregnancy.
The efficacy of IMPLANON does not depend on daily, weekly or monthly administration.
All healthcare providers should receive instruction and training prior to performing insertion and/or removal of IMPLANON.
A single IMPLANON implant is inserted subdermally in the upper arm. To reduce the risk of neural or vascular injury, the implant should be inserted at the inner side of the non-dominant upper arm about 8- 10 cm (3-4 inches) above the medial epicondyle of the humerus. The implant should be inserted subdermally just under the skin, avoiding the sulcus (groove) between the biceps and triceps muscles and the large blood vessels and nerves that lie there in the neurovascular bundle deeper in the subcutaneous tissues. An implant inserted more deeply than subdermally (deep insertion) may not be palpable and the localization and/or removal can be difficult or impossible [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. IMPLANON must be inserted by the expiration date stated on the packaging. IMPLANON is a long-acting (up to 3 years), reversible, hormonal contraceptive method. The implant must be removed by the end of the third year and may be replaced by a new implant at the time of removal, if continued contraceptive protection is desired.
IMPORTANT: Rule out pregnancy before inserting the implant.
Timing of insertion depends on the woman's recent contraceptive history, as follows:
IMPLANON should be inserted between Day 1 (first day of menstrual bleeding) and Day 5 of the menstrual cycle, even if the woman is still bleeding.
If inserted as recommended, back-up contraception is not necessary. If deviating from the recommended timing of insertion, the woman should be advised to use a barrier method until 7 days after insertion. If intercourse has already occurred, pregnancy should be excluded.
IMPLANON should preferably be inserted on the day after the last active tablet of the previous combined oral contraceptive or on the day of the removal of the vaginal ring or transdermal patch. At the latest, IMPLANON should be inserted on the day following the usual tablet-free, ring-free, patch-free or placebo tablet interval of the previous combined hormonal contraceptive.
If inserted as recommended, back-up contraception is not necessary. If deviating from the recommended timing of insertion, the woman should be advised to use a barrier method until 7 days after insertion. If intercourse has already occurred, pregnancy should be excluded.
There are several types of progestin-only methods. IMPLANON should be inserted as follows:
If inserted as recommended, back-up contraception is not necessary. If deviating from the recommended timing of insertion, the woman should be advised to use a barrier method until 7 days after insertion. If intercourse has already occurred, pregnancy should be excluded.
If inserted as recommended, back-up contraception is not necessary. If deviating from the recommended timing of insertion, the woman should be advised to use a barrier method until 7 days after insertion. If intercourse has already occurred, pregnancy should be excluded.
The basis for successful use and subsequent removal of IMPLANON is a correct and carefully performed subdermal insertion of the single, rod-shaped implant in accordance with the instructions. Both the healthcare provider and the woman should be able to feel the implant under the skin after placement.
All healthcare providers performing insertions and/or removals of IMPLANON should receive instructions and training prior to inserting or removing the implant. Information concerning the insertion and removal of IMPLANON will be sent upon request free of charge [1-877- IMPLANON (1-877-467-5266)].
Prior to inserting IMPLANON carefully read the instructions for insertion as well as the full prescribing information.
Before insertion of IMPLANON, the healthcare provider should confirm that:
Insert IMPLANON under aseptic conditions.
The following equipment is needed for the implant insertion:
An applicator and its parts are shown below (Figures 1a and 1b).
Figure 1a (Not to scale) and Figure 1b
 |
The procedure used for IMPLANON insertion is opposite from that of an injection. The obturator keeps IMPLANON in place while the cannula is retracted. The obturator must remain fixed in place while the cannula with needle is retracted from the arm. Do not pus h the obturator.
Step 1. Have the woman lie on her back on the examination table with her non-dominant arm flexed at the elbow and externally rotated so that her wrist is parallel to her ear or her hand is positioned next to her head (Figure 2).
Figure 2
 |
Step 2. Identify the insertion site, which is at the inner side of the non-dominant upper arm about 8-10 cm (3-4 inches) above the medial epicondyle of the humerus, avoiding the sulcus (groove) between the biceps and triceps muscles and the large blood vessels and nerves that lie there in the neurovascular bundle deeper in the subcutaneous tissue (Figure 3). The implant should be inserted subdermally just under the skin [see WARNINGS AND PRECAUTIONS].
Step 3. Make two marks with a sterile marker: first, mark the spot where the etonogestrel implant will be inserted, and second, mark a spot a few centimeters proximal to the first mark (Figure 3). This second mark will later serve as a direction guide during insertion.
Figure 3
 |
Step 4. Clean the insertion site with an antiseptic solution.
Step 5. Anesthetize the insertion area (for example, with anesthetic spray or by injecting 2 mL of 1% lidocaine just under the skin along the planned insertion tunnel).
Step 6. Remove the sterile pre-loaded disposable IMPLANON applicator carrying the implant from its blister. Keep the IMPLANON needle and rod sterile. The applicator should not be used if sterility is in question. If contamination occurs, use a new package of IMPLANON with a new sterile applicator.
Step 7. Keep the shield on the needle and look for the IMPLANON rod, seen as a white cylinder inside the needle tip.
Step 8. If you don't see the IMPLANON rod, tap the top of the needle shield against a firm surface to bring the implant into the needle tip.
Step 9. Following visual confirmation, lower the IMPLANON rod back into the needle by tapping it back into the needle tip. Then remove the needle shield, while holding the applicator upright.
Step 10. Note that IMPLANON can fall out of the needle. Therefore, after you remove the needle shield, keep the applicator in the upright position until the moment of insertion
Step 11. With your free hand, stretch the skin around the insertion site with thumb and index finger (Figure 4).
Figure 4
 |
Step 12. At a slight angle (not greater than 20°), insert only the tip of the needle with the beveled side up into the insertion site (Figure 5).
Figure 5
 |
Step 13. Lower the applicator to a horizontal position. Lift the skin up with the tip of the needle, but keep the needle in the subdermal connective tissue (Figure 6).
Figure 6
 |
Step 14. While “tenting” (lifting) the skin, gently insert the needle to its full length. Keep the needle parallel to the surface of the skin during insertion (Figure 7).
Figure 7
 |
Step 15. If IMPLANON is placed deeply, the removal process can be difficult or impossible. If the needle is not inserted to its full length, the implant may protrude from the insertion site and fall out.
Step 16. Break the seal of the applicator by pressing the obturator support (Figure 8).
Figure 8
 |
Step 17. Turn the obturator 90° in either direction with respect to the needle (Figure 9).
Figure 9
 |
Step 18. While holding the obturator fixed in place on the arm, fully retract the cannula (Figure 10). Note: This procedure is opposite from an injection. Do not pus h the obturator. By holding the obturator fixed in place on the arm and fully retracting the cannula, the implant will be left in its correct subdermal position. Do not simultaneously retract the obturator and cannula from the patient's arm.
Figure 10
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In this figure, the right hand is holding the obturator in place while the left hand is retracting the cannula.
Step 19. Confirm that the implant has been inserted by checking the tip of the needle for the absence of the implant. After insertion of the implant, the grooved tip of the obturator will be visible inside the needle (Figure 11).
Figure 11
 |
Step 20. Always verify the presence of the implant in the woman's arm immediately after insertion by palpation. By palpating both ends of the implant, you should be able to confirm the presence of the 4-cm rod (Figure 12). See section below “If the rod is not palpable”.
Figure 12
 |
Step 21. Place a small adhesive bandage over the insertion site. Request that the woman palpate the implant.
Step 22. Apply a pressure bandage with sterile gauze to minimize bruising. The woman may remove the pressure bandage in 24 hours and the small bandage over the insertion site in 3 to 5 days.
Step 23. Complete the USER CARD and give it to the woman to keep. Also, complete the PATIENT CHART LABEL and affix it to the woman's medical record.
Step 24. The applicator is for single use only and should be disposed in accordance with the Center for Disease Control and Prevention guidelines for handling of hazardous waste.
If the rod is not palpable:
If you cannot feel the implant or are in doubt of its presence, the implant may not have been inserted or it may have been inserted deeply:
Until the presence of the implant has been verified, the woman should be advised to use a non-hormonal contraceptive method, such as condoms .
Once the non-palpable implant has been located, removal is recommended [see WARNINGS AND PRECAUTIONS].
Before initiating the removal procedure, the healthcare provider should carefully read the instructions for removal and consult the USER CARD and/or the PATIENT CHART LABEL for the location of the implant. The exact location of the implant in the arm should be verified by palpation. [See DOSAGE AND ADMINISTRATION, Localization and Removal of a Non-Palpable Implant.]
Procedure For Removal Of An Implant That Is Palpable
Before removal of the implant, the healthcare provider should confirm that:
The following equipment is needed for removal of the implant:
Step 1. Clean the site where the incision will be made and apply an antiseptic. Locate the implant by palpation and mark the distal end (end closest to the elbow), for example, with a sterile marker (Figure 13).
Figure 13
 |
Step 2. Anesthetize the arm, for example, with 0.5 to 1 mL 1% lidocaine at the marked site where the incision will be made (Figure 14). Be sure to inject the local anesthetic under the implant to keep it close to the skin surface.
Figure 14
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Step 3. Push down the proximal end of the implant (Figure 15) to stabilize it; a bulge may appear indicating the distal end of the implant. Starting at the distal tip of the implant, make a longitudinal incision of 2 mm towards the elbow.
Figure 15
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Step 4. Gently push the implant towards the incision until the tip is visible. Grasp the implant with forceps (preferably curved mosquito forceps) and gently remove the implant (Figure 16).
Figure 16
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Step 5. If the implant is encapsulated, make an incision into the tissue sheath and then remove the implant with the forceps (Figures 17 and 18).
Figure 17 and Figure 18
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Step 6. If the tip of the implant does not become visible in the incision, gently insert a forceps into the incision (Figure 19). Flip the forceps over into your other hand (Figure 20).
Figure 19 and Figure 20
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Step 7. With a second pair of forceps carefully dissect the tissue around the implant and grasp the implant (Figure 21). The implant can then be removed.
Figure 21
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Step 8. Confirm that the entire implant, which is 4 cm long, has been removed by measuring its length. There have been reports of broken implants while in the patient's arm. In some cases, difficult removal of the broken implant has been reported. If a partial implant (less than 4 cm) is removed, the remaining piece should be removed by following the instructions in section 2.3. [See DOSAGE AND ADMINISTRATION.] If the woman would like to continue using IMPLANON, a new implant may be inserted immediately after the old implant is removed using the same incision [see DOSAGE AND ADMINISTRATION].
Step 9. After removing the implant, close the incision with a steri-strip and apply an adhesive bandage.
Step 10. Apply a pressure bandage with sterile gauze to minimize bruising. The woman may remove the pressure bandage in 24 hours and the small bandage in 3 to 5 days.
There have been reports of migration of the implant; usually this involves minor movement relative to the original position [see WARNINGS AND PRECAUTIONS], but may lead to the implant not being palpable in the location in which it was placed. An implant that has been deeply inserted or has migrated may not be palpable and therefore imaging procedures, as described below, may be required for localization.
A non-palpable implant should always be located prior to attempting removal. Suitable methods for localization include ultrasound with a high-frequency linear array transducer (10 MHz or greater) or magnetic resonance imaging. Once the implant has been localized in the arm, the implant should be removed according to the instructions in DOSAGE AND ADMINISTRATION, Procedure for Removal of an Implant that is Palpable, and the use of ultrasound guidance during the removal should be considered.
If the implant cannot be found in the arm after comprehensive localization attempts, consult a radiologist familiar with applying advanced imaging techniques to the chest, as events of migration to the pulmonary vasculature have been reported. If the implant is located in the chest, surgical or endovascular procedures may be needed for removal; healthcare providers familiar with the anatomy of the chest should be consulted.
If at any time these imaging methods fail to locate the implant, etonogestrel blood level determination can be used for verification of the presence of the implant. For details on etonogestrel blood level determination, call 1-877-IMPLANON (1-877-467-5266) for further instructions.
If the implant migrates within the arm, removal may require a minor surgical procedure with a larger incision or a surgical procedure in an operating room. Removal of deeply inserted implants should be conducted with caution in order to prevent injury to deeper neural or vascular structures in the arm and be performed by healthcare providers familiar with the anatomy of the arm.
Exploratory surgery without knowledge of the exact location of the implant is strongly discouraged.
Immediate replacement can be done after removal of the previous implant and is similar to the insertion procedure described in section 2.2 Insertion of IMPLANON.
The new implant may be inserted in the same arm, and through the same incision from which the previous implant was removed. If the same incision is being used to insert a new implant, anesthetize the insertion site [for example, 2 mL lidocaine (1%)] applying it just under the skin along the 'insertion canal.'
Follow the subsequent steps in the insertion instructions [see DOSAGE AND ADMINISTRATION].
Single, off-white, soft, flexible, ethylene vinylacetate (EVA) implant, 4 cm in length and 2 mm in diameter containing 68 mg etonogestrel.
One IMPLANON package consists of a single implant containing 68 mg etonogestrel that is 4 cm in length and 2 mm in diameter, which is pre-loaded in the needle of a disposable applicator. The sterile applicator containing the implant is packed in a blister pack.
NDC 0052-0272-01
Store IMPLANON (etonogestrel implant) at 25°C (77°F); excursions permitted to 15°-30°C (59°-86°F) [see USP Controlled Room Temperature]. Protect from light. Avoid storing IMPLANON in direct sunlight or at temperatures above 30°C (86°F).
Manufactured for: Merck Sharp & Dohme Corp., a subsidiary of MERCK & CO., INC., Whitehouse Station, NJ 08889, USA. Manufactured by: N.V. Organon, Oss, The Netherlands, a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ 08889, USA. Revised: Mar 2016
The following adverse reactions reported with the use of hormonal contraception are discussed elsewhere in the labeling:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
In clinical trials including 942 women who were evaluated for safety, change in menstrual bleeding patterns (irregular menses) was the most common adverse reaction causing discontinuation of use of IMPLANON (11.1% of women).
Adverse reactions that resulted in a rate of discontinuation of ≥ 1% are shown in Table 3.
Table 3: Adverse Reactions Leading to Discontinuation
of Treatment in 1% or More of Subjects in Clinical Trials of IMPLANON
| Adverse Reactions | All Studies N = 942 |
| Bleeding Irregularities* | 11.1% |
| Emotional Lability† | 2.3% |
| Weight Increase | 2.3% |
| Headache | 1.6% |
| Acne | 1.3% |
| Depression‡ | 1.0% |
| *Includes “frequent”, “heavy”,
“prolonged”, “spotting”, and other patterns of bleeding irregularity. †Among US subjects (N=330), 6.1% experienced emotional lability that led to discontinuation. ‡Among US subjects (N=330), 2.4 % experienced depression that led to discontinuation. |
|
Other adverse reactions that were reported by at least 5% of subjects in clinical trials of IMPLANON are listed in Table 4.
Table 4: Common Adverse Reactions Reported by
≥ 5% of Subjects in Clinical Trials with IMPLANON
| Adverse Reaction | All Studies N=942 |
| Headache | 24.9% |
| Vaginitis | 14.5% |
| Weight increase | 13.7% |
| Acne | 13.5% |
| Breast pain | 12.8% |
| Abdominal pain | 10.9% |
| Pharyngitis | 10.5% |
| Leukorrhea | 9.6% |
| Influenza-like symptoms | 7.6% |
| Dizziness | 7.2% |
| Dysmenorrhea | 7.2% |
| Back pain | 6.8% |
| Emotional lability | 6.5% |
| Nausea | 6.4% |
| Pain | 5.6% |
| Nervousness | 5.6% |
| Depression | 5.5% |
| Hypersensitivity | 5.4% |
| Insertion site pain | 5.2% |
Implant site complications were reported by 3.6% of subjects during any of the assessments in clinical trials. Pain was the most frequent implant site complication, reported during and/or after insertion, occurring in 2.9% of subjects. Additionally, hematoma, redness, and swelling were reported by 0.1%, 0.3%, and 0.3% of patients, respectively [see WARNINGS AND PRECAUTIONS].
The following additional adverse reactions have been identified during post-approval use of IMPLANON. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
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.
Complications related to insertion or removal of the implant reported include: bruising, slight local irritation, pain or itching, fibrosis at the implant site, paresthesia or paresthesia-like events, scarring and abscess. Expulsion or migration of the implant, have been reported, including to the chest wall. In some cases implants have been found within the vasculature including the pulmonary artery. Some cases of implants found within the pulmonary artery reported chest pain and/or dyspnea; others have been reported as asymptomatic [see WARNINGS AND PRECAUTIONS]. Surgical intervention might be necessary when removing the implant.
Drugs or herbal products that induce enzymes, including CYP3A4, that metabolize progestins may decrease the plasma concentrations of progestins, and may decrease the effectiveness of IMPLANON. In women on long-term treatment with hepatic enzyme inducing drugs, it is recommended to remove the implant and to advise a contraceptive method that is unaffected by the interacting drug.
Some of these drugs or herbal products that induce enzymes, including CYP3A4, include:
Significant changes (increase or decrease) in the plasma levels of progestin have been noted in some cases of co-administration with HIV protease inhibitors or with non-nucleoside reverse transcriptase inhibitors. Consult the labeling of all concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.
CYP3A4 inhibitors such as itraconazole or ketoconazole may increase plasma concentrations of etonogestrel.
Hormonal contraceptives may affect the metabolism of other drugs. Consequently, plasma concentrations may either increase (for example, cyclosporin) or decrease (for example, lamotrigine). Consult the labeling of all concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.
Included as part of the PRECAUTIONS section.
The following information is based on experience with either IMPLANON, other progestin-only contraceptives, or experience with combination (estrogen plus progestin) oral contraceptives .
IMPLANON should be inserted subdermally so that it will be palpable after insertion, and this should be confirmed by palpation immediately after insertion. Failure to insert IMPLANON properly may go unnoticed unless it is palpated immediately after insertion. Undetected failure to insert the implant may lead to an unintended pregnancy. Complications related to insertion and removal procedures, such as pain, paresthesias, bleeding, hematoma, scarring or infection, may occur. Occasionally in postmarketing use, implant insertions have failed because the implant fell out of the needle or remained in the needle during insertion.
If IMPLANON is inserted deeply (intramuscular or in the fascia), neural or vascular injury may occur. To reduce the risk of neural or vascular injury, IMPLANON should be inserted at the inner side of the non-dominant upper arm about 8-10 cm (3-4 inches) above the medial epicondyle of the humerus. IMPLANON should be inserted subdermally just under the skin, avoiding the sulcus (groove) between the biceps and triceps muscles and the large blood vessels and nerves that lie there in the neurovascular bundle deeper in the subcutaneous tissues. Deep insertions of IMPLANON have been associated with paraesthesia (due to neural injury), migration of the implant (due to intramuscular or fascial insertion), and intravascular insertion. If infection develops at the insertion site, start suitable treatment. If the infection persists, the implant should be removed. Incomplete insertions or infections may lead to expulsion.
Implant removal may be difficult or impossible if the implant is not inserted correctly, is inserted too deeply, not palpable, encased in fibrous tissue, or has migrated.
There have been reports of migration of the implant within the arm from the insertion site, which may be related to a deep insertion. There also have been postmarketing reports of implants located within the vessels of the arm and the pulmonary artery, which may be related to deep insertions or intravascular insertion. In cases where the implant has migrated to the pulmonary artery, endovascular procedures may be needed for removal.
If at any time the implant cannot be palpated, it should be localized and removal is recommended.
Exploratory surgery without knowledge of the exact location of the implant is strongly discouraged. Removal of deeply inserted implants should be conducted with caution in order to prevent injury to deeper neural or vascular structures in the arm and be performed by healthcare providers familiar with the anatomy of the arm. If the implant is located in the chest, healthcare providers familiar with the anatomy of the chest should be consulted. Failure to remove the implant may result in continued effects of etonogestrel, such as compromised fertility, ectopic pregnancy, or persistence or occurrence of a drug-related adverse event.
After starting IMPLANON, 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. In clinical trials, bleeding patterns ranged from amenorrhea (1 in 5 women) to frequent and/or prolonged bleeding (1 in 5 women). The bleeding pattern experienced during the first three months of IMPLANON use is broadly predictive of the future bleeding pattern for many women. Women should be counseled regarding the bleeding pattern changes they may experience so that they know what to expect. Abnormal bleeding should be evaluated as needed to exclude pathologic conditions or pregnancy.
In clinical studies of IMPLANON, reports of changes in bleeding pattern were the most common reason for stopping treatment (11.1%). Irregular bleeding (10.8%) was the single most common reason women stopped treatment, while amenorrhea (0.3%) was cited less frequently. In these studies, women had an average of 17.7 days of bleeding or spotting every 90 days (based on 3,315 intervals of 90 days recorded by 780 patients). The percentages of patients having 0, 1-7, 8-21, or > 21 days of spotting or bleeding over a 90-day interval while using the IMPLANON implant are shown in Table 1.
Table 1: Percentages of Patients with 0, 1 - 7, 8 -
21, or > 21 Days of Spotting or Bleeding Over a 90-Day Interval While Using
IMPLANON
| Total Days of Spotting or Bleeding | Percentage of Patients | ||
| Treatment Days 91-180 (N = 745) |
Treatment Days 271-360 (N = 657) |
Treatment Days 631-720 (N = 547) |
|
| 0 Days | 19% | 24% | 17% |
| 1-7 Days | 15% | 13% | 12% |
| 8-21 Days | 30% | 30% | 37% |
| > 21 Days | 35% | 33% | 35% |
Bleeding patterns observed with use of IMPLANON for up to 2 years, and the proportion of 90-day intervals with these bleeding patterns, are summarized in Table 2.
Table 2: Bleeding Patterns Using IMPLANON during the
First 2 Years of Use*
| BLEEDING PATTERNS | DEFINITIONS | % † |
| Infrequent | Less than three bleeding and/or spotting episodes in 90 days (excluding amenorrhea) | 33.6 |
| Amenorrhea | No bleeding and/or spotting in 90 days | 22.2 |
| Prolonged | Any bleeding and/or spotting episode lasting more than 14 days in 90 days | 17.7 |
| Frequent | More than 5 bleeding and/or spotting episodes in 90 days | 6.7 |
| *Based on 3,315 recording periods of 90 day's duration in
780 women, excluding the first 90 days after implant insertion †% = Percentage of 90-day intervals with this pattern |
||
In case of undiagnosed, persistent, or recurrent abnormal vaginal bleeding, appropriate measures should be conducted to rule out malignancy.
As with all progestin-only contraceptive products, be alert to the possibility of an ectopic pregnancy among women using IMPLANON who become pregnant or complain of lower abdominal pain. Although ectopic pregnancies are uncommon among women using IMPLANON, a pregnancy that occurs in a woman using IMPLANON may be more likely to be ectopic than a pregnancy occurring in a woman using no contraception.
The use of combination hormonal contraceptives (progestin plus estrogen) increases the risk of vascular events, including arterial events (strokes and myocardial infarctions) or deep venous thrombotic events (venous thromboembolism, deep venous thrombosis, retinal vein thrombosis, and pulmonary embolism). IMPLANON is a progestin-only contraceptive. It is unknown whether this increased risk is applicable to etonogestrel alone. It is recommended, however, that women with risk factors known to increase the risk of venous and arterial thromboembolism be carefully assessed.
There have been postmarketing reports of serious arterial thrombotic and venous thromboembolic events, including cases of pulmonary emboli (some fatal), deep vein thrombosis, myocardial infarction, and strokes, in women using IMPLANON. IMPLANON should be removed in the event of a thrombosis.
Due to the risk of thromboembolism associated with pregnancy and immediately following delivery, IMPLANON should not be used prior to 21 days postpartum. Women with a history of thromboembolic disorders should be made aware of the possibility of a recurrence.
Evaluate for retinal vein thrombosis immediately if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions.
Consider removal of the IMPLANON implant in case of long-term immobilization due to surgery or illness.
If follicular development occurs, atresia of the follicle is sometimes delayed, and the follicle may continue to grow beyond the size it would attain in a normal cycle. Generally, these enlarged follicles disappear spontaneously. On rare occasion, surgery may be required.
Women who currently have or have had breast cancer should not use hormonal contraception because breast cancer may be hormonally sensitive [see CONTRAINDICATIONS]. Some studies suggest that the use of combination hormonal contraceptives might increase the incidence of breast cancer; however, other studies have not confirmed such findings.
Some studies suggest that the use of combination hormonal contraceptives is associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there is controversy about the extent to which such findings are due to differences in sexual behavior and other factors.
Women with a family history of breast cancer or who develop breast nodules should be carefully monitored.
Disturbances of liver function may necessitate the discontinuation of hormonal contraceptive use until markers of liver function return to normal. Remove IMPLANON if jaundice develops.
Hepatic adenomas are associated with combination hormonal contraceptives use. An estimate of the attributable risk is 3.3 cases per 100,000 for combination hormonal contraceptives users. It is not known whether a similar risk exists with progestin-only methods like IMPLANON.
The progestin in IMPLANON may be poorly metabolized in women with liver impairment. Use of IMPLANON in women with active liver disease or liver cancer is contraindicated [see CONTRAINDICATIONS].
In clinical studies, mean weight gain in US IMPLANON users was 2.8 pounds after 1 year and 3.7 pounds after 2 years. How much of the weight gain was related to the implant is unknown. In studies, 2.3% of the users reported weight gain as the reason for having the implant removed.
Women with a history of hypertension-related diseases or renal disease should be discouraged from using hormonal contraception. For women with well-controlled hypertension, use of IMPLANON can be considered. Women with hypertension using IMPLANON should be closely monitored. If sustained hypertension develops during the use of IMPLANON, or if a significant increase in blood pressure does not respond adequately to antihypertensive therapy, IMPLANON should be removed.
Studies suggest a small increased relative risk of developing gallbladder disease among combination hormonal contraceptive users. It is not known whether a similar risk exists with progestin-only methods like IMPLANON.
Use of IMPLANON may induce mild insulin resistance and small changes in glucose concentrations of unknown clinical significance. Carefully monitor prediabetic and diabetic women using IMPLANON.
Women who are being treated for hyperlipidemia should be followed closely if they elect to use IMPLANON. Some progestins may elevate LDL levels and may render the control of hyperlipidemia more difficult.
Women with a history of depressed mood should be carefully observed. Consideration should be given to removing IMPLANON in patients who become significantly depressed.
In clinical trials with IMPLANON, the etonogestrel levels in blood decreased below sensitivity of the assay by one week after removal of the implant. In addition, pregnancies were observed to occur as early as 7 to 14 days after removal. Therefore, a woman should re-start contraception immediately after removal of the implant if continued contraceptive protection is desired.
Hormonal contraceptives may cause some degree of fluid retention. They should be prescribed with caution, and only with careful monitoring, in patients with conditions which might be aggravated by fluid retention. It is unknown if IMPLANON causes fluid retention.
Contact lens wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist.
There have been reports of broken or bent implants while in the patient's arm. Based on in vitro data, when the implant is broken or bent, the release rate of etonogestrel may be slightly increased.
When an implant is removed, it is important to remove it in its entirety [see DOSAGE AND ADMINISTRATION].
A woman who is using IMPLANON should have a yearly visit with her healthcare provider for a blood pressure check and for other indicated health care.
Sex hormone-binding globulin concentrations may be decreased for the first 6 months after IMPLANON insertion followed by a gradual recovery. Thyroxine concentrations may initially be slightly decreased followed by gradual recovery to baseline.
“See FDA-Approved Patient Labeling (PATIENT INFORMATION)”
FDA-Approved Patient Labeling
See the full patient product information for IMPLANON.
In a 24-month carcinogenicity study in rats with subdermal implants releasing 10 and 20 mcg etonogestrel per day (equal to approximately 1.8-3.6 times the systemic steady state exposure in women using IMPLANON), no drug-related carcinogenic potential was observed. Etonogestrel was not genotoxic in the in vitro Ames/Salmonella reverse mutation assay, the chromosomal aberration assay in Chinese hamster ovary cells or in the in vivo mouse micronucleus test. Fertility returned after withdrawal from treatment.
IMPLANON is not indicated for use during pregnancy [see CONTRAINDICATIONS].
Teratology studies have been performed in rats and rabbits using oral administration up to 390 and 790 times the human IMPLANON dose (based upon body surface) and revealed no evidence of fetal harm due to etonogestrel exposure.
Studies have revealed no increased risk of birth defects in women who have used combination oral contraceptives before pregnancy or during early pregnancy. There is no evidence that the risk associated with IMPLANON is different from that of combination oral contraceptives.
IMPLANON should be removed if maintaining a pregnancy.
Based on limited clinical data, IMPLANON may be used during breastfeeding after the fourth postpartum week. Use of IMPLANON before the fourth postpartum week has not been studied. Small amounts of etonogestrel are excreted in breast milk. During the first months after insertion of IMPLANON, when maternal blood levels of etonogestrel are highest, about 100 ng of etonogestrel may be ingested by the child per day based on an average daily milk ingestion of 658 mL. Based on daily milk ingestion of 150 mL/kg, the mean daily infant etonogestrel dose one month after insertion of IMPLANON is about 2.2% of the weight-adjusted maternal daily dose, or about 0.2% of the estimated absolute maternal daily dose. The health of breast-fed infants whose mothers began using IMPLANON during the fourth to eighth week postpartum (n=38) was evaluated in a comparative study with infants of mothers using a non-hormonal IUD (n=33). They were breast-fed for a mean duration of 14 months and followed up to 36 months of age. No significant effects and no differences between the groups were observed on the physical and psychomotor development of these infants. No differences between groups in the production or quality of breast milk were detected.
Healthcare providers should discuss both hormonal and non-hormonal contraceptive options, as steroids may not be the initial choice for these patients.
Safety and efficacy of IMPLANON have been established in women of reproductive age. Safety and efficacy of IMPLANON are expected to be the same for postpubertal adolescents. However, no clinical studies have been conducted in women less than 18 years of age. Use of this product before menarche is not indicated.
This product has not been studied in women over 65 years of age and is not indicated in this population.
No studies were conducted to evaluate the effect of hepatic disease on the disposition of IMPLANON. The use of IMPLANON in women with active liver disease is contraindicated [see CONTRAINDICATIONS].
No studies were conducted to evaluate the effect of renal disease on the disposition of IMPLANON.
The effectiveness of IMPLANON in women who weighed more than 130% of their ideal body weight has not been defined because such women were not studied in clinical trials. Serum concentrations of etonogestrel are inversely related to body weight and decrease with time after implant insertion. It is therefore possible that IMPLANON may be less effective in overweight women, especially in the presence of other factors that decrease serum etonogestrel concentrations such as concomitant use of hepatic enzyme inducers.
Overdosage may result if more than 1 implant is inserted. In case of suspected overdose, the implant should be removed.
IMPLANON should not be used in women who have
The contraceptive effect of IMPLANON is achieved by suppression of ovulation, increased viscosity of the cervical mucus, and alterations in the endometrium.
Exposure-response relationships of IMPLANON are unknown.
After subdermal insertion of the etonogestrel implant, etonogestrel is released into the circulation and is approximately 100% bioavailable.
The mean peak serum concentrations in 3 pharmacokinetic studies ranged between 781 and 894 pg/mL and were reached within the first few weeks after insertion. The mean serum etonogestrel concentration decreases gradually over time declining to 192 to 261 pg/mL at 12 months (n=41), 154 to 194 pg/mL at 24 months (n=35), and 156 to 177 pg/mL at 36 months (n=17).
The pharmacokinetic profile of IMPLANON from 1 of 3 pharmacokinetic studies is shown in Figure 24.
Figure 24 : Mean Serum Concentration-time Profile of
Etonogestrel During 2 Years of IMPLANON Use and After Removal in 20 Healthy
Women
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The apparent volume of distribution averages about 201 L. Etonogestrel is approximately 32% bound to sex hormone binding globulin (SHBG) and 66% bound to albumin in blood.
In vitro data shows that etonogestrel is metabolized in liver microsomes by the cytochrome P450 3A4 isoenzyme. The biological activity of etonogestrel metabolites is unknown.
The elimination half-life of etonogestrel is approximately 25 hours. Excretion of etonogestrel and its metabolites, either as free steroid or as conjugates, is mainly in urine and to a lesser extent in feces. After removal of the implant, etonogestrel concentrations decreased below sensitivity of the assay by 1 week.
In clinical trials of up to 3 years duration that involved 923 subjects, 18 - 40 years of age at entry, and 1,756 women-years of IMPLANON use, the total exposures expressed as 28-day cycle equivalents by study year were:
Year 1: 10,866 cycles
Year 2: 8,581 cycles
Year 3: 3,442 cycles
The clinical trials excluded women who:
In the subgroup of women 18 to 35 years of age at entry, 6 pregnancies during 20,648 cycles of use were reported. Two pregnancies occurred in each of Years 1, 2 and 3. Each conception was likely to have occurred shortly before or within 2 weeks after IMPLANON removal. With these 6 pregnancies, the cumulative Pearl Index was 0.38 pregnancies per 100 women-years of use.
In clinical trials with IMPLANON, the etonogestrel levels in blood decreased below sensitivity of the assay by one week after removal of the implant. In addition, pregnancies were observed to occur as early as 7 to 14 days after removal. Therefore, a woman should re-start contraception immediately after removal of the implant if continued contraceptive protection is desired.
IMPLANON®
(etonogestrel implant) Subdermal Use
IMPLANON® does not protect against HIV infection (the virus that causes AIDS) or other sexually trans mitted diseases. Read this Patient Information leaflet carefully before you decide if IMPLANON is right for you. This information does not take the place of talking with your healthcare provider. If you have any questions about IMPLANON, ask your healthcare provider.
What is IMPLANON?
IMPLANON is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years. The implant is a flexible plastic rod about the size of a matchstick that contains a progestin hormone called etonogestrel. Your healthcare provider will insert the implant just under the skin of the inner side of your upper arm. You can use a single IMPLANON implant for up to 3 years. IMPLANON does not contain estrogen.
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What if I need birth control for more than 3 years ?
The IMPLANON implant must be removed after 3 years. Your healthcare provider can insert a new implant under your skin after taking out the old one if you choose to continue using IMPLANON for birth control.
What if I change my mind about birth control and want to stop using IMPLANON before 3 years ?
Your healthcare provider can remove the implant at any time. You may become pregnant as early as the first week after removal of the implant. If you do not want to get pregnant after your healthcare provider removes the IMPLANON implant, you should start another birth control method right away.
How does IMPLANON work?
IMPLANON prevents pregnancy in several ways. The most important way is by stopping the release of an egg from your ovary. IMPLANON also thickens the mucus in your cervix and this change may keep sperm from reaching the egg. IMPLANON also changes the lining of your uterus.
How well does IMPLANON work?
When the IMPLANON implant is placed correctly, your chance of getting pregnant is very low (less than 1 pregnancy per 100 women who use IMPLANON for 1 year). It is not known if IMPLANON is as effective in very overweight women because studies did not include many overweight women.
The following chart shows the chance of getting pregnant for women who use different methods of birth control. Each box on the chart contains a list of birth control methods that are similar in effectiveness. The most effective methods are at the top of the chart. The box on the bottom of the chart shows the chance of getting pregnant for women who do not use birth control and are trying to get pregnant.
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Who should not use IMPLANON?
Do not use IMPLANON if you
Tell your healthcare provider if you have or have had any of the conditions listed above. Your healthcare provider can suggest a different method of birth control.
In addition, talk to your healthcare provider about using IMPLANON if you:
Interaction with Other Medicines
Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins and herbal supplements. Certain medicines may make IMPLANON less effective, including:
Ask your healthcare provider if you are not sure if your medicine is one listed above.
If there are medicines that you have been taking for a long time, that make IMPLANON less effective, tell your healthcare provider. Your healthcare provider may remove the IMPLANON implant and recommend a birth control method that can be used effectively with these medicines.
When you are using IMPLANON, tell all of your healthcare providers that you have IMPLANON in place in your arm.
How is the IMPLANON implant placed and removed?
Your healthcare provider will place and remove the IMPLANON implant in a minor surgical procedure in his or her office. The implant is placed just under the skin on the inner side of your upper arm.
The timing of insertion is important. Your healthcare provider may:
Your healthcare provider will cover the site where IMPLANON was placed with 2 bandages. Leave the top bandage on for 24 hours. Keep the smaller bandage clean, dry, and in place for 3 to 5 days.
Immediately after the IMPLANON implant has been placed, you and your healthcare provider should check that the implant is in your arm by feeling for it.
If you cannot feel the implant immediately after insertion, the implant may not have been inserted, or it may have been inserted deeply. A deep insertion may cause problems with locating and removing the implant. Once the healthcare professional has located the implant, removal may be recommended.
If at any time you cannot feel the IMPLANON implant, contact your healthcare provider immediately and use a non-hormonal birth control method (such as condoms ) until your healthcare provider confirms that the implant is in place. You may need special tests to check that the implant is in place or to help find the implant when it is time to take it out.
You will be asked to review and sign a consent form prior to inserting the IMPLANON implant. You will also get a USER CARD to keep at home with your health records. Your healthcare provider will fill out the USER CARD with the date the implant was inserted and the date the implant is to be removed. Keep track of the date the implant is to be removed. Schedule an appointment with your healthcare provider to remove the implant on or before the removal date.
Be sure to have checkups as advised by your healthcare provider.
What are the most common side effects I can expect while using IMPLANON?
Talk with your healthcare provider right away if:
Besides changes in menstrual bleeding patterns, other frequent side effects that caused women to stop using the implant include:
Other common side effects include:
Implants have been reported to be found in a blood vessel including a blood vessel in the lung.
This is not a complete list of possible side effects. For more information, ask your healthcare provider for advice about any side effects that concern you. You may report side effects to the FDA at 1-800-FDA-1088.
What are the possible risks of using IMPLANON?
The implant may not be placed in your arm at all due to a failed insertion or if the implant has fallen out of the needle. If this happens, you may become pregnant. Immediately after insertion, and with help from your healthcare provider, you should be able to feel the implant under your skin. If you can't feel the implant, tell your healthcare provider.
Location and removal of the implant may be difficult or impossible because the implant is not where it should be. Special procedures, including surgery in the hospital, may be needed to remove the implant. If the implant is not removed, then the effects of IMPLANON will continue for a longer period of time.
Implants have been found in the pulmonary artery (a blood vessel in the lung). If the implant cannot be found in the arm, your healthcare professional may use imaging methods on the chest. If the implant is located in the chest, surgery may be needed.
Other problems related to insertion and removal are:
Some examples of serious blood clots are blood clots in the:
The risk of serious blood clots is increased in women who smoke. If you smoke and want to use IMPLANON, you should quit. Your healthcare provider may be able to help.
Tell your healthcare provider at least 4 weeks before if you are going to have surgery or will need to be on bed rest. You have an increased chance of getting blood clots during surgery or bed rest.
When should I call my healthcare provider?
Call your healthcare provider right away if you have:
What if I become pregnant while using IMPLANON?
You should see your healthcare provider right away if you think that you may be pregnant. It is important to remove the implant and make sure that the pregnancy is not ectopic (occurring outside the womb). Based on experience with other hormonal contraceptives, IMPLANON is not likely to cause birth defects.
Can I use IMPLANON when I am breastfeeding?
If you are breastfeeding your child, you may use IMPLANON if 4 weeks have passed since you had your baby. A small amount of the hormone contained in IMPLANON passes into your breast milk. The health of breast-fed children whose mothers were using the implant has been studied up to 3 years of age in a small number of children. No effects on the growth and development of the children were seen. If you are breastfeeding and want to use IMPLANON, talk with your healthcare provider for more information.
Additional Information
This Patient Information leaflet contains important information about IMPLANON. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider for information about IMPLANON that is written for healthcare professionals. You may also call 1-877- IMPLANON (1-877-467-5266) or visit www.IMPLANON-USA.com
Manufactured for: Merck Sharp & Dohme Corp., a subsidiary of MERCK & CO., INC., Whitehouse Station, NJ 08889, USA. Manufactured by: N.V. Organon, Oss, The Netherlands, a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ 08889, USA. Revised: 03/2016
IMPLANON®
(etonogestrel implant) 68 mg For Subdermal Use Only
Patient Consent Form
I understand the Patient Labeling for IMPLANON . I have discussed IMPLANON with my healthcare provider who answered all my questions. I understand that there are benefits as well as risks from using IMPLANON. I understand that there are other birth control methods and that each has its own benefits and risks.
I also understand that this Patient Consent Form is important. I understand that I need to sign this form to show that I am making an informed and careful decision to use IMPLANON, and that I have read and understand the following points.
After learning about IMPLANON, I choose to use IMPLANON.
_______________________________
(Name of Healthcare Provider)
_______________________________ _______________
(Patient Signature) (Date)
WITNESSED BY:
The patient above has signed this consent in my presence after I counseled her and answered her questions.
_______________________________ _______________
(Healthcare Provider Signature) (Date)
I have provided an accurate translation of this information to the patient whose signature appears above. She has stated that she understands the information and has had an opportunity to have her questions answered.
_______________________________ ______________
(Signature of Translator) (Date)
