Managing Any Problems

Problems Reported as Side Effects or Complications

May or may not be due to the method.

• Problems with side effects and complications affect women's satisfaction and use of implants. They deserve the provider's attention. If the client reports any side effects or complications, listen to her concerns, give her advice, and, if appropriate, treat.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Irregular bleeding (bleeding at unexpected times that bothers the client)

• Reassure her that many women using implants experience irregular bleeding. It is not harmful and usually becomes less or stops after the first year of use.
• For modest short-term relief, she can take 800 mg ibuprofen or 500 mg mefenamic acid 3 times daily after meals for 5 days, beginning when irregular bleeding starts.
• If these drugs do not help her, she can try one of the following, beginning when irregular bleeding starts:
  • Combined oral contraceptives with the progestin levonorgestrel. Ask her to take one pill daily for 21 days.
  • 50 µg ethinyl estradiol daily for 21 days.
• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

No monthly bleeding

• Reassure her that some women stop having monthly bleeding when using implants, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Heavy or prolonged bleeding (twice as much as usual or longer than
8 days)

• Reassure her that some women using implants experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.
• For modest short-term relief, she can try any of the treatments for irregular bleeding, above, beginning when heavy bleeding starts. Combined oral contraceptives with 50 µg of ethinyl estradiol may work better than lower-dose pills.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

Ordinary headaches (nonmigrainous)

• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol
  (325–1000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during use of implants should be evaluated.

Mild abdominal pain

• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol
  (325–1000 mg), or other pain reliever.
• Consider locally available remedies.

Acne

• If client wants to stop using implants because of acne, she can consider switching to COCs. Many women’s acne improves with COC use.
• Consider locally available remedies.

Weight change

• Review diet and counsel as needed.

Breast tenderness

• Recommend that she wear a supportive bra (including during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol
  (325–1000 mg), or other pain reliever.
• Consider locally available remedies.

Mood changes or changes in sex drive

• Ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give her support as appropriate.
• Clients who have serious mood changes such as major depression should be referred for care.
• Consider locally available remedies.

Nausea or dizziness

• Consider locally available remedies.

Pain after insertion or removal

• For pain after insertion, check that the bandage or gauze on her arm is not too tight.
• Put a new bandage on the arm and advise her to avoid pressing on the site for a few days.
• Give her aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol
  (325–1000 mg), or other pain reliever.

Infection at the insertion site (redness, heat, pain, pus)

• Do not remove the implants.
• Clean the infected area with soap and water or antiseptic.
• Give oral antibiotics for 7 to 10 days.
• Ask the client to return after taking all antibiotics if the infection does not clear. If infection has not cleared, remove the implants or refer for removal.
• Expulsion or partial expulsion often follows infection. Ask the client to return if she notices an implant coming out.

Abscess (pocket of pus under the skin due to infection)

• Clean the area with antiseptic.
• Cut open (incise) and drain the abscess.
• Treat the wound.
• Give oral antibiotics for 7 to 10 days.
• Ask the client to return after taking all antibiotics if she has heat, redness, pain, or drainage of the wound. If infection is present when she returns, remove the implants or refer for removal.

Expulsion (when one or more implants begins to come out of the arm)

• Rare. Usually occurs within a few months of insertion or with infection.
• If no infection is present, replace the expelled rod or capsule through a new incision near the other rods or capsules, or refer for replacement.

Severe pain in lower abdomen

• Abdominal pain may be due to various problems, such as enlarged ovarian follicles or cysts.
  • A woman can continue to use implants during evaluation.
  • There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. Reassure the client that they usually disappear on their own. To be sure the problem is resolving, see the client again in 6 weeks, if possible.
• With severe abdominal pain, be particularly alert for additional signs or symptoms of ectopic pregnancy, which is rare and not caused by implants, but it can be life-threatening (see p. 129, Question 7). In the early stages of ectopic pregnancy, symptoms may be absent or mild, but eventually they will become severe. A combination of these signs or symptoms should increase suspicion of ectopic pregnancy:
  • Unusual abdominal pain or tenderness
  • Abnormal vaginal bleeding or no monthly bleeding—especially if this is a change from her usual bleeding pattern
  • Light-headedness or dizziness
  • Fainting
• If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care. (See Female Sterilization, Managing Ectopic Pregnancy, p. 179, for more on ectopic pregnancies.)

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