Etonogestrel

Breast cancer is a hormonal sensitive tumor and the prognosis for women with current or a recent history of breast cancer may be worse with progestin only contraceptive use (Curtis 2016a). Use is contraindicated in women with (or history of) breast cancer.

Ectopic pregnancy (rare) may occur more commonly than in women using no contraception.

Follicular development may occur and may continue to increase in size beyond what may occur in a normal cycle; generally, ovarian cysts resolve spontaneously without intervention; however, surgery may rarely be required.

Discontinue if unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions occur and immediately evaluate for retinal vein thrombosis.

Combination hormonal contraceptives may increase the risk of thromboembolism and other vascular events (eg, deep vein thrombosis [DVT], myocardial infarction [MI], pulmonary embolism [PE]). Women with inherited thrombophilias (eg, protein C or S deficiency) may have increased risk of venous thromboembolism when using combination hormonal contraceptives (DeSancho 2010; van Vlijmen 2011). The risk of DVT/PE is expected to be less with progestin only contraceptives than that observed with combination hormonal contraceptives (Curtis 2016b). Use of etonogestrel is contraindicated in women with thrombosis or thromboembolic disorders (current or history of).

Changes in bleeding patterns are likely to occur. Presentation of undiagnosed, persistent, or recurrent abnormal vaginal bleeding warrants further evaluation to rule out malignancy.

Use commonly results in an average weight gain of ~2.8 pounds after 1 year and ~3.7 pounds after 2 years of treatment. Disease-related concerns:

Use with caution in patients with risk factors for cardiovascular disease (eg, hypertension, hypercholesterolemia, morbid obesity, diabetes, women who smoke) (Curtis 2016b)

May impair glucose tolerance; use caution in women with diabetes or prediabetes.

Use with caution in patients with diseases that may be exacerbated by fluid retention.

Use of combination hormonal contraceptives may have an increased risk of developing gallbladder disease; it is not known if this risk increases with progestin only products.

Use of combination hormonal contraceptives is associated with hepatic adenomas (rare). The risk with progestin only contraceptives is not known. Etonogestrel is contraindicated with preexisting hepatic tumors.

May be poorly metabolized in women with hepatic impairment. Discontinue if jaundice develops during therapy or if liver function becomes abnormal. Use is contraindicated in hepatic disease.

Use caution in patients treated for hyperlipidemia; progestins may increase low-density lipoprotein (LDL) concentrations.

According to the manufacturer, women with a history of hypertension-related diseases should be encouraged to use a nonhormonal form of contraception. In women with hypertension that is well-controlled, use may be considered; monitor blood pressure closely. If sustained hypertension develops during use, or if a significant increase in blood pressure does not respond adequately to antihypertensive therapy, remove the implant. Women with adequately controlled hypertension may use progestin only implants; other risk factors for cardiovascular disease (such as older age, smoking, diabetes) should be considered when prescribing (Curtis 2016b).

Women with renal disease should be encouraged to use a nonhormonal form of contraception. Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

Any changes with lens tolerance or vision should be evaluated by an ophthalmologist.

Use with caution in overweight women (may be less effective, especially in the presence of other risk factors); women >130% of ideal body weight were not included in clinical studies. However, contraceptive failure was not observed in obese women in a prospective study (Xu 2012). Progestin only implants may be used in women with a body mass index (BMI) ≥30 kg/m2 (Curtis 2016b).

Not for use prior to menarche.

Consider removal during periods of prolonged immobilization due to surgery or illness. Dosage form specific issues:

Broken or bent implants while in the patient's arm have been reported; the release rate of etonogestrel may be slightly increased. Ensure implant is removed in its entirety. Other warnings/precautions:

For use in women who request long-acting (up to 3 years) contraception. Insertion/removal should be done by a trained health care provider and implant must be palpable after insertion. Complications may occur from insertion and removal procedures, or inserting the implant too deep. Treatment should be instituted for infection at the insertion site; if infection persists, the implant should be removed. Expulsion may occur following incomplete insertion or infection. The implant must be removed by the end of the third year.

The use of combination hormonal contraceptives has been associated with a slight increased risk of cervical cancer; however, studies are not consistent and may be related to additional risk factors (Gierisch 2013). Women awaiting treatment for cervical or ovarian cancer may use progestin only contraceptives (Curtis 2016b).

Use does not protect against HIV infection or other sexually transmitted diseases (Curtis 2016a; Curtis 2016b).

The use of estrogens and/or progestins may change the results of some laboratory tests (eg, coagulation factors, lipids, glucose tolerance, binding proteins). The dose, route, and the specific estrogen/progestin influences these changes. In addition, personal risk factors (eg, cardiovascular disease, smoking, diabetes, age) also contribute to adverse events; use of specific products may be contraindicated in women with certain risk factors.