1. Pre-service Education on FP and AYSRH
Session II, Topic 7 Implants

2. What Are Implants?
Progestin-filled rods (each about the size of a match stick) that are inserted under the skin
Jadelle: 2-rod system, highly effective for 5 years
Sino-implant (II): 2-rod system, being registered with WHO as effective for 3 years. (Studies are underway to see if it lasts for 4 years.) Will be marketed globally as Levoplant.
Implanon: 1-rod system, a recent study shows it is highly effective for 5 years
Nexplanon: The same as Implanon, but can be seen on an x-ray
Norplant: 6-capsule system, effective for 5 years (possibly 7); no longer manufactured but some women are still using it and may need removal
Illustration credits: WHO; Salim Khalaf/FHI
Implants are hormone-filled rods (sometimes referred to as capsules) that are inserted under the skin in a woman’s upper arm.
Jadelle®, Sino-implant (II)®, Implanon®, Nexplanon® and Norplant® are types of implants.
Jadelle® is a two-rod system that is effective for up to five years. It was designed to deliver the same daily dose of levonorgestrel as Norplant.
Sino-implant® (II) is a two-rod system that is identical to Jadelle, but labeled for up to four years of use, although efforts are under way to extend the labeled use to five years. Sino-implant (II) is marketed under various names in different countries.
Implanon® is a single-rod system that continually releases a low, steady dose of the progestin etonogestrel for up to three years.
Nexplanon® is the same as Implanon, but can be seen on an x-ray
Norplant® was the first progestin-only implant system developed. It consisted of six thin, flexible capsules made of silicone. Norplant is no longer being manufactured but many women who had it inserted are still relying on it for contraceptive protection. Norplant is labeled for five years of use, but studies have found that it is effective for seven years which may provide current users with additional years of protection.
The newer implant systems—Jadelle®, Sino-implant® (II), Implanon® —and Nexplanon® have fewer rods than Norplant®, making insertion and removal much easier. The newer implants are also more comfortable for the user.
Introduce the types of implants available in the country

3. Key Points for Providers and Clients
Implants are small flexible rods that are placed just under the skin of the upper arm.
Provide long-term pregnancy protection. Very effective for 3 to 5 years, depending on the type of implant. Immediately reversible.
Require specifically trained provider to insert and remove. A woman cannot start or stop implants on her own.
Little required of the client once implants are in place.
Bleeding changes are common but not harmful. Typically, prolonged irregular bleeding over the first year, and then lighter, more regular bleeding or infrequent bleeding.
Give an overview of the key points about implants (What are they, how do they work, what to expect, important points about implants).

4. Effectiveness of Implants
In this progression of effectiveness, where would you place implants?
Implants
Less effective
More effective
Male Sterilization
Female Sterilization
IUDs
Progestin-Only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
Less effective
More effective
The purpose of this activity is to emphasize the effectiveness of implants.
The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and IUDs.
Ask students: Where would you put progestin-only implants on this list? <after students respond, click the mouse to reveal the answer>
Conclude by emphasizing that implants would be in top tier of methods, as they are one of the most effective reversible methods available. As commonly used, implants are more effective than sterilization and IUDs.

5. Implants: Mechanism of Action
Implants work in two ways
Changing the menstrual cycle, including preventing ovulation
Illustration credit: Salim Khalaf/FHI
Explain that implants prevent pregnancy in two ways:
They prevent the release of eggs from the ovaries by suppressing the hormones that cause ovulation. When there is no egg, there is nothing for sperm to fertilize.
Implants also cause the cervical mucus to thicken. The thicker mucus acts as a barrier, making it more difficult for sperm to enter the uterine cavity. In the unlikely event that a woman does ovulate, this barrier of mucus greatly reduces the chance that the egg will be fertilized.
Implants do not disrupt an existing pregnancy and have no adverse effect on a woman or a fetus if accidentally inserted in the arm of a woman who is already pregnant.
However, in the rare event that a woman is found to be pregnant with an implant in place, the device should be removed.
Thickens
cervical mucus to block sperm
Implants have no effect on an existing pregnancy.

6. Implants: Characteristics
Very safe and effective, less than 1 pregnancy per 100 women in over 5 years of use
Both long-lasting and reversible
Do not interrupt sex
Fertility returns without delay when removed
Can be used by breastfeeding women
Offer health benefits
Have side effects
Require minor surgery to insert and remove
Cannot be initiated and discontinued without provider’s help
Provide no protection from STIs/HIV
The purpose of this activity is to keep students focused on how they translate technical information into concepts that their clients can understand.
Brainstorming instructions:
Ask trainees to brainstorm first a list of positive characteristics (advantages) and then negative characteristics of implants.
Write these suggested characteristics on a flip chart. Then show the slide of implant characteristics and compare them to the list generated through brainstorming.
Source: Hatcher, 2007; WHO, 2010; CCP and WHO, 2011.

7. Implants: Health Benefits
Helps protect against pregnancy
Reduced risk of symptomatic pelvic inflammatory disease (PID)
May help reduce the risk of iron-deficiency anemia
In addition to being an effective way to prevent pregnancy, implants offer other health benefits.
Physicians have observed that women who use implants tend to have fewer cases of symptomatic pelvic inflammatory disease, or PID. It is not clear if this is due to actual prevention of PID or whether using implants makes PID symptoms less severe.
Because most implant users experience an overall reduction in the amount of menstrual blood loss, implant use can reduce the likelihood of iron-deficiency anemia.
Because implants are so effective at preventing pregnancy, they dramatically lower a woman’s chances of having an ectopic pregnancy, which is a potentially life-threatening condition.
The risk of ectopic pregnancy is reduced by a factor of more than 100; the rate of ectopic pregnancy among women using implants is 6 per 100,000 women per year compared with 650 per 100,000 women per year among women using no contraceptive method.
In the rare event that implants fail and pregnancy occurs, providers must be aware that an ectopic pregnancy is possible and be prepared to treat this life-threatening condition.
Source: CCP and WHO, 2011; Task Force for Epidemiological Research on Reproductive Health, 1998.

8. Possible Side-Effect of Implants (part 1)
Some users report changes in bleeding patterns:
First several months
Lighter bleeding and fewer days of bleeding
Irregular bleeding
Prolonged bleeding
Infrequent bleeding
No monthly bleeding
After about one year:
Implanon users are more likely to have
infrequent bleeding, prolonged bleeding or
no monthly bleeding rather than irregular bleeding
Remind students that as with many contraceptive methods, there are some side effects associated with implants that are not harmful but may be unpleasant.
Women’s preferences for certain methods are often related to side effects.
Ask the students: What side effects of implants, have you heard about?
Show slides 8 and 9 on side effects. Explain that many women who use implants experience side effects.
The most commonly reported side effects are menstrual changes. Light bleeding or spotting, irregular bleeding that occurs frequently, prolonged bleeding that lasts more than eight days, infrequent bleeding, and amenorrhea are the types of menstrual irregularities that women report. In the first year of implant use, the majority of women experience menstrual changes that deviate from their normal bleeding pattern.
Typically, the frequency of these menstrual changes—especially prolonged bleeding—decreases with time and is less of a problem by the end of the first year of use. These menstrual irregularities are not usually medically harmful, but they may be unacceptable for some women.
The type of implant can also have an impact on the bleeding pattern that users experience. For example, Implanon users are more likely to experience infrequent or no menstrual bleeding than prolonged bleeding.
Explain that complications are uncommon or rare. (slide 10)
How would you feel about these side-effects?

9. Possible Side-Effect (part 2)
Headaches
Lower abdominal pain
Acne (can improve or worsen)
Weight change
Breast tenderness
Dizziness
Mood changes
Nausea
Other possible physical changes:
Enlarged ovarian follicles

10. Complications from Implants Are Uncommon or Rare
Infection at insertion site
If occurs, most likely within the first 2 months
Difficult removal
Uncommon if inserted properly and removed by a trained provider
Rare
Expulsions
expulsions most often occur within the first 4 months after insertion

11. Implants Are Safe for Nearly All Women
Almost all women can use implants safely, including women who:
Have just had an abortion, miscarriage or ectopic pregnancy
Have just given birth
Have anemia now or in the past
Have varicose veins
Have or have not had children
Are not married
Are of any age including adolescents and women over 40 years old
Are infected with HIV
Nearly all women can use implants safely and effectively, including women who:
Have or have not had children
Are not married
Are of any age, including adolescents and women over 40 years old
Have just had an abortion, miscarriage or ectopic pregnancy
Smoke cigarettes, regardless of age or number of cigarettes smoked
Have just given birth (breastfeeding or not breastfeeding)
Have anemia now or in the past
Have varicose veins
Are infected with an HIV, whether or not on antiretroviral therapy
Most health conditions do not affect safe and effective use of implants and only few conditions or situations may affect a woman’s eligibility to use progestin-only implants.
In addition, many women who cannot use contraceptive methods that contain estrogen can safely use implants.
WHO medical eligibility criteria were developed to reassure providers about some conditions that do not interfere with safe use of contraceptives and highlight all conditions that might affect women’s eligibility to use any given contraceptive method.
Most health conditions do not affect safe and effective use of implants.
Many women who cannot use methods that contain estrogen can safely use implants.

12. Who Can and Cannot Use Implants (part 1)
Most women can safely use implants
But usually cannot use implants if:
Remind students of the 4 categories of medical eligibility.
Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions
Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Women with Category 2 conditions generally can use the method, but careful follow-up may be required. For women with category 2 conditions, the advantages of using this method outweigh the theoretical or proven risks.
Category 3: For women with these conditions or characteristics, the theoretical or proven risks of using the method usually outweigh the benefits. Women with Category 3 conditions generally should not use the method. However, if no better options for contraception are available or acceptable, the provider may judge that the method is appropriate, depending on the severity of the condition. In such cases, ongoing access to clinical services and careful follow-up will be required.
Category 4: For women with these conditions or characteristics, the method presents an unacceptable health risk and should not be used.
WHO also notes that, in settings where clinical judgment is limited, category 2 conditions should be treated in the same manner as category 1 conditions. This means that women with category 1 and category 2 conditions should be able to obtain and use progestin-only implants without restrictions.
Explain that most women can safely use implants as mentioned in the previous slide. Show the slides and discuss which women should not use implants.
Some other serious health conditions
May be pregnant

13. Who Can and Cannot Use Implants (part 2)
Most women can safely use implants. But usually cannot use implants if:
“We can find out if implants are safe for you. Usually, women with any of these conditions should use another method.”
May be pregnant
If in doubt, use pregnancy checklist or perform pregnancy test.
Has blood clot in lungs or deep in legs. Women with superficial clots (including varicose veins) CAN use implants.
Ever had breast cancer.
Unexplained vaginal bleeding: if the bleeding suggests a serious condition, help her choose a method without hormones to use until unusual bleeding is assessed.
Serious liver disease or jaundice (yellow skin or eyes).
Systemic lupus erythematosus
Some other serious health conditions
Usually cannot use with any of these serious health conditions (if in doubt, check handbook or refer)

14. Category 1 and 2 Examples (not inclusive): Who Can Start Implants
Implants are safe for nearly all women.
WHO Category
Conditions
Category 1
adolescents, nulliparity, heavy smokers, breastfeeding 6 weeks to < 6 months, endometriosis, endometrial or ovarian cancer, thyroid disorders, uterine fibroids, hepatitis, hypertension /90-99,HIV, PID
Reference:
1. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Fourth Edition. Geneva: WHO, 2010.
blood pressure ≥160/100, postpartum and breast feeding < 6 weeks, cervical cancer, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD, heart disease, hypertension >160->100, migraine with aura
Category 2
Source: WHO, 2015.

15. Category 3 and 4 Who Should Not Start Implants
A small number of women may not be able to use implants.
WHO Category
Conditions
Category 3
acute DVT/PE, unexplained vaginal bleeding, history of breast cancer, serious liver disease, infection or tumor, certain cases of systemic lupus
Continuation only: ischemic heart disease, stroke, migraine with aura
Reference:
1. World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive Use. Fourth Edition. Geneva: WHO, 2010.
Category 4
current breast cancer
Source: WHO, 2010.

16. Implant Use by Women with HIV
WHO Eligibility Criteria
Condition
Category
HIV-infected 1
AIDS
ARV therapy 2
Women with HIV or AIDS can use without restrictions
Some ARV drugs reduce blood progestin level
Efficacy is not affected because implants provide consistent dose of hormone over time
Dual method use should be encouraged
Ask students: Let us take a closer look at the conditions and categories pertaining to clients with HIV or AIDS.
Use slide to present the following:
According to the MEC, progestin-only implants can be used without restrictions by women with HIV who may or may not have AIDS. These are considered category 1 conditions. This table shows the specific WHO recommendations.
HIV-positive women who are on antiretroviral (ARV) therapy can generally use progestin-only implants, but follow-up may be required in some cases. This is because progestin blood levels are slightly reduced by some ARVs. However, these reductions are probably not enough to affect contraceptive efficacy because implants provide a consistent dose of hormone over time.
As with other hormonal methods, progestin-only implants do not provide protection from STIs.
Ask students: What advice should you give to clients with HIV who choose implants? <accept responses from several students; click the mouse to reveal the next bullet>
Source: WHO, 2010; Mildvan, 2002.

17. When to Start Implants (part 1)
Anytime a provider is reasonably certain a woman is not pregnant
Pregnancy can be ruled out if any of these situations apply:
Is fully breastfeeding, has no menses, and baby is less than 6 months
Abstained from intercourse since last menses or delivery
Had a baby in the past 4 weeks
Started monthly bleeding within the past 7 days (5 days for Implanon)
Had a miscarriage or abortion in the past 7 days (5 days for Implanon)
Is using a reliable contraceptive method consistently and correctly
If none of the above apply, pregnancy can be ruled out by pregnancy test, pelvic exam, or by waiting till next menses
For the Experiential Learning Exercise, see the Session Plan
Remind students that questions #6–11 in the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants are used to rule out pregnancy as part of the screening process for initiating implants.
Ask students: If a woman is medically eligible and wants to use implants, when can she initiate them? <students brainstorm; accept responses from several students>
Let us compare your responses with the information on the next several slides. <click the mouse to reveal each bullet on the slide>
Progestin-only implants can be initiated anytime during the menstrual cycle as long as the provider can be reasonably sure the woman is not pregnant.
A provider can be reasonably certain that a woman is not pregnant if any of these situations apply:
The woman is fully breastfeeding, has no menses, and her baby is less than six months old.
She has abstained from intercourse since her last menses or since delivery.
She has given birth in the past four weeks.
Her monthly bleeding started within the past seven days.
She had a miscarriage or an abortion in the past seven days.
She has been using a reliable contraceptive method consistently and correctly.
If none of these situations apply, a provider can use a urine pregnancy test or conduct a bimanual pelvic exam to determine if the woman is pregnant. If no other means to rule out pregnancy are available, a provider can ask a woman to come back at a time of her next menses and use a backup contraceptive method in a meantime.
Source: WHO, 2004 (updated 2008).

18. When to Start Implants (part 2)
First 7 days of menstrual cycle (5 days for Implanon), no backup method needed
After 7th day of menstrual cycle (5th for Implanon), rule out pregnancy and use backup method for 7 days
Postpartum
Not breastfeeding: immediately (no need to rule out pregnancy until 4 weeks postpartum)
Breastfeeding: delay 6 weeks
Remind students that the instruction sections below the questions on the Checklist for Screening Clients Who Want to Initiate Contraceptive Implants also provide guidance about when to initiate implants for women who are eligible.
If two rod-implant systems, like Jadelle or Sino-implant (II), are initiated during the first seven days of the menstrual cycle—where day one is the first day of bleeding—no backup contraceptive method is necessary. With Implanon, no backup method is needed if it is initiated within the first five days of the menstrual cycle.
If progestin-only implants are initiated more than seven days after the start of woman’s monthly bleeding (more than five days for Implanon), she should be counseled to use a backup contraceptive method such as condoms for the first seven days following insertion.
A woman who is not breastfeeding may have implants inserted immediately after delivery. If a woman who is not breastfeeding wants to start using implants more than four weeks after she has given birth, it is necessary to rule out pregnancy before they can be inserted.
Ideally, women who are breastfeeding should not start using implants until six weeks postpartum because of theoretical concern that hormones in breast milk may have an adverse effect on a newborn during the first six weeks after birth.
Source: WHO, 2004 (updated 2008).

19. When to Start Implants (part 3)
(continued)
Postabortion or miscarriage: immediately; without backup
Switching from a hormonal method: immediately if it was used consistently and correctly
Injectable users can have implants inserted within the reinjection window; without backup
After using emergency contraceptive pills:
Insert within 7 days after start of next menstrual period (5 days for Implanon); provide with backup method during interim
Implants can be initiated immediately following an abortion or miscarriage without need for a backup method.
If a woman is switching to implants from a hormonal method, she can have the implants inserted immediately provided that she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain that she is not pregnant. There is no need for her to wait for her next monthly bleeding. There is no need for her to use a backup method.
If she is switching from injectables, she can have implants inserted anytime during the reinjection window. There is no need for a backup method.
If a woman has taken emergency contraceptive pills, it is recommended that she delay implant insertion until her menses return to ensure that emergency contraception was effective. Implants can be inserted within the first seven days after the start of her menstrual period (within five days for Implanon) or any other time it is reasonably certain that she is not pregnant. Give her a backup method such as condoms, or oral contraceptives to start the day after she finishes taking the emergency contraceptive pills, until the implants can be inserted.
Source: WHO, 2004 (updated 2008).

20. When to Start Implants (A Review)
What if this client, who has no medical conditions that would preclude implants use, wants to initiate implants?
Client situation:
In day 4 of menstrual cycle
Condom user in day 8 of menstrual cycle
2½ weeks postpartum, not breastfeeding
2½ weeks postpartum, breastfeeding
Injectable user, amenorrheic, within reinjection window
IUD user, mid-cycle, had sex since last menses
After taking emergency contraceptive pills (ECPs)
Click through the client situations on Slide 20 and ask students whether the clients can have an implant inserted immediately and if not, when can she have an implant inserted?

21. Key Counseling Topics for Implant Users
Safety and efficacy
How Implants work
Health benefits
Possible side effects
No protection from STIs/HIV
Inform provider she has an implant in case of serious new health problem
Reasons to return: questions, concerns or experiencing any warning signs
Review the Key Counseling Topics for Implant Users and the Additonal Counseling Topics
Introduce the role play instructions:
Divide students into groups of three. Ask the members of each group to choose who will play the role of client, provider, or observer.
Ask each group to review the instructions included in Handout #2, including the Roleplay Observation Checklist
Ask students to use Handout #3 Competency-based Skills Checklist for Contraceptive Implants Counseling and Clinical Skills to ensure that the appropriate steps for counseling are followed.

22. Counseling about Implants: Additional Key Counseling Topics
Explain the insertion and removal procedure
Provide post-insertion instructions
Explain the length of protection and when to return for removal or replacement
Describe reasons to return for follow-up

23. Counseling About Side Effects
Before insertion, describe possible side effects:
Changes in bleeding pattern (most common)
Headaches, breast tenderness, mild abdominal pain (less common)
Explain that side effects:
Are not signs of illness
Often subside within the first year
Encourage the client to come back with questions or concerns
If the client cannot tolerate side effects, management or discontinuation may be necessary
Use the slide to present the following important points:
Counseling—both prior to insertion and for women already using implants—is the best way to help women manage the side effects associated with progestin-only implants.
The most common side effects of implants are irregular bleeding, prolonged bleeding, infrequent bleeding, or no bleeding at all. Headaches, mild abdominal pain, and breast tenderness are examples of less common side effects.
Women who are considering using implants should be counseled that menstrual changes are expected and that they are not signs of disease or health problems. For most women, side effects will become less pronounced or will stop within the first year. Some women may not have any side effects.
After an implant is inserted, the practitioner should tell the client to come back with any questions or concerns. Ongoing counseling and reassurance should be provided if needed.
If the user continues to be concerned or finds the side effects unacceptable, it may be necessary to manage the side effects or remove the implants.

24. Implant Insertion and Removal
Insertion and removal should be quick and easy.
Injection prevents pain.
Provider puts 1 or 2 rods just under the skin of inside upper arm.
Provider bandages opening in skin and wraps the arm—no stitches.
Need to be removed after 3 to 5 years, depending on the type of implant and your weight.
Adapted from WHO’s Decision-making tool for family planning clients and providers.
A client who has chosen an implant needs to know what will happen during insertion. Clients will want to know the following:
Implants usually only take a few minutes to insert, but can sometimes take longer.
Complications related to the insertion are rare.
The provider will carefully clean the area on the arm and will use sterile gloves and equipment.
The client will receive a small injection under the skin so that she will not feel the implant being inserted. The injection may sting a bit.
The client will be awake during the procedure.
The provider will make a small incision on the inside of the upper arm.
The provider will insert the implant (1 or 2 rods, depending on the type.
After the implant has been inserted the provider will put on a small bandage and then gauze will be wrapped around the arm to keep the area clean.

25. What to Remember Keep the insertion area dry for 4 days.
Expect a bit of soreness and bruising.
Come back when it is time to have the implants removed.
Side effects are common but rarely harmful Come back if they bother you.
Come back any time if you have problems or want implants removed.
See a nurse or doctor if:
Yellow skin or eyes
May be pregnant, especially if pain or soreness in belly
Unusually heavy or long bleeding
Infection or continued pain in the insertion site or sees rod coming out
A bright spot in your vision before bad headaches
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Use slide to present the following:
Key messages that clients remember.
Scheduled follow-up visits are not necessary for implant users, but clients should be advised to return to the clinic anytime they have questions or concerns.
Discuss how to remember when to have the implant removed.
Having contact with the client within the first two to six months may improve continuation among women experiencing side effects, because this is when such problems are most likely to occur.
The provider should also ask whether the client’s reproductive goals have changed, as she may want to become pregnant or desire a long-acting or permanent method.
If the client reports or complains about side effects, the provider should assess her symptoms and, if appropriate, reassure her that the side effects are not harmful and discuss ways to manage them.
If the client has developed any conditions that are contraindications for continuing to use implants, or if the client finds side effects unacceptable, the provider should help her choose another method.

26. Helping Continuing Implant Users
No routine visit required, but if she returns, ask:
Whether satisfied with method or has questions.
If she is concerned about bleeding changes.
About new health problems or major life changes (plans for more children, change in STI/HIV risk).
Significant weight changes.
If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.
Explain that no routine visit required for implants, but if she returns, ask:
Whether satisfied with method or has questions.
If she is concerned about bleeding changes.
About new health problems or major life changes (plans for more children, change in STI/HIV risk).
About significant weight changes (if using Jadelle, significant weight gain may affect the duration of the implants’ effectiveness).
If she wants to continue using implant and has no new medical condition, remind her how much longer her implant will protect her.

27. Management of Implant Side Effects: Bleeding Changes
Counseling and reassurance are key
Problem
Action/Management
Heavy or prolonged bleeding
Reassure the client that this is common and not harmful
Recommend a 5-day course of ibuprofen (up to 800 mg 3 times per day for 5 days)
If no relief, offer COCs for 3 weeks
If bleeding is heavy, iron tablets may prevent anemia
Amenorrhea
Reassure client
For short-term relief offer ibuprofen or indomethacin 2 times daily after meals for 5 days
Ask participants: What is the most important thing that you can do for women who experience side effects? <participants brainstorm; accept responses from several participants> Let us compare your responses with the slide. <click the mouse to reveal the answer>
As we have discussed, the best way to reduce the anxiety some women feel when they experience side effects is to provide detailed information about possible side effects before implant insertion. If side effects occur, the first step is to address the client’s concerns through follow-up counseling.
If a client complains about irregular or breakthrough bleeding, the provider should explain that implants make the uterine lining thinner, sometimes causing it to shed earlier than usual, resulting in this type of bleeding. It is also important to reassure the woman that this bleeding does not mean that anything is wrong and remind her that it will likely diminish with time.
If the irregular bleeding is unacceptable to the client, the provider may recommend up to 800 mg of ibuprofen, or an equivalent amount of another non-steroidal anti-inflammatory drug (NSAID) other than aspirin, three times per day for five days. Women who are experiencing irregular bleeding should not take aspirin, since it may increase bleeding, not decrease it.
If an NSAID does not provide relief, the provider can give a low-dose combined oral contraceptive (COC) containing the progestin levonorgestrel for 21 days. An alternative to COCs is to give 50 µg ethinyl estradiol daily for 21 days. If bleeding is prolonged or heavy—twice as long or twice as much as usual—the provider can suggest that the woman take iron tablets to help prevent anemia. If irregular or heavy bleeding continues to bother the client or starts after several months of normal monthly bleeding or amenorrhea, the provider should rule out a possible underlying condition unrelated to method use, such as uterine fibroids, an STI, genital cancer, or pregnancy.
Amenorrhea is another common side effect of implants. Providers can reassure their clients that it does not indicate a health problem and no medical treatment is necessary. This side effect is similar to not having monthly bleeding during pregnancy.
If side effects persist and are unacceptable to the client, the provider should help her choose another contraceptive method.
Source: CCP and WHO, 2011.

28. Management of Implant Side Effects: Non-Menstrual Problems
Action/Management
Common headache
Reassure and suggest painkillers; evaluate headaches that worsened since implant initiation
If side effects persist and are unacceptable to the client, counsel about non-hormonal methods
Mild abdominal pain
Reassure; suggest pain- killers; follow-up if needed
Breast tenderness
Recommend a supportive bra, compresses, or painkillers
Weight change
Inform about healthy eating habits and exercise
There are several non-menstrual side effects that clients who are using implants may experience.
If a client experiences frequent headaches that are not migraines, reassure her that ordinary headaches do not indicate dangerous conditions and usually diminish over time. Standard doses of painkillers such as aspirin, ibuprofen, paracetamol, or other pain relievers may be used to alleviate symptoms. However, if headaches get worse or occur more often after insertion of implants, they should be evaluated.
Mild abdominal pain may be caused by many conditions, including enlarged ovarian follicles or cysts. Reassure the client that ovarian follicles or cysts usually disappear on their own and standard doses of painkillers or other local remedies will usually alleviate discomfort. To be sure the problem is resolving, see the client again in six weeks. There is no need to treat enlarged ovarian follicles or cysts unless they grow abnormally large, twist, or burst. However, if abdominal pain becomes severe, refer at once for immediate diagnosis and care. This is especially true if the severe abdominal pain occurs with other signs or symptoms of ectopic pregnancy such as abnormal vaginal bleeding or no monthly bleeding (especially if this is a change from her usual bleeding pattern), light-headedness, dizziness, or fainting. Ectopic pregnancy is rare but can be life-threatening.
Clients who experience breast tenderness may try wearing a supportive bra and can apply hot or cold compresses. They can also take standard doses of painkillers such as aspirin, ibuprofen, or paracetamol.
In case of weight gain, review the client’s diet and counsel her about healthy eating habits and exercise as a way to better control her weight.
If side effects persist and the client wants to stop using implants, health care providers should counsel about non-hormonal options and help the woman choose another method.
Source: CCP and WHO, 2011.

29. Management of Implant Side Effects: Problems Related to Insertion
Action/Management
Pain after insertion or removal
Check that the bandage or gauze is not too tight; replace bandage; avoid pressing on site
Give painkillers for a few days
Infection
Clean the infected area
Give antibiotics for 7–10 days
Remove implants if no improvement
Abscess
Clean, cut open, and drain the abscess
Treat the wound
Expulsion or partial expulsion
Expulsion or partial expulsion of the implants often follows an infection
Ask the client to return for follow-up care if she notices an implant coming out
Clients may sometimes experience problems related to the insertion of implants.
Ask participants to brainstorm what side effects may occur as a result of insertion and what advice would they give to the client. These problems can usually be addressed easily.
For pain after insertion, check that the bandage on the client’s arm is not too tight. Put a new bandage on the arm and advise the client to avoid pressing on the site for a few days. Standard doses of aspirin, ibuprofen, paracetamol, or other pain reliever may also be helpful.
If the woman experiences redness, heat, pain, or pus at the insertion site, this may indicate an infection. In this case, do not remove the implants. Clean the infected area with soap and water or antiseptic. Give oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If the infection has not cleared after completing the course of antibiotics, ask the client to return for removal of the implants.
In some cases, the client may develop an abscess—a pocket of pus under the skin caused by an infection. If this happens, clean the area with antiseptic. Cut open and drain the abscess, and treat the wound. Give the woman oral antibiotics for 7 to 10 days. Instruct the client to take all the antibiotics. If she still has signs of infection—such as heat, redness, pain, or drainage of the wound—after completing the antibiotics, ask the client to return for removal of the implants.
Expulsion or partial expulsion of the implants often follows an infection. Ask the client to return for follow-up care if she notices an implant coming out.
Source: CCP and WHO, 2011.

30. Problems That May Require Switching from Implants to Another Method (Part 1)
Action/Management
Unexplained vaginal bleeding
Refer or evaluate by history and pelvic exam
If an STI is diagnosed, treat with implants in place
If no cause can be found, consider removing implants to make diagnosis easier
Migraines
If the client develops migraines with aura after implants are inserted, the implants should be removed
Help client choose a method without hormones
Blood clots, liver or heart disease, stroke, or breast cancer
Remove implants
Treat or refer to a specialist for treatment
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Explain that there are some serious health conditions that may require a client to stop using implants. These include:
If a client experiences unexplained vaginal bleeding or heavy or prolonged bleeding that is suggestive of a medical condition not related to the method, she might need to discontinue use of implants.
Refer the client or evaluate by taking her medical history and doing a pelvic examination. Diagnose and treat as appropriate.
If no cause of bleeding can be found, consider stopping implants to make the diagnosis easier. Provide the client with another contraceptive method of her choice until the condition is evaluated and treated. The alternative method should be something other than progestin-only injectables or a copper-bearing or hormonal IUD.
If the bleeding is caused by an STI or PID, the client can continue using implants during treatment.
Although women who have migraine headaches with an aura can initiate implants, implants should be removed if a woman develops migraines with aura after implants are inserted. The provider should help her choose a non-hormonal method.
If a woman develops health conditions such as blood clots in the deep veins of the legs or lungs, heart disease due to blocked or narrowed arteries, severe liver disease, or breast cancer, the implants must be removed.
Although women with ischemic heart disease and women who have had a stroke can initiate use of implants, use of implants should be discontinued if these conditions develop or get worse while using implants.
Remove the implants or refer for removal and give the woman a backup method to use until her condition is evaluated. Refer her for diagnosis and care if she is not already receiving treatment.
Finally, if a woman is pregnant, the implants should be removed. However, there are no known risks to a fetus conceived while a woman has the implants in place.
Source: CCP and WHO, 2011.

31. Problems That May Require Switching from Implants to Another Method (Part 2)
Action/Management
Heart disease due to blocked or narrowed arteries (ischemic heart disease)
A woman who has one of these conditions can safely
start implants. If, however the condition develops while
she is using implants:
Remove the implants or refer for removal
Help her choose a method without hormones
Refer for diagnosis and care if not already under care
Suspected pregnancy
Assess for pregnancy, including ectopic pregnancy
Remove the implants or refer for removal if she will carry the pregnancy to term
There are no known risks to a fetus conceived while a woman has implants in place
As a review, brainstorm side effects and their management. Then discuss problems that may require switching to another method.
Source: CCP and WHO, 2011.

32. Complications from Implants Are Uncommon or Rare
Infection at insertion site
If occurs, most likely within the first 2 months
Difficult removal
Rare if inserted properly and removed by a trained provider
Expulsions
Rare; most occur within the first 4 months
Whereas side effects—especially those related to menstruation—are relatively common with progestin-only implants, complications are uncommon or rare. They may include:
Infection at the insertion site is an uncommon complication. If an infection occurs, it will most likely be within the first two months.
Difficulty with removal may occur if insertion was done improperly or if removal is attempted by an untrained provider. However, if implants are properly inserted and removed by a trained provider, difficulty in removing implants is rare.
Expulsion of an implant is a rare complication. If this occurs, it is most likely to happen in the first four months. If no infection is present, a fresh implant may be inserted through a new incision near the other rods or capsules to replace the one that was expelled.
Source: CCP and WHO, 2011.

33. Counseling about Implants: Explain Removal Procedure to Client
Prior to removal, the provider should tell the client that:
An injection of local painkiller is given. The client stays awake.
A small cut is made near the implant.
A special instrument is used to pull out each implant. The client may feel tugging or slight pain.
The site may be sore for a few days.
The cut is closed with an adhesive bandage; no stitches.
The cut is covered and wrapped with gauze.
Prior to removal, a provider should describe for the client that removing implants usually takes somewhat longer than insertion. Providers should also reassure clients that complications related to implant removal are rare.
The simplified description, from the Global Handbook page shown on the slide, is designed to explain the removal procedure to clients. <participants take turns reading the steps aloud>
The provider uses proper infection prevention procedures.
The woman receives an injection of local anesthetic under the skin of her arm to prevent pain during implant removal. This injection may sting. She stays fully awake throughout the procedure.
The health care provider makes a small incision in the skin on the inside of the upper arm, near the site of insertion.
The provider uses an instrument to pull out each implant. A woman may feel tugging, slight pain, or soreness during the procedure and for a few days after.
The provider closes the incision with an adhesive bandage. Stitches are not needed. An elastic bandage may be placed over the adhesive bandage to apply gentle pressure for two or three days and reduce swelling.
If a woman wants to continue using implants, a new set of implants may be inserted through the same incision, either in the same or in the opposite direction.
Providers must not refuse or delay when a woman asks to have her implants removed, regardless of the reason.
All staff must understand and agree that clients must not be pressured or forced to continue using implants.
Source: CCP and WHO, 2011; Bayer.

34. Infection Prevention: Prior to Implant Insertion or Removal
Getting ready
Have the client wash her arm
Cover the procedure table
Prepare a clean instrument tray
Open the sterile instrument pack
Before insertion/removal
Wash hands thoroughly and put on gloves
Clean the insertion/removal site
Use a sterile drape with a hole over the site
Use a new disposable syringe and needle
Inserting and removing progestin-only implants are minor surgical procedures, and it is important that providers follow careful infection prevention procedures with every client.
Use slide 33 to describe infection prevention procedures prior to implant insertion or removal.
Use slide 34 to describe infection prevention procedures after implant insertion or removal.
Ask students to brainstorm: “What steps should you take to prevent infection prior to, during, and after the insertion or removal procedure?” <students brainstorm; accept responses from several students; click the mouse to reveal the information on the slide>
Distribute to each participant a copy of the Handout #4: Checklist: Providing Implants with Appropriate Infection Prevention Practices; review each step on page 5 of the checklist.
Source: INFO Reports, 2007.

35. Infection Prevention: After Implant Insertion or Removal
Stop any bleeding with gauze and clean the insertion/removal site
Apply a sterile adhesive bandage
Place sharps in a safety container
Decontaminate instruments
Dispose of contaminated objects
Sterilize instruments and gloves
Decontaminate all surfaces
Wash hands with soap
Source: INFO Reports, 2007.

36. Implants: Summary
Implants are a new option that fulfills an unmet need for many women
Provides long-term protection
Safe and easy to use
Highly effective and readily reversible
Appropriate for most women, including young and nulliparous
Little is required of the client once the implant is in place
Irregular bleeding patterns may be a problem for some women
Thorough counseling is essential
Summarize the important points about implants.
*Note to trainer: There are slide sets for both single-rod and double-rod implants. Each of the slide sets include both implant insertion and removal. Choose the appropriate slide set for your program. This presentation is focused solely on the mechanics of the clinical procedure; refer to the basic presentation slide sets for guidance about counseling users and other implant-related issues.
Before demonstrating implant insertion and removal, review instructions for demonstration and return demonstration in the Facilitator’s Guide. Students must have the opportunity to practice insertion and removal procedures in the skills lab before performing insertions and removals on clients. In some countries, implant removals are performed by physicians or health officers. If your country allows nurses and/or midwives to perform implant removals, you must ensure that students have a sufficient number of clients to become proficient. Use Handout #3 Competency-based Skills Checklist for Contraceptive Implants, Counseling and Clinical Skills to evaluate skills.