Side Effect

Management

04/13/2022 1
Amenorrhea (absence of menses)
•Amenorrhea is common side effect among implant
users,
•especially within the first several months of use.
• If there is some reason to suspect pregnancy or
possibility that implant was inserted while woman was
already pregnant,
•Take history and pelvic assessment (speculum and
bimanual), AND /OR pregnancy test, to check for
pregnancy (intrauterine, ectopic).

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If no pregnancy
•Reassure that some women stop having monthly
bleeding when using implants.
•This is not harmful and doesn’t indicate pregnancy
and There is no need to lose blood every month.
•Do not give hormonal treatment (COC) to induce
withdrawal bleeding.
•It is not necessary and usually is not successful
unless 2 or 3 cycles of COCs are given.
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If pregnant
•an intrauterine pregnancy, counsel client and refer
for antenatal services.
•Remove rods and inform the client that small doses
of LNG will not harm the fetus.
•If spontaneous abortion, manage the pregnancy loss
and leave in the rods if the client wishes to continue
with this method.
•If ectopic pregnancy is suspected, refer immediately
for complete evaluation and surgical management.
04/13/2022 4
Irregular bleeding/spotting
•This is common, expected side effect of implants.
•If there are reasons to suspect that irregular
bleeding is due to something other than implant
•for example, if these bleeding changes continue for
several months or starts after several months of
normal or no bleeding), take history and perform
pelvic examination
•Rule out genital tract problems such as vaginitis,
cervicitis, cervical polyps or uterine fibroids…..

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Management
•Reassure the client that light, irregular bleeding or
spotting occurs in a large percentage of women
during the first few months of use.
•Most women can expect their bleeding pattern to
become more regular after 6-12 months.
•If the client is not satisfied after counseling and
reassurance but wants to continue with the
implants, give NSAD and COC

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•Ibuprofen (up to 800 mg 3 times daily) for five days or any
other NSAID OR/ AND
•One cycle of COCs containing progestin levonorgestrel and
either30-
•35 micrograms or 50 micrograms of ethinyl estradiol.
•Inform the client to expect bleeding during the week after
completing the COC pack.
•If an abnormality of the genital tract, treat the conditions or
refer for further evaluation.
•Do not remove rods.

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Heavy bleeding or prolonged
bleeding
•Is twice as long or twice as much as normal
•If there are reasons to suspect that bleeding
changes are due to something other than implant
If these bleeding changes continue for several months or
starts after several months of normal or no bleeding,
•Take history and perform pelvic examination
(speculum and bimanual) to be sure bleeding is not
due to other causes.
•Check for significant anemia (pale conjunctiva or
nail beds, low hematocrit or hemoglobin).
04/13/2022 8
Management
•Reassure her that some women using implants
experience heavy or prolonged bleeding.
•It is generally not harmful and usually becomes less
or stops after any few months.
•For modest short-term relief suggest:
One cycle of COCs containing progestin levonorgestrel and
30-35 mcg or 50 mcg of ethinyl estradiol, AND
Ibuprofen (up to 800 mg 3 times daily) for five days

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•If hemoglobin is <9 g/dl or hematocrit is ≤ 27, give :
Iron (FeSO4), 1 tablet containing at least 100 mg
elemental iron, daily for 1-3 months and give
nutritional counseling.
•If anemia persists or client request, remove rods
and help client choose another method.
•If a pregnancy-related condition, manage
accordingly

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Lower abdominal pain
•Take a history, perform abdominal and pelvic
examination
•Check vital signs
•Examine to rule out:
Ectopic pregnancy
PID
Appendicitis
Ovarian cysts

•Perform lab test for Hb/Hct and pregnancy test if

indicated and available.
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•Refer immediately if
•Moderate to severe lower abdominal tenderness
(rebound).
•Elevated resting pulse (> 100 bpm).
•Decreased blood pressure (< 90/60 mm Hg).
•Elevated temperature (> 38⁰C).
•Suspected/confirmed pregnancy and acute anemia
(e.g., Hb < 9 g/dl or Hct < 27).

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Weight gain or loss (change in
appetite)
•Compare weight prior to implants use (if known) and
current weight.
•Check that the client is eating and exercising properly.
•Counsel client that normal fluctuations of 1-2 kg (2-4
lbs) may occur
•Review diet if weight change is excessive (+/-2 kg or
more).
•If weight gain (or loss) is unacceptable, even after
counseling, remove rods and help client choose
another method.
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Acne
•Ask how and how often the client cleans her face.
•Ask if she is currently under great stress.
•In some women, the use of implants can make
acne worse.
•Recommend cleaning the face twice a day and
avoiding use of heavy facial creams.
• If condition is not tolerable, help the client choose
another (nonhormonal) method.

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Breast fullness or tenderness
•In most cases breast tenderness is due to implant
use and requires only reassurance. 
•Rule out pregnancy
•Check breasts for:
•Lumps or cysts,
•Discharge or leakage of milk-like fluid, if not
breastfeeding.
•If breastfeeding and breast(s) is tender, examine for
breast infection.
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Management
•Recommend to use supportive bra or apply hot/
cold compresses.
•In some cases pain killers may provide relief.
Suggest aspirin (325-650 mg.),
ibuprofen (200-400 mg), or other available pain
relievers.
•If pregnancy, manage accordingly

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•If physical examination shows lump or discharge
suspicious for cancer
e.g., firm, non-tender or fixed and which does not change
during menstrual cycle
•Refer to appropriate provider or facility for
diagnosis.
•If no abnormality found, reassure the client.
•If there is an infection, advise the client to continue
breastfeeding and give antibiotics as appropriate.

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Depression (mood changes or loss of
libido)
•Discuss changes in mood or libido.
•Depression or loss of libido may be
associated with the use of progestins; give
her support as appropriate.
•Clients who have series mood changes such
as major depression should be referred for
care.

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Headache
•Ask if there has been a change in pattern or
severity of headaches since insertion of the
rods.
•Ask for symptoms of aura during migraine,
and if these symptoms are new.
•Measure blood pressure

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•If headaches are mild, treat with analgesics and
reassure.
•Re-evaluate after 1 month, if mild headaches
persist.
•If headaches have changed since beginning use of
implants
i.e., became more frequent, stronger or now accompanied
by aura,
•Remove implants and help the client choose
another (non-hormonal) method
04/13/2022 20
Infection at the site
•Check area of insertion for infection (pain, heat,
and redness), pus or abscess.
•If infection (no abscess), wash area with soap and
water and give appropriate oral antibiotics for 7-10
days.
•Do not remove rods.
•Tell the client to return after 1 week.
•If no improvement, remove rods and insert a new
set in the other arm or help the client choose
another method.
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If abscess:
•Prep with antiseptic ,Incise and drain.
•Treat the wound and Give oral antibiotics for 7 to
10 days.
•Perform daily wound care as indicated.
•Ask client to return after taking all antibiotics.
•If no improvement, remove rods and insert new set
in the other arm or help the client choose another
method
04/13/2022 22
Rod coming out
•Check for partial or complete expulsion or the
rod(s).
•Remove partially expelled rod(s). Check to
determine if remaining rod is in place.
•If area of insertion is not infected (no pain, heat,
redness), replace the rod.
•If area of insertion is infected:
•Remove the remaining rod, Insert a new set in the
other arm, or Help the client choose another
04/13/2022 23
“Missing” rods
•Usually due to rods being inserted too deeply or,
rarely, a rod spontaneously expelled and forgotten
by the client.
•Can almost always be detected by x-ray or
ultrasound.
•If regular ultrasound is available, scan to determine
presence of the rods and document if present.
•If removal will be difficult, an expert in removal of
implants should be consulted.

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Nausea, dizziness, vomiting
•These are among the side effects of the
implant and do not require evaluation.
•In rare cases, there are reasons to suspect
pregnancy
•Reassure woman that these symptoms are
common in implant users and usually
diminish or go away in a few months of use.

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IUCD
• Suspected pregnancy (amenorrhea) IUCD in situ
•Ask client when she had her last menstrual period
(LMP)
•If she has any symptoms of pregnancy.
•If necessary do a speculum and bimanual
examination to rule out pregnancy, including
ectopic pregnancy.

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•If pregnant and pregnancy less than 13 weeks (by
LMP) and strings visible,
•explain IUCD in uterus during pregnancy increases
risk of miscarriage, including septic miscarriage.
•Advise her that it is best to remove IUCD.
•If she agrees to removal, gently pull the strings to
remove IUCD.
•If she chooses to keep IUCD, her pregnancy should
be followed closely and she should contact provider
immediately
04/13/2022 27
•Do not attempt to remove if:
Strings are not visible, or
Pregnancy is greater than 13 weeks (by
LMP)
•This woman must be followed closely
because she is at risk of spontaneous septic
miscarriage

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Ectopic Pregnancy
•Abnormal vaginal bleeding with or without
symptoms of pregnancy or infection,
amenorrhea, pelvic pain or tenderness, or
palpable adnexal mass
•Refer to appropriate facility for complete
evaluation without any delay.

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Cramping
•Explain that cramping is common in the first
3 to 6 months after insertion.
•If cramping is unusually severe, do
abdominal and pelvic (speculum and
bimanual)
•other causes of cramping, such as partial
expulsion of the IUCD, cervical or uterine
perforation, PID or ectopic pregnancy

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•If cramping is not severe, reassure the client that it
will diminish or stop after a few months of IUCD
use, and provide aspirin or similar analgesic.
•If cramping is severe and no cause found, offer to
try a course of analgesic or, if the woman prefers,
to remove the IUCD. Help the client choose another
method.
•If cause is found (e.g. infection, partial expulsion,
perforation), manage accordingly

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Heavy or prolonged
Bleeding
•Reassure that many women using IUCD experience
heavy or prolonged bleeding.
• It is usually not harmful and diminishes or stops after a
few months.
•If there are reasons to suspect another underlying
cause
e.g. heavy or prolonged bleeding continues or starts after several
months of normal bleeding

•Evaluate by performing speculum and bimanual exams

to ensure that there is neither cervical pathology nor
evidence of intrauterine or ectopic pregnancy, abortion
04/13/2022 32
Management
•If client has had IUCD less than six months, reassure
that this is expected side effect of IUD.
•For modest short-term relief offer:
•NSAID, such as ibuprofen (400 mg) or indomethacin
(25 mg) 2 times a day for 5 days, beginning when heavy
bleeding starts (but no aspirin).
•Give iron tablets (one tablet daily for one to three
months).
• Ask client to return in three months for another check-
up.
•
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•If underlying condition is found on pelvic exam
(done in cases when there are reasons to suspect it
is not due to IUCD), manage according to diagnosis
or refer as appropriate.
•In rare cases when anemia is severe and cannot be
improved by treatment, consider removing IUCD
and helping client to choose another method.

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Partner complains about strings
•Check to be sure that IUCD is in place (i.e.,
not partially
•expelled)
•Counsel client that one option is to cut string
to a length even with cervical OS and record
in chart

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Pelvic Infection
•Cramping accompanied by abdominal tenderness,
fever, flu-like symptoms, headache, chills, nausea
or vomiting, vaginal discharge, painful intercourse,
and/or palpable pelvic mass.
•Perform abdominal and pelvic (speculum and
bimanual) exams and look for signs of PID

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•If signs and/or symptoms of PID, treat with
antibiotic according to the national syndromic
approach treatment guidelines, or immediately
refer for treatment.
•There is no need to remove an IUCD.
•If woman does not improve in 2-3 days after
starting treatment refer her to a hospital.
•Her sex partner should be checked for an STI

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Suspected Uterine Perforation at Time
of Insertion
•When sounding the uterus:
•Stop the procedure immediately.
•Observe for signs of intra of intra-abdominal
bleeding (i.e. failing BP, rising pulse, severe
abdominal pain, tenderness, guarding and rigidity).
•For the first hour, keep the woman at bed rest and
check her vital signs every 5 to 10 minutes.

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•If the woman remains stable after one hour, check
for signs of intra-abdominal bleeding,
•She can be sent home, but she should avoid sex for
2 weeks. Help her choose another method.
•If she has a rapid pulse and falling blood pressure,
or new pain or increasing pain around the uterus,
refer her to a higher level of care.

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Syncope, Bradycardia,
Vasovagal Episode
•These could happen during IUCD insertion or
removal
•Is woman anxious? Does she have a small uterus
or relative cervical stenosis?
•Maintain a calm, relaxed, unhurried atmosphere
with a gently reassuring approach to the client
•At the earliest sign of fainting, stop the insertion
•Put a cool, wet cloth to the client’s forehead

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•If severe pain occurred as the IUCD was being
inserted through the cervical canal, allow the
patient to rest.
•Keep the client supine, the head lowered, and legs
elevated, to ensure adequate blood flow.
•If pain is severe (very rare), do not proceed with
inserting an IUCD, and help client choose another
method.
•In most cases symptoms go away in a few minutes.

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