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Contraceptive counselling often features in OSCEs, and it’s important to be familiar with the various methods of contraception available.
This article focuses on counselling patients about the sub-dermal contraceptive implant (commonly referred to as “the implant”), including the common questions patients ask, the information you’ll be expected to give and how best to structure the consultation.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain the reason for the consultation: “I understand you are interested in using the implant for contraception. Is that correct?”.
It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions (this is often referred to as ‘chunking and checking’).
Ideas, concerns and expectations
A key component of contraceptive counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
In a contraceptive consultation, it is important to explore ICE, as many patients will have researched or have prior experience with contraceptive methods. This will help you tailor the consultation and the advice you give regarding specific methods. It is important to identify any patient concerns and expectations early in the consultation, as this may affect the tolerability of the method and subsequent contraceptive efficacy.
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your contraceptive consultation, but we have provided some examples for each of the three areas below.
Ideas
Explore what the patient currently understands about the implant:
- “Have you heard of the implant?”
- “What do you already know about the implant?”
Concerns
Ask if the patient has any concerns about the implant:
- “Is there anything that worries you about the implant?”
Expectations
Explore the patient’s expectations of the implant:
- “What factors have made you consider using the implant?”
- “Why do you think the implant is the best choice for you?”
What is the contraceptive implant?
Using patient-friendly language, explain that the implant is a form of long-acting reversible contraception (commonly referred to as LARC methods or ‘fit and forget’ methods).
The implant itself is a small, flexible plastic rod that is inserted subdermally into the upper arm during a procedure in clinic. It also contains a small amount of barium, which means it can be visualised on an X-ray if required.
The only licenced implant in the UK is the Nexplanon, which lasts up to 3 years. In other countries, some implants are in use that can provide contraception for up to 5 years.
Example
“The implant is a small plastic device, a similar size and shape to a matchstick, that will sit under the skin of your upper arm and act to prevent pregnancy. It is the most effective method of reversible contraception, and you do not need to remember to take it every day. It lasts up to 3 years. As the device sits in the arm, it requires a small procedure in clinic to fit and remove it.”
How effective is the contraceptive implant?
When counselling patients regarding contraception, it is very important to explain how effective any method is and highlight any factors which may impact efficacy.
Explain to the patient that the implant is the most effective method of reversible contraception available, and it is over 99% effective at preventing pregnancy.
Example
“Less than 1 implant user in 100 will get pregnant in one year.”
“If 100 sexually active women don’t use any contraception, 80–90 will get pregnant in a year.”
How does the contraceptive implant work?
Explain to the patient that the implant is embedded with the hormone etonogestrel, which is a progestogen. The etonogestrel is slowly released from the implant over time.
The primary mechanism of action of the implant is to prevent ovulation. The progestogenic effect of etonogestrel will also thicken cervical mucus and thin the endometrium, making passage of sperm into the womb more difficult, and impeding implantation.
Example
“The hormone within the implant works to prevent an egg from being released each month. It also acts to thicken the mucus at the entrance to the womb, as well as thinning the lining of the womb. This means that it is more difficult for sperm to travel into the womb, and would also be more difficult for a pregnancy to implant and grow there.”
Advantages and disadvantages of the contraceptive implant
When discussing contraceptive options, it is important to give the patient enough information to make an informed decision and direct them to reputable sources of further information.
When explaining potential advantages and disadvantages, you should consider the patient’s ideas, concerns and expectations (identified earlier in the consultation).
Signposting is important to help you structure the consultation: “Next, I’d like to talk about some of the additional benefits of having the implant and some of the potential disadvantages. Is that ok?.”
Advantages of the contraceptive implant
Advantages of the contraceptive implant include:
- Highly effective
- Long lasting (3 years)
- ‘Fit and forget’ – no requirement to take a daily pill or attend regular appointments
- Easily reversible (once removed, fertility returns instantly)
- Does not contain oestrogen, therefore suitable for some patients who may be unable to have combined methods of contraception due to their medical history
- Prevents ovulation and may help patients who experience premenstrual symptoms
- Safe in breastfeeding
Example
“The implant can last up to 3 years and is over 99% effective. You can continue to have new implants fitted every 3 years until you want to stop using them, or you go through the menopause. One of the reasons why it is so effective is that you do not need to remember to use it.”
“It is a progestogen-only method of contraception and does not contain oestrogen. For that reason, it is safe to use for a larger proportion of people. Because the progestogen in the implant stops ovulation, it may help to reduce any premenstrual symptoms (PMS) you experience. As soon as the implant is removed, fertility resumes as normal.”
Disadvantages of the contraceptive implant
Potential disadvantages of the contraceptive implant include:
- Unpredictable effect on bleeding pattern that may change over time
- Does not protect against sexually transmitted infections
- Requires a procedure to fit and remove (associated with a small risk of infection and damage to nerves and vessels within the arm)
- Possible hormonal side effects (though these are often temporary)
- Efficacy can be reduced by some other medications
- Small increased risk of breast cancer
Example
“It is very unpredictable how the implant may affect your bleeding pattern. It is not uncommon to have irregular bleeding in the first few months of having the implant fitted and this improves with time for a significant portion of users. In the longer term, some people continue to have their periods in their usual pattern, some may have no periods at all, and others may experience either frequent or infrequent irregular bleeding. There is no way to know how the implant will affect your bleeding pattern in advance.”
“Unfortunately, the implant does not protect you from sexually transmitted infections (STIs). Barrier contraception (e.g. condoms) are the only method of contraception to also provide protection from infections.”
“The implant requires a short procedure to fit and remove it. We’ll discuss this shortly, as there are a few things you need to be aware of.”
“After fitting of the implant, a minority of people can experience hormonal side effects, especially in the first few weeks to months. These often settle after the first few months, but can include headaches, breast tenderness and changes to your skin or mood.”
“There are a small number of other medications that can reduce the contraceptive effectiveness of the implant. It is always a good idea to check with your doctor about this if you are started on any new medications whilst using the implant.”
“There is some evidence to suggest that the implant may be linked with a small increase in risk of breast cancer. The evidence suggests that this risk reduces back to baseline again when you stop using the method”.
How is the contraceptive implant fitted and removed?
Fitting of a contraceptive implant
An implant can be inserted at any point during the menstrual cycle. Insertion of an implant can be done in a community clinic and requires a trained fitter.
The procedure involves injecting local anaesthetic to numb the insertion site, followed by the fitting of the implant itself under the skin. This is done using a specific insertion device. Patients may have anxieties about having an implant fitted. It is important to explore their ideas and concerns regarding the procedure.
Risks of implant insertion include:
- Pain and discomfort, although local anaesthetic is used to reduce this
- Bruising and bleeding
- Infection
- Deep insertion and neurovascular insertion
- Scarring
It is important to give safety netting advice to the patient so that they know what to expect and what is not normal during the healing process.
If it is fitted on days 1-5 of the menstrual cycle, the implant will be effective immediately for contraceptive purposes.
If fitted at any other time in the menstrual cycle, it will take 7 days to become effective for contraception, and the patient should use extra precautions (such as condoms) for those 7 days. If the patient is switching from another form of contraception, it may be effective immediately, depending on the type being switched from.
Using patient-friendly language, explain the procedure for fitting an implant and address any patient concerns.
Example
“As we’ve discussed, inserting an implant into the arm requires a short procedure. Normally it is inserted in your non-dominant arm, but as everyone’s anatomy is different we may need to switch to work out the safest position to insert an implant in you. The procedure involves having some local anaesthetic to numb the area where the implant will be fitted. This means that the insertion of the implant itself should not be painful. If you have an injected local anaesthetic, you will experience a stinging sensation when it is injected, but this should fade quickly.”
“Following this, the clinician will then insert the implant just beneath the skin of your arm. You should always be able to feel the implant under your skin and the clinician will show you how to do this. It is about the size of a matchstick.”
“The whole procedure should not take more than 10 minutes. Depending on when your last period was, the implant can take 7 days to start working for contraception. The clinician will talk to you about this on the day so that you know when you will be protected”.
“The area where the implant was inserted will be dressed using a bandage and the clinician will give you instructions on when this should be removed. It is important that you keep the area clean and dry whilst the bandage is on, to reduce the risk of infection and help with the healing process.”
“The area where the implant was inserted may be slightly tender, bruised or swollen for a couple of days following the procedure. If you experience any pain that is not controlled with simple paracetamol, any unusual change in sensation to your arm or hand, or if you have any concerns about infection or healing, do not hesitate to seek advice.”
Removal of a contraceptive implant
An implant is removed during another short procedure. Whilst the implant can provide contraception for up to 3 years, the patient can have it removed at any point if they wish.
Risks of implant removal include:
- Pain and discomfort, although local anaesthetic is again used to reduce this
- Bruising and bleeding
- Infection
- Damage to surrounding structures
- Scarring
- Difficulty removing the implant, which may require referral for removal under ultrasound guidance
Example
“The implant provides contraception for up to 3 years. If you decide you do not want to continue to use this method of contraception, a trained healthcare professional can remove the implant at any time.”
“Just like with the insertion, you’ll be given a local anaesthetic to numb the area so that the removal itself will not be painful. A small cut will be made in your arm over one end of the implant, and the implant will be removed through this. This should only take a couple of minutes. Once removed, your fertility returns immediately.”
“The area where the implant was removed will be dressed using a bandage and the clinician will give you instructions on when this should be removed. It is important that you keep the area clean and dry whilst the bandage is on, to reduce the risk of infection and help with the healing process.”
“The area where the implant was removed may be slightly tender, bruised or swollen for a couple of days following the procedure. If you experience any pain that is not controlled with simple paracetamol, any unusual change in sensation to your arm or hand, or if you have any concerns about infection or healing, do not hesitate to seek advice.”
“Occasionally, there can be some difficulty removing the implant. If this is the case, you will be referred to a specialist centre to remove it with the assistance of an ultrasound scan.”
Aftercare
Checking the implant
Explain to the patient that they should always be able to feel the implant under their skin. They will be shown where to feel for this and what to feel when their implant is fitted.
Safety netting
Patients should be informed to seek medical advice if:
- They are unable to feel their implant
- They experience ongoing pain after the fitting, or they develop new pain
- They experience an unexpected/ unwanted change in their bleeding pattern
- They experience unusual redness or swelling around the site of insertion, or fever, which could indicate infection relating to the device
- There is a change to their medical history
Example
“You should always be able to feel the implant under your skin. You will be shown where to feel for this and what it feels like when you have your implant inserted.”
“If you cannot feel the implant then do not rely on it for contraception, and you should book an appointment for a clinician to review its position to make sure that it is still in the correct position. Additionally, if you experience ongoing pain after fitting, unexpected or unwanted change in your bleeding pattern, any persistent redness or swelling around the site of insertion, fever or a change in your medical history, then please seek medical advice.”
Closing the consultation
Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation to ensure patient understanding.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
If the patient is not currently using contraception, offer bridging contraception to prevent pregnancy whilst awaiting the insertion of the implant.
Finally, thank the patient for their time and offer them a leaflet summarising the key information related to the implant (e.g. Sexwise implant leaflet).
Dispose of PPE appropriately and wash your hands.
Reviewer
Dr Ashley Jefferies
Community Sexual and Reproductive Health Registrar
References
- FSRH. Progestogen-only Implant. Published 2023. Available from [LINK]
