Contraceptive implant and injectable

01Purpose and principlesWhat the treatment does and how it fits into care.

The implant releases etonogestrel, suppressing ovulation and thickening cervical mucus with minimal user action. In May 2026 the UK product licence extended from three to five years following phase 3 data with no pregnancies in years four and five. Older chapters, cards and reminders stating three years are now unsafe if used as the current replacement rule.

DMPA is a depot injection whose contraceptive effect persists for weeks and cannot be removed after administration. This makes adherence easier but side effects cannot be rapidly reversed. Repeat every 13 weeks; an injection up to 14 weeks after the last dose does not require extra contraception. After that point, ovulation timing is variable and the recent-sex history matters.

Both methods can alter bleeding. Implant effectiveness is vulnerable to enzyme induction, while DMPA is not. DMPA temporarily lowers oestrogen and bone density and commonly delays return to fertility after the last injection. The implant should be palpable after placement; localisation precedes any attempt to remove a non-palpable rod.

Key points

The etonogestrel implant is a single radiopaque rod that now provides licensed UK contraception for five years; the change covers both existing and new implants.
The five-year licence is not an eight-year LNG-IUD extension. Record the insertion date and remove or replace by five years unless pregnancy is desired sooner.
Hepatic enzyme induction reduces implant efficacy throughout treatment and for 28 days after stopping; offer DMPA, LNG-IUD or copper IUD rather than relying on early implant replacement.
DMPA is given every 13 weeks. Up to 14 weeks from the previous dose is within the guidance grace interval; after 14 weeks assess EC, quick-start criteria, seven-day backup and a test 21 days after the latest unprotected sex.
Implant bleeding is unpredictable and DMPA often causes irregular bleeding then amenorrhoea. Investigate clinically concerning change without promising a regular pattern.
DMPA causes a small average loss of bone mineral density that usually recovers after stopping; reassess long-term use and individual osteoporosis risks without imposing an arbitrary maximum.
Return to fertility is rapid after implant removal but can be delayed for months after the final DMPA injection; counselling must distinguish this from permanent infertility.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Palpable implant

A correctly placed rod is usually palpable subdermally along its full length; both clinician and user should confirm this after insertion.

Deep or migrated implantRed flag

Failure to palpate, neurological symptoms or location away from the insertion site requires imaging and expert removal.

Late DMPA returnRed flag

More than 14 weeks since the previous injection ends the no-backup grace interval and requires pregnancy-risk assessment.

Expected bleeding change

Spotting, prolonged bleeding or amenorrhoea may occur with either method and should be evaluated in clinical context.

Possible pregnancyRed flag

New pregnancy symptoms or pelvic pain after interaction or late injection requires testing and ectopic safety-netting.

Red flags requiring action

Nexplanon is licensed in the UK for up to five years from insertion as of 13 May 2026, applying to implants already in place and newly inserted devices.
Enzyme-inducing medicines can reduce implant effectiveness during use and for 28 days afterwards; DMPA and intrauterine methods are unaffected.
A non-palpable implant may be deeply inserted, migrated or absent; exclude pregnancy and localise it before removal.
DMPA is scheduled every 13 weeks and can be given up to 14 weeks from the last injection without additional precautions; later return requires EC and pregnancy assessment.
Severe pain, neurovascular symptoms or signs of infection after implant insertion or removal need urgent examination and specialist referral.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Insertion and injection recordFirst step
Why
Confirm product, exact date, site, lot and calculated replacement or repeat date.
Interpretation and limitations
A remembered year or obsolete three-year implant card is insufficient after the 2026 licence change.
02
Pregnancy assessment
Why
Exclude pregnancy at initiation, after late DMPA or during a known implant interaction.
Interpretation and limitations
Test again 21 days after the latest unprotected intercourse when the initial result may be too early.
03
Implant localisation imaging
Why
Identify a non-palpable radiopaque Nexplanon before attempted removal.
Interpretation and limitations
Ultrasound is commonly first; radiography and specialist imaging follow when not identified, with chest imaging only if migration is suspected.
04
Bone and health risk review
Why
Assess DMPA in people with osteoporosis risk, adolescence, perimenopause or chronic steroid exposure.
Interpretation and limitations
Routine DXA is not required for every user; investigate or change method when individual clinical risk warrants it.

04Treatment approachPreparation, options, escalation and aftercare.

01Implant pathwayInsert, palpate and date five yearsFirst stepAn eligible patient chooses etonogestrel implant contraception.

1Exclude pregnancy reasonably, review enzyme-inducing medicines and counsel about bleeding, duration and procedure risks.
2Insert subdermally with trained technique, palpate the whole rod with the patient and document product, site and date.
3Set the removal or replacement date at five years, with earlier access for symptoms, pregnancy intention or preference. The CoSRH May 2026 five-year contraceptive duration applies both to Nexplanon implants already in place and to new insertions, calculated from the original insertion date.

02Late injection pathwayCount weeks from the previous DMPA doseA DMPA user returns after the scheduled 13-week date.

1At 14 weeks or less, give DMPA without additional precautions after confirming no other pregnancy concern.
2Beyond 14 weeks, establish unprotected-sex dates and offer copper IUD or suitable oral EC; immediate DMPA can follow LNG, whereas UPA requires a five-day delay.
3Use condoms for seven days and arrange a pregnancy test 21 days after the latest unprotected sex.

03Non-palpable pathwayLocate before removingThe implant cannot be palpated or removal is difficult.

1Exclude pregnancy, advise additional contraception if placement or efficacy is uncertain and review the insertion record.
2Localise with high-frequency ultrasound and radiography as needed because Nexplanon is radiopaque.
3Refer deep, intramuscular, neurovascular or migrated implants to an experienced removal service; never explore blindly.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Suppresses ovulation and thickens cervical mucus with highly effective user-independent contraception.

Etonogestrel implant 68mg

Insert one radiopaque rod subdermally in the non-dominant upper arm for up to five years of contraception under the UK licence current from May 2026.

Enzyme inducers reduce efficacy during use and for 28 days after; confirm palpability, investigate pregnancy symptoms and localise before difficult removal.

Provides oestrogen-free injectable contraception unaffected by hepatic enzyme induction.

Depot medroxyprogesterone acetate

Give the licensed intramuscular or subcutaneous preparation at its product dose every 13 weeks; administration up to 14 weeks after the last injection needs no extra contraception.

Discuss bleeding, weight, temporary bone-density loss, delayed fertility return and inability to remove the dose; after 14 weeks assess EC and pregnancy risk.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Update older three-year implant reminders to the five-year UK licence and verify the current insertion date before advising replacement.
At every medicine change, identify enzyme induction and cover the implant during treatment and for 28 days afterwards.
Review troublesome bleeding, pregnancy symptoms, insertion-site problems and whether the implant remains palpable.
Reassess DMPA benefits, bleeding, bone risks, cardiovascular changes and fertility plans around two-yearly rather than imposing automatic discontinuation.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

The licence changed in 2026

Five years now applies to existing and newly inserted Nexplanon devices in the UK.

Replacement does not fix induction

A new implant is still metabolised faster, so an unaffected method is preferable during enzyme-inducing therapy.

DMPA has a grace week

The planned 13-week interval can extend to 14 weeks without backup under current guidance.

Return differs after stopping

Implant fertility returns promptly, whereas ovulation after DMPA may be delayed for many months.

08Common pitfallsFrequent interpretation and management errors.

01
Replacing every implant at three years after the licence extension.
02
Using the five-year implant rule for lower-dose LNG-IUDs.
03
Attempting blind removal of a non-palpable rod.
04
Calling 15 weeks after DMPA continuously protected without EC assessment.
05
Promising that bleeding or fertility returns on an exact date.

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