Nexplanon and PCOS: Influence on Periods and Insulin Resistance

“Nexplanon and PCOS” as the title says is about the role of Nexplanon in women and girls with PCOS.

Nexplanon is a subdermal implant that contains the progestin hormone in a depot form. It is released slowly in a rate-limiting form over a period of up to three years.

Once inserted, Nexplanon is effective for up to 3 years. It is a highly effective form of contraceptive implant with a failure rate of less than 1%.

However, Nexplanon is not only indicated for preventing pregnancy. It may be used in girls and women with irregular periods, especially girls with PCOS.

What is PCOS?

PCOS or polycystic ovarian syndrome is a metabolic problem affecting young girls and women in their reproductive ages.

Why some girls develop PCOS is not fully known. However, increased insulin production, insulin resistance, and high testosterone have been seen in the majority of women with PCOS.

In response to insulin, the ovaries produce more testosterone which interrupts the female menstrual cycles.

Cysts are formed in the ovaries which can enlarge and have local effects too. In addition, these cysts are lined by the theca cells which produce testosterone when stimulated by the GnRH, a hypothalamic hormone.

Women with PCOS primarily seek help for infertility. Young girls have symptoms of high testosterone levels.

Symptoms of PCOS include:

• Irregular periods or amenorrhea (absent periods or periods not started until 15 years of age)
• Scanty or infrequent periods (fewer than 8 periods per year)
• Acne and oily skin
• Hirsutism or facial hair
• Frontal balding
• Coarse pubic and axillary hair
• Weight gain
• Obesity and difficulty losing weight
• Infertility and difficulty conceiving
• Acanthosis Nigricans (velvety blackish pigmentation around the axilla and groin)
• Insulin resistance and Type 2 Diabetes Mellitus

How is PCOS Diagnosed? [Ref]

PCOS is diagnosed when a woman or a girl has menstrual irregularities, oligomenorrhea, amenorrhea, or infrequent and scanty periods along with cysts in the ovaries and virilization.

Virilization is caused by high testosterone levels. Girls develop acne, deep voice, excessive facial hair, frontal balding, thick axillary and pubic hair, and weight gain.

There are 3 different diagnostic tools used to diagnose PCOS.

All three diagnostic tools include:

• Hyperandrogenism and
• Menstrual irregularities

Two of these also include the presence of polycystic ovaries as well.

Conditions associated with PCOS:

It is important to screen women with PCOS for other associated medical conditions after the diagnosis of PCOS is confirmed.

Medical conditions associated with PCOS include:

• Prediabetes or Diabetes
• Prehypertension or Hypertension
• Dyslipidemia
• Anxiety and Depression
• Sleep Apnea
• Endometrial Cancer, and 
• Heart Disease

Women with PCOs who become pregnant are also at an increased risk of developing pregnancy-associated complications.

These include:

• Miscarriages 
• Preterm delivery
• Gestational Diabetes
• Preeclampsia

How is PCOS treated?

Treatment of PCOS is multifaceted. Each abnormality is treated differently as outlined below [Ref]:

Treatment of anovulation:

• Clomiphene citrate (First-line)
• Metformin (or Metformin + Clomiphene citrate)
• Gonadotrophins or FSH
• Letrozole or Anastrozole

Treatment of androgen excess:

• Spironolactone
• Flutamide
• Finasteride

Treatment of Menstrual irregularities:

• Combined estrogen and progestin-containing oral contraceptive pills
• Progestin-only contraceptives

A table of Progestin-only contraceptives is presented here:

Other treatments:

• Statins
• Medroxyprogesterone

How Nexplanon Helps Women with PCOS?

Nexplanon is a more advanced form of Implanon (discontinued in the US). It slowly releases the active drug via a rate-limiting membrane over a period of 3 years.

The implant is placed under the skin of the non-dominant arm and removed or replaced after 3 years.

Unlike most other implants, Nexplanon is radio-opaque and hence tracable.

Nexplanon is a progestin-only contraceptive primarily indicated for the long-term prevention of pregnancy.

It is also used to treat women with endometriosis and endometriosis-associated cyclical pains and bleeding.

Because Nexplanon contains Progestin-only hormone, it is considered safer than combined oral contraceptives and contraceptives containing estrogen.

Apart from preventing pregnancy in women with PCOS, Nexplanon helps women with PCOS in the following ways:

• Nexplanon is a birth control implant. It can help with some issues caused by extra male hormones in women, like too much facial hair, baldness, a deep voice, and weight gain.
• Nexplanon is safer than some other birth control pills. It’s less likely to cause headaches, blood clots, or heart problems.
• Nexplanon can also make the periods of women with PCOS more regular.

Effects of Nexplanon on Periods in Women with PCOS:

Nexplanon is an effective form of contraceptive with effects lasting for up to 3 years. It helps women with abnormally prolonged bleeding.

Most women who use Nexplanon have changes in bleeding which may be lighter or only spotting for the first 6 to 12 months. This can happen in about 1 in every 3 women.

It is normal not to have a cycle while on Nexplanon. However, some women may have prolonged and heavy periods.

In clinical trials, women who used Nexplanon had the following bleeding patterns over a 90-day period (3 months):

• Scanty bleeding: Fewer than 7 days over a 90-day period (3 months)
• Normal bleeding: 8 – 21 days over 3 months
• Heavy bleeding: More than 21 days over 3 months

In another study, bleeding pattern in women using Nexplanon over a 3-month and 6-month period was compared. Here are the results:

The effect of Nexplanon in women with PCOS may be slightly different than in normal women because they have a preexisting hormonal problem.

The effect of Nexplanon on the sexual profile of women was also favorable.

Women reported an increase in the frequency and quality of coitus, greater satisfaction and frequency of orgasms, and an increase in sexual desire and fantasy [Ref].

Effects of Nexplanon on Insulin Resistance:

Insulin resistance is one of the key problems faced by young girls and women. In fact, more than half of the women with PCOS develop diabetes type 2 after the age of 40 years [Ref].

Glucophage is used to treat women with insulin resistance and deranged metabolic parameters.

Female hormones, including Progestins, have been associated with insulin resistance and impaired fasting glucose.

In one study, Implanon implant use was associated with insulin resistance and weight gain.

Weight gain may be due to the direct hormonal influence of Nexplanon on reducing insulin clearance and degradation or a result of the increased fatty acids which result in insulin resistance [Ref].

Hyperinsulinemia and increased water content are also responsible for weight gain associated with Nexplanon.

Nexplanon, in this context, can be counter-productive in women with PCOS.

When to Consider Nexplanon for PCOS?

Nexplanon can be used by women with PCOS who have frequent abnormal bleeding or heavy bleeding and those who do not plan pregnancy in the coming three years.

It might have some anti-androgenic effects and may improve symptoms of high testosterone levels such as acne, excessive facial hair, and hair thinning.

However, on the other hand, women with PCOS who have insulin resistance or hyperglycemia and weight gain might notice that their problems have worsened with Nexplanon.

Summarizing Nexplanon and PCOS:

Nexplanon is a progestin-containing advanced formulation of Implanon implant. It is inserted into the skin of the non-dominant forearm. Nexplanon can be traced on X-rays.

It effectively prevents pregnancy for up to 3 years and may help women with heavy menstrual cycles and painful menstrual cramps.

Because of its anti-androgenic effects, it is an attractive option for women with PCOS who have symptoms of high testosterone levels such as acne, hirsutism, and balding.

However, on the other hand, it may worsen insulin resistance in women with PCOS.

It is best to discuss all the PROS and CONS of Nexplanon with your doctor, especially if you have PCOS.