Norplant

Norplant is a sustained-release contraceptive system that acts continuously for five years. It consists of six silicone rubber capsules, each the length and diameter of a matchstick, which are surgically implanted under the skin of the upper arm. The synthetic progestin Levonorgestrel, a hormone found in many oral contraceptives, is slowly released into the bloodstream, resulting in a constant hormone level. The contraceptive effect of Norplant is due primarily to inhibition of ovulation, although secondary mechanisms include thickening of cervical mucus, and formation of an atrophic endometrium. Although 20 percent of Norplant users ovulate in year one and up to 50 percent ovulate by year five of use, studies suggest that when ovulation does occur, it is defective and the ovum is not subject to fertilization. The cumulative pregnancy rate of Norplant users is 3.8 pregnancies per one hundred women over five years; the first-year failure rate is only 0.09 per hundred women per year. Ectopic (tubal) pregnancies are reduced by two-thirds in comparison to noncontracepting women, although should Norplant fail, there is a greater conditional probability (proportionate risk) that the pregnancy will be located in the fallopian tube rather than in the uterus.

Studies that have evaluated the metabolic effects of Norplant have found minimal impact. There is no effect on cholesterol or lipoprotein metabolism, glucose metabolism, or propensity to blood clotting. Norplant is an appropriate method of contraception for women who desire long-term contraception, who have completed childbearing but do not desire permanent sterilization and have had problems with other methods of contraception (including combined OCs), and for postpartum women, whether nursing or not.

The technique of insertion of Norplant involves anesthetizing the skin with local anesthetic and creation of a four-millimeter incision, followed by placement of a twelve-gauge trochar to insert the capsules in a fan-shaped pattern. The procedure takes less than ten minutes and is well tolerated by most women. The method should be inserted within five days of the onset of the menses and provides a contraceptive effect within twenty-four hours. More problematic is Norplant removal, which requires substantially more skill and takes between fifteen and forty minutes. The ease of removal is related to a number of factors, including the correctness of the initial Norplant insertion, the amount of fibrous tissue that has developed around the capsules, and the skill of the clinician.

The most prevalent adverse effect of Norplant is the unpredictability and irregularity of menstrual cycles, especially in the first year of use. Cycles may be shorter or longer than usual and associated with more or less bleeding; there may be bleeding between cycles, or no bleeding at all. Although there is no cure for irregular bleeding patterns, short-term palliation of the problem can be achieved by the use of low-dose oral estrogen therapy (e.g., ethinyl estradiol 20 mcg orally per day for two to three weeks). Other side effects include mild weight gain, headaches, hair loss, and new onset or exacerbation of depression.

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