• implants
• family planning service provision
• unanticipated bleeding

We would like to thank Dr Dickson et al. 1 for their helpful commentary on unanticipated bleeding with the etonogestrel implant that appeared in the July 2014 Journal.

We have found in our audit of early implant removals in the Lanarkshire Sexual Health Service that the commonest reason for early removal was problematic bleeding. Of the 184 implants removed in our first audit cycle, 25% were removed within 12 months of insertion and 47% of these were removed for problematic bleeding.

In response to these findings we prepared a protocol for management of irregular bleeding with contraceptive implants based on guidance from the Faculty of Sexual & Reproductive Healthcare.2 This was circulated to all local general practitioner surgeries and to all sexual health/family planning staff. A teaching session was held for sexual health staff on the management of irregular bleeding in women using implants. As the authors have suggested, we emphasised the importance of good counselling prior to implant insertion and a trial of a combined oral contraceptive pill (COC) or progestogen-only pill (POP) after initial assessment if women presented with problematic bleeding.

In our second audit cycle, of 264 implants removed, 25% were removed within 12 months of insertion and 43% of these were removed for problematic bleeding. Therefore introduction of the protocol did not help to reduce the rate of early removal for problematic bleeding in our service.

We noticed that 78% of the early removals for problematic bleeding were between 6 and 12 months post-insertion. It is possible that some of these women may have been offered the COC/POP to control bleeding without much benefit. We are currently analysing these data and conducting a further audit to assess these results.