Management of abnormal bleeding in etonogestrel-releasing implant users: quo vadis? An exploratory study on the attitudes of a cohort of Italian gynaecologists and review of the literature

Introduction: Long-acting reversible contraceptives (LARCs) are increasingly gaining popularity due to their high efficacy and ease of use compared to short-acting reversible contraceptives (SARCs). Among available LARCs, the etonogestrel (ENG) subdermal implant represents a particularly effective contraceptive method. However, many patients request early removal of the device due to the persistence of unfavourable bleeding patterns. Methods: We developed a short, multiple-choice ad hoc questionnaire distributed online from October 2024 to March 2025 to investigate the attitude of Italian gynaecologists towards medical treatment of unfavourable bleeding in women using the ENG-releasing implant. A total of 141 physicians responded reporting their first- and second-line treatments for patients with and without a contraindication to combined oral contraceptives (COC). We discuss the results of our survey in the light of the existing literature, through a systematic review including studies evaluating medical treatments in ENG implant users experiencing troublesome bleeding. Results and conclusion: The results of our survey and the review of the literature highlight the diverse, sparse, and sometimes confused approaches to unfavourable bleeding in ENG implant users. In our survey, up to 19% of practitioners indicated they would not know what to do in different case scenarios. In order to help gynaecologists gain greater confidence in managing this symptom, large randomised controlled trials (RCTs) with long-term follow-up on which clinical guidelines and standardized training programs can be based, are needed.