Jadelle and Levoplant

The two levonorgestrel two-rod systems share the same drug, the same 75 mg load in each rod and the same insertion and removal technique, but they are licensed and used for different durations: one system is effective for 5 years and the other for 3 years. Correct recording of which system was inserted is therefore essential to avoid unrecognised loss of protection.

Shared features. Two flexible silicone rods; levonorgestrel 75 mg in each rod, 150 mg in total; subdermal insertion in a narrow V in the inner upper arm; mechanism through cervical mucus thickening, partial ovulation suppression and endometrial thinning; first-year pregnancy rate about 0.05 per 100 women with typical and perfect use.

Comparison of the two systems.

Release and effectiveness. Both systems release levonorgestrel at broadly similar rates in the first years. Effectiveness is comparable through 3 years. Beyond 3 years, effectiveness of the 3-year system is not relied upon, while the 5-year system continues to protect to 5 years.

Return to fertility. Rapid with both systems after removal of both rods.

Choice between systems. Both systems have identical eligibility, interactions and contraindications. The choice rests on how long the patient wants protection, the number of procedures she is willing to have, and the supply available at the facility. A patient wanting 5 years of protection is better served by the 5-year system; a patient planning pregnancy within 3 years can use either.

Eligibility categories (both systems).

• Category 1: adolescents, nulliparity, smoking, obesity, hypertension, sickle cell disease, HIV infection.

• Category 2: breastfeeding under 6 weeks postpartum, past venous thromboembolism, migraine without aura, uncomplicated diabetes, efavirenz, nevirapine, ritonavir-boosted protease inhibitors, rifampicin, rifabutin, enzyme-inducing antiseizure medicines.

• Category 3: current deep vein thrombosis or pulmonary embolism, severe cirrhosis or hepatic tumours, unexplained vaginal bleeding before evaluation, ischaemic heart disease, stroke or worsening migraine with aura during use.

• Category 4: current or past breast cancer.

Interactions (both systems). Efavirenz, rifampicin, rifabutin and enzyme-inducing antiseizure medicines lower levonorgestrel levels. Advise condoms throughout and for 28 days after stopping the inducer, or switch to an unaffected method. Dolutegravir and raltegravir do not interact.

Body weight. No restriction by weight for either system. Falling levels in heavier users matter most towards the end of a lifespan.

Counselling points. Tell the patient the name of the duration she has received in plain terms (3 years or 5 years), write it on the card, and give a removal date. Explain that the two systems look alike and that the card, not the appearance, shows when replacement is due.

Regimen lines.

• 5-year system: levonorgestrel two 75 mg rods; subdermal, inner upper arm, about 8 cm proximal to the elbow crease; lidocaine 1%, 2 to 3 mL; immediate protection within 7 days of the start of bleeding, otherwise backup 7 days; replace at 5 years.

• 3-year system: levonorgestrel two 75 mg rods; same site and technique; same start and backup rules; replace at 3 years.

• For both: no grace window after expiry; condoms with enzyme inducers or efavirenz throughout and for 28 days after stopping; no adjustment for breastfeeding, adolescence or perimenopause.

Start and switching rules (both systems). Within 7 days of the start of bleeding, no backup; later, exclude pregnancy and use backup 7 days. Non-breastfeeding postpartum up to 21 days, no backup. Breastfeeding, from immediately postpartum. Postabortion, immediately. From another hormonal method used correctly, immediately. From an injectable, when the next injection is due. From an IUD, insert within 7 days of bleeding and remove the IUD at the same visit; after day 7, keep the IUD until the next period.

Documentation. Record the system, batch number, arm, insertion date and planned removal date in the register and on the card. Errors in recorded duration are the main avoidable cause of pregnancy with these systems.

Replacement and overdue implants. At the end of the lifespan, remove both rods and insert a new set through the same incision if the patient wishes, with no gap in protection. If the implant is overdue, exclude pregnancy, replace, and use backup 7 days unless pregnancy can be reasonably excluded and replacement falls within 7 days of the start of bleeding.

Follow up. No routine visit; return at the removal date or for any problem.

Shared adverse effects. Irregular or prolonged bleeding, especially in the first year; amenorrhoea in a minority; headache, breast tenderness, acne, mood change, weight change and ovarian follicle enlargement. Profiles of the two systems do not differ in a clinically meaningful way.

Bleeding management. Exclude pregnancy, STI and pelvic pathology. Ibuprofen 800 mg three times daily for 5 days or mefenamic acid 500 mg twice daily for 5 days; ethinylestradiol 30 micrograms with levonorgestrel 150 micrograms daily for 21 days if oestrogen is eligible; tranexamic acid 500 mg three times daily for 5 days for heavy bleeding. Remove if unacceptable.

Complications. Site infection, expulsion of a rod, deep placement, difficult removal from fibrous sheathing, and nerve injury. Removal of both rods must be confirmed; a rod left behind may continue to release levonorgestrel.

Supply errors. When the facility switches between systems, mismatched removal dates are a recognised risk. Check the system on the card and register before advising a patient she is protected beyond 3 years.

Referral and escalation. Refer non-palpable or deep rods, a single missing rod after removal, suspected ectopic pregnancy and suspected nerve injury.