CAN THE ETONORGESTREL IMPLANT BE INSERTED INTO THE THIGH?

CASE REPORT 1 In October 2018, a 24-year-old nulligravida woman with oxalosis and a functioning liver transplant was referred to the Family Planning Service due to increased menstrual flow causing clinical repercussions, specifically multifactorial iron-deficiency anemia with a hemoglobin level of 6.4 g/dL. The patient also had dialytic renal insufficiency, neurogenic bladder, and bone mineral disease resulting from medullary impregnation by calcium oxalate crystals.Given the patient's virgin status and the presence of arteriovenous fistulas in both arms, precluding the usual upper arm insertion of Implanon®, and considering the potential need for peritoneal dialysis in the future (preventing abdominal insertion), as well as the patient's reduced mobility due to bone disease leading to prolonged periods of bed rest (preventing dorsal insertion), a unique approach was chosen. The decision was made to insert the implant on the medial side of the patient's left thigh (Fig. 1), performed under local anesthesia. The implant remained superficial and palpable. Notably, the patient achieved amenorrhea one month post-insertion, maintaining this status during semi-annual follow-up visits.After three years, the patient returned for implant replacement. As a new implant was unavailable at that time, and considering the patient's sustained amenorrhea, it was decided to retain the existing implant until a replacement device became available. The replacement occurred after three years and four months of utilizing the initial implant, with the patient remaining amenorrheic following the insertion of the second device.  CASE REPORT 2 In November 2022, a 27-year-old nulligravida woman, currently not using any contraceptive method, sought consultation at the Family Planning Service expressing a desire for contraception. The patient presented with chronic dialytic renal disease, possessing a single atrophied kidney while awaiting a renal transplant. A history of hyperparathyroidism led to a total parathyroidectomy with cervical emptying and parathyroid implantation in the left upper limb. Initially, the patient preferred the insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS). However, she brought forth a previous cytology result indicating a high-grade squamous intraepithelial lesion (HSIL) without appropriate follow-up and treatment.Given the untreated cervical lesion (HSIL), a collaborative decision-making process with the patient led to the choice of Implanon NXT® for contraception. The decision to insert the implant on the inner side of the right lower limb was prompted by the presence of arteriovenous fistulas in the upper limbs and the anticipated abdominal access during the proposed renal transplant surgery. Implanon® was successfully inserted on the medial side of the right thigh (Fig. 2-4), with the implant remaining superficial and palpable.The patient returned for a follow-up assessment three months post-implant insertion, reporting a significant reduction in menstrual flow and localized itching. Guidance was provided, recommending the use of a local moisturizer. Subsequent evaluations at six and 12 months revealed the patient experiencing amenorrhea, and she was advised to return for semi-annual check-ups.