Family Health Intl - Checklist for Screening Clients who want to initiate DMPA (or NET-EN)
Publication date: 2008
Assessing Medical Eligibility for DMPA 1. Have you ever had a stroke or heart attack, or do you currently have a blood clot in your legs or lungs? This question is intended to identify women with already known serious vascular disease, not to determine whether women might have an undiagnosed condition. Women with these conditions may be at somewhat increased risk of blood clots if they use DMPA. Women who have had any of these conditions will commonly have been told that they have the condition and will answer “yes.” Answering “yes” to any part of the question means that the woman is not a good candidate for DMPA. 2. Have you ever been told you have breast cancer? This question is intended to identify women who know they have had or currently have breast cancer. These women are not good candidates for DMPA because breast cancer is a hormone-sensitive tumor, and DMPA use may adversely affect the course of the disease. 3. Do you have a serious liver disease or jaundice (yellow skin or eyes)? This question is intended to identify women who know that they currently have a serious liver disease and to distinguish between current severe liver disease (such as severe cirrhosis or liver tumors) and past liver problems (such as treated hepatitis). Women with serious liver disease should not generally use DMPA because it is processed by the liver and hence its use may adversely affect women whose liver function is already weakened by the disease. Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) Research fi ndings have established that depot medroxyprogesterone acetate (DMPA) and norethisterone enantate (NET-EN) are safe and eff ective for use by most women, including those who are at risk of sexually transmitted infections (STIs) and those living with or at risk of HIV infection. For some women, DMPA and NET-EN are usually not recommended because of the presence of certain medical conditions such as liver tumors and breast cancer. For these reasons, women who desire to use DMPA must be screened for certain medical conditions to determine if they are appropriate candidates for DMPA. Family Health International (FHI), with support from the U.S. Agency for International Development (USAID), has developed a simple checklist (see center spread) to help health care providers screen clients who were counseled about contraceptive options and made an informed decision to use DMPA. This checklist is a revised edition of the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) produced by FHI in 2002. This checklist is based on recommendations included the Medical Eligibility Criteria for Contraceptive Use (WHO, 2004). The main changes in this version of the checklist include the addition of high blood pressure (systolic ≥160mmHg or diastolic ≥100mmHg) as a condition that would prohibit the use of DMPA and the inclusion of a series of questions to determine with reasonable certainty whether a woman is not pregnant before initiating the method. The checklist is designed for use by both clinical and nonclinical health care providers, including community health workers. It consists of 13 questions designed to identify medical conditions that would prevent safe DMPA use or require further screening, as well as provide further guidance and directions based on clients’ responses. Clients who are ruled out because of their response to some of the medical eligibility questions may still be good candidates for DMPA after the suspected condition is excluded through appropriate evaluation. This checklist is part of a series of provider checklists for reproductive health services. The other checklists include the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, the Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, and the Checklist on How to be Reasonably Sure a Client is Not Pregnant. For more information about the provider checklists, please visit www.fhi.org. 4. Have you ever been told you have diabetes (high sugar in your blood)? This question is intended to identify women who know that they have diabetes, not to assess whether they may have an undiagnosed condition. Women who have had diabetes for 20 years or longer or those with vascular complications should generally not use DMPA because of the increased risk of blood clots. Evaluate or refer for evaluation as appropriate and, if these complications are absent, the woman may still be a good candidate for DMPA. 5. Have you ever been told you have high blood pressure? This question is intended to identify women who may have high blood pressure. These women should be evaluated or referred for evaluation as appropriate. Based on evaluation, women with blood pressure levels of 160/100 Hg or more should not initiate DMPA. 6. Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse (sex)? This question is intended to identify women who may have an underlying pathological condition. While DMPA use does not make these conditions worse, it may change the bleeding pattern and mask a serious underlying condition. Unusual bleeding changes may indicate pregnancy or tumor that should be evaluated soon or treated by a higher-level health care provider. DMPA use should be delayed until the condition can be evaluated. In contrast, women for whom it is not unusual to have heavy or prolonged bleeding, or irregular bleeding patterns, may safely initiate DMPA use. 7. Are you currently breastfeeding a baby less than six weeks old? This question is included because of the theoretical concern that hormones in breast milk can have an adverse effect on a newborn during the fi rst six weeks after birth. A breastfeeding woman can initiate DMPA six weeks after her baby is born. Determining Current Pregnancy Questions 8–13 are intended to help a provider determine, with reasonable certainty, whether a client is not pregnant. If a client answers “yes” to any of these questions and there are no signs or symptoms of pregnancy, it is highly likely that she is not pregnant. The client can start DMPA now. If the client is within 7 days of the start of her menstrual bleeding, she can start the method immediately. No back-up method is needed. If it has been more than 7 days since her fi rst day of bleeding, she can start DMPA immediately but must use a back-up method (i.e., using a condom or abstaining from sex) for 7 days to ensure adequate time for the DMPA to become effective. If you cannot determine with reasonable certainty that your client is not pregnant (using the checklist) and if you do not have access to a pregnancy test, then she needs to wait until her next menstrual period begins before starting DMPA. She should be given condoms to use in the meantime. © Family Health International, 7/2007 • P.O. Box 13950, Research Triangle Park, NC 27709 USA • Fax: (919) 544-7261 • http://www.fhi.org Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) If the client answered NO to all of questions 1–7, the client can use DMPA. Proceed to questions 8–13. If the client answered YES to any of questions 1–3, she is not a good candidate for DMPA. Counsel about other available methods or refer. If the client answered YES to any of questions 4–6, DMPA cannot be initiated without further evaluation. Evaluate or refer as appropriate, and give condoms to use in the meantime. See explanations for more instructions. If the client answered YES to question 7, instruct her to return for DMPA as soon as possible after the baby is six weeks old. © 7/2007 If the client answered NO to all of questions 8–13, pregnancy cannot be ruled out. She must use a pregnancy test or wait until her next menstrual period to be given DMPA. Give her condoms to use in the meantime. If the client answered YES to at least one of questions 8–13 and she is free of signs or symptoms of pregnancy, you can be reasonably sure that she is not pregnant. The client can start DMPA now. If the client began her last menstrual period within the past 7 days, she can start DMPA immediately. No additional contraceptive protection is needed. If the client began her last menstrual period more than 7 days ago, she can be given DMPA now, but instruct her that she must use condoms or abstain from sex for the next 7 days. Give her condoms to use for the next 7 days. NO 1. Have you ever had a stroke or heart attack, or do you currently have a blood clot in your legs or lungs? YES NO 2. Have you ever been told you have breast cancer? YES NO 3. Do you have a serious liver disease or jaundice (yellow skin or eyes)? YES NO 4. Have you ever been told you have diabetes (high sugar in your blood)? YES NO 5. Have you ever been told you have high blood pressure? YES NO 6. Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse (sex)? YES NO 7. Are you currently breastfeeding a baby less than 6 weeks old? YES To determine if the client is medically eligible to use DMPA, ask questions 1–7. As soon as the client answers YES to any question, stop, and follow the instructions below. Ask questions 8–13 to be reasonably sure that the client is not pregnant. As soon as the client answers YES to any question, stop, and follow the instructions below. YES 8. Did your last menstrual period start within the past 7 days? NO YES 9. Did you have a baby less than 6 months ago, are you fully or nearly-fully breastfeeding, and have you had no menstrual period since then? NO YES 10. Have you abstained from sexual intercourse since your last menstrual period or delivery? NO YES 11. Have you had a baby in the last 4 weeks? NO YES 12. Have you had a miscarriage or abortion in the last 7 days? NO YES 13. Have you been using a reliable contraceptive method consistently and correctly? NO
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