INFO Project- Injectable Contraceptives: Tools for Providers

Publication date: 2006

Injectable Contraceptives: Tools for Providers Common Trade Names Formulation Injection Type and Schedule Progestin-Only Injectables Depo-Provera®, Megestron®, Contracep®, Depo-Prodasone® Depot medroxyprogesterone acetate (DMPA) 150 mg One intramuscular (IM) injection every 3 months depo-subQ provera 104® (DMPA-SC) DMPA 104 mg One subcutaneous injection every 3 months Noristerat®, Norigest®, Doryxas® Norethisterone enanthate (NET-EN) 200 mg One IM injection every 2 months Combined Injectables (progestin + estrogen)1 Cyclofem®, Ciclofeminina®, Lunelle® 2 Medroxyprogesterone acetate 25 mg + Estradiol cypionate 5 mg (MPA/E2C) One IM injection every month Mesigyna®, Norigynon® NET-EN 50 mg + Estradiol valerate 5 mg (NET-EN/E2V) One IM injection every month Deladroxate®, Perlutal®, Topasel®, Patectro®, Deproxone®, Nomagest® Dihydroxyprogesterone (algestone) acetophenide 150 mg + Estradiol enanthate 10 mg One IM injection every month Anafertin®, Yectames® Dihydroxyprogesterone (algestone) acetophenide 75 mg + Estradiol enanthate 5 mg One IM injection every month Chinese Injectable No. 1® 17α-hydroxyprogesterone caproate 250 mg + Estradiol valerate 5 mg One IM injection every month, except 2 injections in fi rst month Table 1. Formulations and Injection Schedules of Injectable Contraceptives See companion Population Reports, “Expanding Services for Injectables” INFO Project Center for Communication Programs Coming Soon: “Injectables Toolkit” Web site. Go to www. injectablestoolkit.org for job aids and information about injectable contraceptives More than twice as many women are using injectable contraceptives today as a decade ago, and the numbers keep growing. Women choose injectables because they are highly effective, long-acting, reversible, and private. At the same time many women do not choose injectables or stop using them because of side effects—particularly irregular bleeding, no monthly bleeding, and weight gain—or because they have trouble returning for injections (13, 70, 135, 168). Family planning programs are meeting increasing demand while helping providers to maintain good quality of care. Attention to quality, and to counseling especially, can be the difference between successful and unsuccessful efforts to expand access to injectables (77, 78). Using the tools in this INFO Reports, providers can inform women about injectables and help them be satisfi ed users. Sources: International Planned Parenthood Federation 2005 (83), Lande 1995 (99), Liggeri 2006 (103), WHO 1990 (204), WHO 1993 (205) 1Also called monthly injectables. 2The U.S. Food and Drug Administration approved Lunelle, but it is currently not available in the United States. December 2006 • Issue No. 8 205402_JHU-InfoReport.indd 1205402_JHU-InfoReport.indd 1 12/12/06 10:52:44 AM12/12/06 10:52:44 AM Prepare equipment and supplies q In advance, assemble the supplies and materials needed Single-dose vial Sterile needle and syringe (If auto-disable (AD) or conventional disposable syringes and needles are not available, use sterile equipment designed for steam sterilization. Do not reuse disposable equipment.) Cotton wool q Wash hands with soap and water before giving the injection, if possible. Gloves are not needed unless there is a chance of direct contact with blood or other body fl uids. q Inspect the vial and check expiry date. Discard any with visible cracks or leaks. q With injectables containing DMPA, roll the vial back and forth or gently shake to mix contents. If the vial of NET-EN is cold, warm to skin temperature before giving the injection. Give the injection safely q Explain the injection procedure to the client and point out that the syringe and needle are sterile. q Ask the client her preferred site for injection: upper arm (deltoid muscle) or buttocks (gluteal muscle). To decrease discomfort, position her so that her muscles are relaxed. q Wash the injection site with soap and water if it is visibly dirty. Swabbing clean skin or wiping the skin with antiseptic before giving an injection is not necessary. q Pierce the top of the vial with the sterile needle and fi ll syringe with the proper dose. q With a smooth, steady motion, insert the needle deep into the muscle at a right angle (90°) and inject the contents of the syringe. q After the injection ask the client to hold cotton wool on the injection site. Instruct the client not to massage the injection site. q Wash hands with soap and water after giving the injection, if possible. Dispose of waste appropriately q Do not recap, bend, cut, or break needles after use. Discard the used disposable needle and syringe immediately in an enclosed sharps container. q If reusable syringes and needles are used, they must be sterilized again after each use. q Seal and dispose of sharps containers when they are three-fourths full. Follow program or clinic guidelines for proper waste management. • • • Checklist for Giving Intramuscular Contraceptive Injections Family planning providers can use this checklist to help ensure that injections are safe. Intramuscular injections can be given in the deltoid muscle of either arm or the left or right buttock (gluteal muscle, upper outer portion), whichever the woman prefers.1 To minimize the risk of injury, providers should take care to deliver the injection in the proper site. This report was prepared by Robert Lande and Catherine Richey, MPH. Ward Rinehart, Editor. Rafael Avila and Francine Mueller, Designers. The INFO Project appreciates the assistance of the following reviewers: Jacob Adetunji, Kim Best, Richard Blackburn, Marc G. Boulay, Steve Brooke, Gloria Coe, María del Carmen Cravioto, Juan Díaz, Maxine Eber, Douglas Huber, Barbara Janowitz, Sophie Logez, Enriquito R. Lu, Kuhu Maitra, Kavita Nanda, Fredrick Ndede, Carib Nelson, Paula Nersesian, Gael O’Sullivan, Joseph F. Perz, James Phillips, Roberto Rivera, Ruwaida Salem, Hilary Schwandt, Stephen Settimi, James D. Shelton, Jenni Smit, Cathy Solter, J. Joseph Speidel, Jeff Spieler, Tara M. Sullivan, Jagdish Upadhyay, Ushma Upadhyay, Marcel Vekemans, Irina Yacobson, and Vera Zlidar. Suggested citation: Lande, R. and Richey, C. “Injectable Contraceptives: Tools for Provid- ers,” INFO Reports, No. 8. Baltimore, Johns Hopkins Bloomberg School of Public Health, INFO Project, Dec. 2006. Available online: http://www.infoforhealth.org/inforeports/ INFO Project Center for Communication Programs Johns Hopkins Bloomberg School of Public Health 111 Market Place, Suite 310 Baltimore, Maryland 21202 USA 410.659.6300 410.659.6266 (fax) www.infoforhealth.org infoproject@jhuccp.org Earle Lawrence, Project Director, INFO Project; Stephen Goldstein, Chief, Publications Division; Theresa Norton, Associate Editor; Linda Sadler, Production Manager. INFO Reports is designed to provide an accurate and authoritative report on important developments in family planning and related health issues. The opinions expressed herein are those of the authors and do not necessarily refl ect the views of the U.S. Agency for International Development (USAID) or the Johns Hopkins University. Published with support from USAID, Global, GH/POP/PEC, under the terms of Grant No. GPH-A-00-02-00003-00. ˛ Adapted from: Hutin 2003 (80) 1Intramuscular injection of the combined injectable Cyclofem can also be given in the thigh (lateral muscle of the quadriceps). How to Use This Report Family planning providers can use the checklists and tables in this report to: Counsel about injectables or answer clients’ questions (see Table 2, pp. 3–4), Identify women who may not be able to use DMPA or NET-EN for medical reasons (see Checklist, pp. 5–6), Be reasonably sure that a woman is not preg- nant before giving the fi rst injection (see Checklist, p. 6, questions 8–13), Review the steps required to give an injection safely (see Checklist, this page), and Help women be informed and satisfi ed con- tinuing users of injectables (see Table 3, p. 7). This report accompanies Population Reports, “Expanding Services for Injectables”. See also Population Reports, “When Contraceptives Change Monthly Bleeding,” Series J, No. 54, August 2006. • • • • • 2 205402_JHU-InfoReport.indd 2205402_JHU-InfoReport.indd 2 12/12/06 10:57:31 AM12/12/06 10:57:31 AM Ta bl e 2. H el pi ng C lie nt s M ak e a W el l-I nf or m ed C ho ic e of In je ct ab le C on tra ce pt iv es E ffe ct iv en es s, s id e ef fe ct s, a nd s af et y ar e th e fa ct or s th at w om en c on si de r m os t i m po rta nt w he n th ey c ho os e a co nt ra ce pt iv e m et ho d (2 7, 5 5, 2 27 ). W he n th ey s ee k fa m ily p la nn in g se rv ic es , m os t w om en a lre ad y ha ve a m et ho d in m in d th at in te re st s th em (1 98 ). In cr ea si ng ly, th at m et ho d is a n in je ct ab le c on tra ce pt iv e. G oo d- qu al ity pr og ra m s en su re th at a w om an in te re st ed in a n in je ct ab le u nd er st an ds it s ef fe ct iv en es s an d si de e ffe ct s, is a ss ur ed o f i ts s af et y, a nd k no w s ho w it is u se d. C ou ns el in g al so h el ps a w om an d ec id e if th e m et ho d su its h er n ee ds , p re fe re nc es , a nd c ur re nt s itu at io n. T hi s ta bl e of fe rs in fo rm at io n to h el p w om en w ith th ei r d ec is io n- m ak in g. Pr og es tin -O nl y In je ct ab le s1 C om bi ne d In je ct ab le s K EY P O IN TS : G iv e w om en th is in fo rm at io n W om en n ee d th is in fo rm at io n to m ak e an in fo rm ed c ho ic e ab ou t i nj ec ta bl es • O ne o f t he m os t e ffe ct iv e co nt ra ce pt iv e m et ho ds . • W om en h av e an in je ct io n ev er y 3 m on th s fo r D M PA o r e ve ry 2 m on th s fo r N E T- E N . I m po rta nt t o try to b e on ti m e fo r t he n ex t i nj ec tio n. • M os t w om en h av e fre qu en t o r i rr eg ul ar b le ed in g at fi rs t a nd th en li ttl e or n o m on th ly b le ed in g. T hi s is n ot h ar m fu l. G ra du al w ei gh t g ai n is c om m on a nd n ot h ar m fu l. • W om en ta ke 4 m on th s lo ng er o n av er ag e to b ec om e pr eg na nt a fte r s to pp in g D M PA th an a fte r s to pp in g m et ho ds o th er th an in je ct ab le s. 2 • O ne o f t he m os t e ffe ct iv e co nt ra ce pt iv e m et ho ds . • W om en h av e an in je ct io n on ce a m on th . I m po rta nt to t ry to b e on ti m e fo r t he n ex t i nj ec tio n. • L ik el y to c ha ng e bl ee di ng p at te rn s un pr ed ic ta bl y du rin g t he fi rs t 3 m on th s of u se . T hi s is n ot h ar m fu l. A fte r 3 m on th s m os t w om en h av e re gu la r p at te rn s (a ro un d 2 8 da ys fr om s ta rt of a m on th ly b le ed in g to th e ne xt ). Ef fe ct iv en es s: D ep en ds o n ha vi ng in je ct io ns o n tim e Ef fe ct iv en es s • T yp ic al ly, a bo ut 3 p re gn an ci es p er 1 00 w om en in th e fir st y ea r o f u se if u se rs d o no t r et ur n on ti m e. • L es s th an 1 p re gn an cy p er 1 00 w om en in th e fir st y ea r o f u se (3 p er 1 ,0 00 w om en ) i f u se rs re tu rn o n tim e (1 90 ). H ow o fte n to re tu rn fo r i nj ec tio ns • D M PA : E ve ry 3 m on th s (4 ti m es a y ea r) . N E T- E N : E ve ry 2 m on th s (6 ti m es a y ea r) . • C an c om e up to 2 w ee ks e ar ly o r 2 w ee ks la te a nd s til l h av e in je ct io n. • E ve ry m on th (1 2 tim es a y ea r). C an c om e up to 7 d ay s ea rly o r 7 d ay s la te a nd s til l h av e in je ct io n. C ou ns el in g gu id an ce • D is cu ss w he th er re tu rn in g to th e cl in ic fo r i nj ec tio ns w ill b e co nv en ie nt a nd e as y to re m em be r. • I f t he c lie nt m ay re tu rn la te , d is cu ss u si ng a b ac ku p m et ho d3 o r o ra l c on tra ce pt iv es o r e m er ge nc y co nt ra ce pt iv e pi lls . M an y w om en c an ha ve fi rs t i nj ec tio n im m ed ia te ly S cr ee ni ng C lie nt s W ho W an t t o In iti at e D M PA (o r N E T- E N ), pp . 5 –6 , q ue st io ns 8 –1 3. T he se q ue st io ns a ls o ap pl y to c om bi ne d in je ct ab le s) . I f s ta rti ng a fte r da y 7 of h er m on th ly b le ed in g, s he w ill n ee d a ba ck up m et ho d3 fo r t he fi rs t 7 d ay s af te r t he in je ct io n. Si de E ffe ct s: C ha ng es in m on th ly b le ed in g an d w ei gh t g ai n ar e co m m on C le ar a nd h on es t i nf or m at io n on s id e ef fe ct s, e sp ec ia lly c ha ng es in m on th ly b le ed in g, h el ps c lie nt s av oi d su rp ris e an d co nc er n if si de e ffe ct s oc cu r. W om en w ho a re w el l-i nf or m ed w he n th ey s ta rt in je ct ab le s ar e m or e lik el y to c on tin ue u si ng th em th an w om en w ho a re n ot w el l-i nf or m ed (3 0, 75 ,1 00 ). B le ed in g ch an ge s • D M PA : A t fi rs t, irr eg ul ar b le ed in g an d pr ol on ge d bl ee di ng , t he n no b le ed in g or in fre qu en t b le ed - i ng .4 Af te r 1 y ea r 4 0% –6 0% o f u se rs h av e no m on th ly b le ed in g (7 , 2 05 ). N o m on th ly b le ed in g is m or e lik el y w ith D M PA th an w ith N E T- E N (4 8) . • N E T- E N : I rr eg ul ar a nd p ro lo ng ed b le ed in g in th e fir st 6 m on th s, b ut b le ed in g ep is od es a re s ho rte r t ha n fo r D M PA u se rs . A fte r 1 y ea r a bo ut 3 0% o f u se rs h av e no m on th ly b le ed in g (2 02 ). • I rr eg ul ar , f re qu en t, or p ro lo ng ed b le ed in g in fi rs t 3 m on th s. 4 M os tly re gu la r b le ed in g pa tte rn s (a ro un d 28 - d ay in te rv al s) b y 1 ye ar . A fte r 1 y ea r a bo ut 2 % o f u se rs h av e no m on th ly b le ed in g (2 05 ). C ou ns el in g gu id an ce D is cu ss w ith e ac h cl ie nt h ow im po rta nt re gu la r m on th ly b le ed in g is to h er a nd h ow c ha ng es d ue to a n in je ct ab le w ou ld a ffe ct h er d ai ly li fe . S om e w om en co ns id er re gu la r m on th ly b le ed in g ve ry im po rta nt . O th er s lik e ha vi ng n o m on th ly b le ed in g (6 2) . P oi nt o ut th at : • B le ed in g ch an ge s du e to a n in je ct ab le a re n ot h ar m fu l a nd n ot a s ig n of il ln es s. • H av in g no m on th ly b le ed in g do es n ot m ea n th at a w om an is in fe rti le o r t ha t s he is p re gn an t. • M on th ly b le ed in g ev en tu al ly re tu rn s af te r i nj ec tio ns s to p. • A fte r a n in je ct io n, b le ed in g ch an ge s ca nn ot b e st op pe d an d m ay c on tin ue u nt il th e in je ct io n w ea rs o ff— at le as t 3 m on th s fo r D M PA , 2 m on th s fo r N E T- E N , a nd 1 m on th fo r c om bi ne d in je ct ab le s. • H ea vy b le ed in g4 is n ot c om m on b ut , i f i t h ap pe ns , s ho rt- te rm tr ea tm en t i s av ai la bl e. W ei gh t c ha ng e • A ve ra ge g ai n of 1 to 2 k ilo gr am s (2 to 4 p ou nd s) p er y ea r ( 87 ,2 20 ). S om e w om en , p ar tic ul ar ly o ve rw ei gh t a do le sc en ts , h av e ga in ed m uc h m or e (2 2, 2 3) . S om e us er s lo se w ei gh t o r h av e no s ig ni fic an t c ha ng e in w ei gh t ( 40 , 1 20 , 1 88 ). •A ve ra ge g ai n of 1 k ilo gr am (2 p ou nd s) p er y ea r ( 68 ). So m e us er s lo se w ei gh t o r h av e no s ig ni fic an t c ha ng e in w ei gh t ( 67 ). C ou ns el in g gu id an ce • S om e of th e w ei gh t g ai n m ay b e th e us ua l i nc re as e as p eo pl e ag e (1 79 ). A sk if m od er at e w ei gh t g ai n w ou ld b ot he r t he c lie nt o r h er p ar tn er . A pp ro pr ia te d ie tin g an d ex er ci se s om et im es c an c on tro l w ei gh t g ai n. N o ne ed to a sk th e w om an to re tu rn d ur in g he r n ex t m on th ly b le ed in g if pr ov id er c an b e re as on ab ly s ur e sh e is n ot p re gn an t ( se e th e C he ck lis t f or 3 (c on tin ue d on p . 4 ) 205402_JHU-InfoReport.indd 3205402_JHU-InfoReport.indd 3 12/12/06 10:14:41 PM12/12/06 10:14:41 PM R et ur n to fe rt ili ty st op in je ct io ns to be co m e pr eg na nt ) • D M PA : O n av er ag e 4 m on th s lo ng er th an fo r w om en w ho u se d m et ho ds o th er th an i nj ec ta bl es — 10 m on th s fro m th e la st in je ct io n, o r 7 m on th s fro m w he n th e ne xt in je ct io n w ou ld h av e be en g iv en (1 30 , 1 71 , 2 12 ). Th es e ar e av er ag es s o a w om an s ho ul d no t b e w or rie d if sh e ha s no t b ec om e pr eg na nt a fte r 1 2 m on th s. • N ET -E N : O n av er ag e 1 m on th lo ng er th an fo r w om en u si ng m et ho ds o th er th an in je ct ab le s (2 12 ). • O n av er ag e 1 m on th lo ng er th an fo r w om en w ho u se d m et ho ds o th er th an in je ct ab le s (1 53 ). C ou ns el in g gu id an ce • I t m ay ta ke a fe w m on th s af te r a w om an s to ps u si ng D M PA , b ut m on th ly b le ed in g ev en tu al ly re tu rn s, a nd s he w ill b e ab le to g et p re gn an t a s be fo re . • T he le ng th o f t he d el ay in b ec om in g pr eg na nt is th e sa m e fo r s ho rt- te rm a nd lo ng -te rm u se rs (5 7, 1 30 ). • I nj ec ta bl es d o no t c au se p er m an en t i nf er til ity o r s po nt an eo us a bo rti on s. O th er s id e ef fe ct s5 • H ea da ch e, d iz zi ne ss , a bd om in al d is co m fo rt, m oo d ch an ge s, le ss s ex d riv e (1 74 , 2 02 ). • H ea da ch e, d iz zi ne ss , b re as t t en de rn es s (1 53 , 1 67 , 2 21 ). C ou ns el in g gu id an ce • T el l w om en th at th es e m ay o cc ur b ut a re n ot c om m on . O th er p os si bl e ph ys ic al c ha ng e: B on e de ns ity • D M PA : S m al l l os s of b on e de ns ity d ur in g us e. U su al ly re ga in ed a fte r u se s to ps ( 2 16 ). • N E T- E N : M ay h av e no e ffe ct o n w om en a ge 4 0– 49 (1 5) . L itt le e vi de nc e av ai la bl e. • L itt le e vi de nc e av ai la bl e bu t n ot a c on ce rn w ith c om bi ne d m et ho ds (1 2, 2 16 ). C ou ns el in g gu id an ce • P ro gr am s ne ed to d ec id e if pr ov id er s sh ou ld m en tio n lo ss o f b on e de ns ity w ith D M PA .6 Sa fe ty : I nj ec ta bl es a re s af e fo r m os t w om en P ro gr am s sh ou ld tr y to g iv e ea ch c lie nt th e fa m ily p la nn in g m et ho d sh e w an ts a nd to a vo id d en yi ng w om en th ei r c ho ic e of a m et ho d ar bi tra ril y or fo r r ea so ns th at la ck a b as is in ev id en ce . F or e xa m pl e, w om en c an s af el y us e in je ct ab le s ev en if th ey h av e no t h ad c hi ld re n, a re n ot m ar rie d, a re a do le sc en ts , a re o ve r 4 0 ye ar s ol d, o r h av e H IV /A ID S ( 2 12 ).7 M ed ic al e lig ib ili ty cr ite ria :C on su lt a ha nd bo ok fo r g ui da nc e on s cr ee ni ng w om en fo r co nd itio ns th at m ay m ak e us e of in je ct ab le s le ss s af e8 W om en u su al ly s ho ul d no t s ta rt us in g a pr og es tin -o nl y in je ct ab le if th ey h av e ve ry h ig h bl oo d pr es su re (s ys to lic ≥ 16 0 m m H g or d ia st ol ic ≥ 10 0) , h is to ry o f b re as t c an ce r, un ex pl ai ne d va gi na l bl ee di ng th at s ug ge st s an u nd er ly in g m ed ic al c on di tio n (u nt il di ag no se d) , a nd c er ta in c on di tio ns of th e he ar t, bl oo d ve ss el s, o r l iv er in cl ud in g hi st or y of s tro ke o r h ea rt at ta ck a nd c ur re nt d ee p ve in th ro m bo si s. A ls o, a w om an b re as tfe ed in g a ba by le ss th an 6 w ee ks o ld s ho ul d no t u se pr og es tin -o nl y in je ct ab le s (s ee C he ck lis t, pp . 5 –6 ). W om en u su al ly s ho ul d no t s ta rt us in g a co m bi ne d in je ct ab le if th ey h av e hi gh b lo od p re ss ur e (s ys to lic ≥ 14 0 m m H g or d ia st ol ic ≥ 90 ), m ig ra in e he ad ac he w ith a ur a, 9 m ig ra in e he ad ac he w ith ou t a ur a an d ag e 35 o r o ld er , hi st or y of b re as t c an ce r, he av y sm ok in g an d ag e 35 o r ol de r, an d ce rta in c on di tio ns o f t he h ea rt, b lo od v es se ls , or li ve r i nc lu di ng h is to ry o f s tro ke o r h ea rt at ta ck a nd cu rre nt d ee p ve in th ro m bo si s. A w om an b re as tfe ed in g a ba by le ss th an 6 m on th s ol d sh ou ld n ot u se c om bi ne d in je ct ab le s. W om en n ot b re as tfe ed in g sh ou ld n ot u se co m bi ne d in je ct ab le s le ss th an 3 w ee ks a fte r g iv in g bi rth . Te st s • N on e ne ce ss ar y (2 15 ). P ro vi de rs c an u se a c he ck lis t t o be re as on ab ly s ur e th at a w om an is n ot p re gn an t ( se e C he ck lis t, p. 6 , q ue st io ns 8 –1 3) . Se xu al ly tr an sm itt ed in fe ct io ns (S TI s) • D o no t p re ve nt tr an sm is si on o f S TI s, in cl ud in g H IV . W om en a t r is k fo r S TI s sh ou ld a ls o us e co nd om s to p re ve nt S TI tr an sm is si on . C ou ns el in g gu id an ce • H el p th e w om an d ec id e if sh e m ig ht b e at ri sk o f S TI s. If s he m ig ht b e at ri sk , h el p he r d ec id e ho w s he w ill p ro te ct h er se lf an d ot he rs . H ea lth B en efi ts : I nj ec ta bl es h el p pr ot ec t a ga in st s om e he al th c on di tio ns • D M PA h el ps p ro te ct a ga in st c an ce r o f t he li ni ng o f t he u te ru s (e nd om et ria l c an ce r) (2 5) . • D M PA h el ps p ro te ct a ga in st u te rin e fib ro id s (1 06 ). • D M PA m ay h el p pr ot ec t a ga in st s ym pt om at ic p el vi c in fla m m at or y di se as e (1 0, 6 4) . • F or w om en w ith e nd om et rio si s, D M PA re du ce s pa in d ur in g m en st ru al p er io ds , p ai n du rin g in te rc ou rs e, a nd p el vi c pa in a nd te nd er ne ss (3 7, 1 70 , 1 99 ). • B ot h D M PA a nd N E T- E N m ay h el p pr ot ec t a ga in st ir on -d efi ci en cy a ne m ia (7 3, 2 22 ). Lo ng -te rm s tu di es o f c om bi ne d in je ct ab le s ar e lim ite d, b ut m os t r es ea rc he rs e xp ec t t ha t h ea lth be ne fit s an d ris ks a re s im ila r t o th os e of c om bi ne d or al c on tra ce pt iv es . F or m or e in fo rm at io n, c on su lt a ha nd bo ok o f f am ily p la nn in g. 8 1 In cl ud es in tra m us cu la r a nd s ub cu ta ne ou s in je ct io n of D M PA . A m on g he al th b en e fi ts , o nl y re du ce d sy m pt om s of e nd om et rio si s ar e re po rte d fo r s ub cu ta ne ou s D M PA (3 7, 17 0) . 2 P ro gr am s ca n de ci de w he th er w om en n ee d to k no w a bo ut th e on e- m on th d el ay to b ec om e pr eg na nt a fte r s to pp in g N E T- E N a nd c om bi ne d in je ct ab le s. 3 B ac ku p m et ho ds in cl ud e ab st in en ce , m al e an d fe m al e co nd om s, s pe rm ic id es , a nd w i th dr aw al . T el l h er th at s pe rm ic id es a nd w ith dr aw al a re th e le as t e ffe ct iv e co nt ra ce pt iv es . I f p os si bl e, g iv e he r c on do m s. 4 Ir re gu la r b le ed in g is a t u ne xp ec te d tim es ; p ro lo ng ed b le ed in g is lo ng er th an 8 d ay s; fr eq ue nt b le ed in g is m or e th an 4 b le ed in g or s po tti ng e pi so de s in 3 m on th s; in fre qu en t b le ed in g is fe w er th an 2 b le ed in g e pi so de s in 3 m on th s; h ea vy b le ed in g is tw ic e th e us ua l a m ou nt ( 1 6, 1 7, 2 19 ). 5 R ep or te d by a t l ea st 5 % o f u se rs . 6 F or m or e in fo rm at io n ab ou t b on e lo ss , s ee Q ue st io ns a nd A ns w er s A bo ut In je ct ab le s, p . 2 1 in th e co m pa ni on is su e of P op ul at io n R ep or ts , “ E xp an di ng S er vi ce s fo r I nj ec ta bl es .” 7 S ee b ox , W om en W ith H IV /A ID S C an U se In je ct ab le s, p . 2 1 in th e co m pa ni on is su e of P op ul at io n R ep or ts . 8 S ee T ab le 3 , K ey R es ou rc es fo r P ro gr am M an ag er s an d P ro vi de rs , p . 2 2 in th e co m pa ni on is su e of P op ul at io n R ep or ts . 9 A n au ra is u su al ly a b rig ht a re a of lo st v is io n in th e ey e, o fte n be fo re a m ig ra in e he ad ac he b eg in s . (a m on g w om en w ho • F or w om en w ith s ic kl e ce ll di se as e , D M PA re du ce s th e fre qu en cy a nd p ai n of s ick le c el l c ris es (4 3) . Pr og es tin -O nl y In je ct ab le s1 C om bi ne d In je ct ab le s 4 Ta bl e 2 (c on tin ue d) 205402_JHU-InfoReport.indd 4205402_JHU-InfoReport.indd 4 12/12/06 10:14:45 PM12/12/06 10:14:45 PM 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 or are contraindicated because of the presence of certain medical conditions such as liver tumors and breast cancer. This checklist (see next page) is designed for use by both clinical and nonclinical health care providers, including community health workers, to help screen clients who were counseled about contraceptive options and made an informed decision to use DMPA. It consists of 13 questions designed to identify medical conditions that would prevent safe DMPA use or require further screening, as well as to provide further guidance and directions based on clients’ responses. Clients who are ruled out because of their response to some of the medical eligibility or pregnancy questions may still be good candidates for DMPA after the suspected condition is excluded through appropriate evaluation. The checklist is based on recommendations by the World Health Organization in the Medical Eligibility Criteria for Contraceptive Use (212). This checklist is part of a series of provider checklists developed by Family Health International (FHI), with support from the U.S. Agency for International Development (USAID). The checklist is included in this issue of INFO Reports as a collaborative distribution service of the INFO Project. For more information, please visit www.fhi.org. Assessing Medical Eligibility for DMPA 1. Have you ever had a stroke, blood clot in your legs or lungs, or heart attack? 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 had this condition and will answer “yes,” if appropriate. 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. 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 mm 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 breastmilk 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. Note: Clients with multiple risk factors for cardiovascular disease (e.g., a combination of older age, smoking, and diabetes even without complications) generally are not good candidates for DMPA. Determining Current Pregnancy Questions 8–13 of the checklist 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.A to o lf rffo m Fa m ily H ea lth In te rn at io n al to he lp pr o v id er s u se th e W H O M ed ic al El ig ib ili ty Cr ite ria 5 205402_JHU-InfoReport.indd 5205402_JHU-InfoReport.indd 5 12/12/06 10:53:04 AM12/12/06 10:53:04 AM Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) NO 1. Have you ever had a stroke, blood clot in your legs or lungs, or heart attack? 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 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 on p. 5 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. © 2006 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. 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 6 205402_JHU-InfoReport.indd 6205402_JHU-InfoReport.indd 6 12/12/06 10:53:07 AM12/12/06 10:53:07 AM Ta bl e 3. H el pi ng C lie nt s B e In fo rm ed U se rs o f I nj ec ta bl e C on tr ac ep tiv es W om en w ho m ak e an in fo rm ed c ho ic e of in je ct ab le s ne ed to b e in fo rm ed u se rs a s w el l. In p ar tic ul ar , t he y ne ed to k no w w he n to re tu rn fo r t he ir ne xt in je ct io n, w ha t t o do if th ey a re la te , a nd th at s id e ef fe ct s ar e us ua lly n ot h ar m fu l. P ro vi de rs c an h el p w om en m an ag e so m e bo th er so m e si de e ffe ct s. Pr og es tin -O nl y In je ct ab le s1 C om bi ne d In je ct ab le s K ey P oi nt s Su pp or t c lie nt s us in g in je ct ab le s G iv e th e in je ct io n sa fe ly a nd s af el y di sp os e of u se d eq ui pm en t ( se e C he ck lis t, p. 2 ). Te ll th e cl ie nt th e na m e of th e in je ct io n an d w he n sh e ne ed s to h av e he r n ex t i nj ec tio n. G iv e he r a n ap po in tm en t c ar d or re m in de r c ar d, if p os si bl e. H el p he r m an ag e an y si de e ffe ct s an d co nt in ue w ith th e in je ct ab le if s he w is he s, o r, if sh e is n ot s at is fi e d, h el p he r c ho os e a di ffe re nt m et ho d. 2 • • • “C om e on ti m e fo r t he n ex t i nj ec tio n” H el p th e cl ie nt ch oo se a d at e fo r th e ne xt in je ct io n In 3 m on th s fo r D M PA o r i n 2 m on th s fo r N E T- E N . D is cu ss h ow to re m em be r t he d at e, p er ha ps ty in g it to a h ol id ay o r o th er e ve nt . S ug ge st th at h er p ar tn er h el p he r r em em be r t he d at e. R em in d th e cl ie nt th at s he c an c om e up to 2 w ee ks e ar ly o r 2 w ee ks la te . S he s ho ul d re tu rn e ve n if sh e is m or e th an 2 w ee ks la te . S he s til l m ay b e ab le to h av e he r i nj ec tio n. D is cu ss u si ng a b ac ku p m et ho d3 o r o ra l c on tra ce pt iv es (O C s) o r e m er ge nc y co nt ra - ce pt iv e pi lls w he n m or e th an 2 w ee ks la te . In vi te h er to c om e ba ck a ny ti m e sh e ha s pr ob le m s or q ue st io ns . • • • • • In 4 w ee ks fo r c om bi ne d in je ct ab le s. D is cu ss h ow to re m em be r t he d at e, p er ha ps ty in g it to a h ol id ay o r ot he r e ve nt . S ug ge st th at h er p ar tn er h el p he r r em em be r t he d at e. R em in d th e cl ie nt th at s he c an c om e up to 7 d ay s ea rly o r 7 d ay s la te . S he s ho ul d co m e ba ck e ve n if sh e is m or e th an 7 d ay s la te . S he s til l m ay b e ab le to h av e he r i nj ec tio n. D is cu ss u si ng a b ac ku p m et ho d3 o r o ra l c on tra ce pt iv es (O C s) o r em er ge nc y co nt ra ce pt iv e pi lls w he n m or e th an 7 d ay s la te . In vi te h er to c om e ba ck a ny ti m e sh e ha s pr ob le m s or q ue st io ns . • • • • • C ou ns el th e cl ie nt w he n sh e re tu rn s fo r i nj ec tio ns “H ow a re y ou do in g? ” A sk if s he h as a ny q ue st io ns o r a ny th in g to d is cu ss . A sk e sp ec ia lly a bo ut b le ed in g ch an ge s. G iv e he r a ny in fo rm at io n, h el p, o r r ea ss ur an ce s he n ee ds . If sh e is h av in g pr ob le m s, le t h er k no w th at y ou m ay b e ab le to h el p. If s he d oe s no t w an t t o co nt in ue in je ct ab le s, h el p he r c ho os e an ot he r m et ho d. • • “A ny tr ou bl e re tu rn in g on tim e? ” If sh e ha s tro ub le re tu rn in g on ti m e, d is cu ss re as on s an d so lu tio ns a nd d is cu ss u si ng a b ac ku p m et ho d3 o r O C s or e m er ge nc y co nt ra ce pt iv e pi lls w he n la te . If sh e of te n re tu rn s la te r t ha n th e gr ac e pe rio d pe rm its (2 w ee ks fo r p ro ge st in -o nl y in je ct ab le s an d 7 da ys fo r c om bi ne d in je ct ab le s) , h el p he r c on si de r w he th er an ot he r m et ho d w ou ld b et te r s ui t h er — pe rh ap s im pl an ts o r a n IU D o r, if sh e do es n ot w an t m or e ch ild re n, fe m al e st er iliz at io n (o r v as ec to m y fo r h er p ar tn er ). • • If th e cl ie nt is ea rly o r l at e fo r th e in je ct io n If sh e is 2 w ee ks e ar ly o r l es s, s he c an re ce iv e he r i nj ec tio n. If sh e is 2 w ee ks la te o r l es s, s he c an re ce iv e he r i nj ec tio n. N o ne ed fo r t es ts , ev al ua tio n, o r a b ac ku p m et ho d. If sh e is m or e th an 2 w ee ks la te , s he c an re ce iv e he r i nj ec tio n if (1 ) s he h as n ot h ad s ex si nc e th e da y sh e w ou ld h av e be en tw o w ee ks la te , ( 2) s he h as u se d a ba ck up m et ho d du rin g th is p er io d, o r s he h as ta ke n em er ge nc y co nt ra ce pt iv e pi lls w ith in 5 d ay s af te r a ny un pr ot ec te d se x, o r ( 3) s he is fu lly o r n ea rly fu lly b re as tfe ed in g an d sh e ga ve b irt h le ss th an 6 m on th s ag o. S he w ill ne ed a b ac ku p m et ho d3 fo r t he fi rs t 7 d ay s af te r t he in je ct io n. If th e cl ie nt is m or e th an 2 w ee ks la te a nd d oe s no t m ee t t he se c rit er ia , c on su lt a fa m ily pl an ni ng h an db oo k fo r w ay s to b e re as on ab ly s ur e sh e is n ot p re gn an t.2 • • • • If sh e is 7 d ay s ea rly o r l es s, s he c an re ce iv e he r i nj ec tio n. If sh e is 7 d ay s la te o r l es s, s he c an re ce iv e he r i nj ec tio n. N o ne ed fo r t es ts , e va lu at io n, o r a b ac ku p m et ho d. If sh e is m or e th an 7 d ay s la te , s he c an re ce iv e he r i nj ec tio n if (1 ) s he ha s no t h ad s ex s in ce th e da y sh e w ou ld h av e be en 7 d ay s la te , o r (2 ) s he h as u se d a ba ck up m et ho d du rin g th is p er io d, o r s he h as ta ke n em er ge nc y co nt ra ce pt iv e pi lls w ith in 5 d ay s af te r a ny u np ro te ct ed s ex . Sh e w ill ne ed a b ac ku p m et ho d3 fo r t he fi rs t 7 d ay s af te r t he in je ct io n. If th e cl ie nt is m or e th an 7 d ay s la te a nd s he d oe s no t m ee t t he se cr ite ria , s he c an re ce iv e he r n ex t i nj ec tio n an yt im e it is re as on ab ly ce rta in s he is n ot p re gn an t ( se e C he ck lis t, p. 6 , q ue st io ns 8 –1 3) . • • • • Pl an th e ne xt in je ct io n A gr ee o n a da te fo r h er n ex t i nj ec tio n. R em in d he r t ha t s he s ho ul d try to c om e on ti m e, b ut s he s ho ul d co m e ba ck n o m at te r h ow la te s he is . G iv e he r c on do m s or e m er ge nc y co nt ra ce pt iv e pi lls if n ee de d. • • C he ck fo r m aj or li fe c ha ng es o nc e a ye ar Ev er y ye ar , a t a ro ut in e re -in je ct io n vi si t, as k ab ou t ch an ge s th at c ou ld af fe ct h er u se o f co nt ra ce pt io n A sk if s he h as h ad a ny n ew h ea lth c on di tio ns . C he ck w he th er a ny o f t he se c on di tio ns w ou ld m ak e us e of in je ct ab le s le ss s af e (s ee C he ck lis t, pp . 5 –6 ). A sk a bo ut m aj or li fe c ha ng es th at m ay a ffe ct h er n ee ds — pa rti cu la rly p la ns fo r h av in g ch ild re n an d he r S TI /H IV ri sk . I f a D M PA u se r p la ns to h av e a ba by , re m in d he r t ha t s he m ay n ee d a fe w m or e m on th s to b ec om e pr eg na nt th an w om en w ho h av e st op pe d ot he r c on tra ce pt iv es . C he ck b lo od p re ss ur e, if p os si bl e. S he m ay n ee d to c ho os e an ot he r m et ho d: - If sh e is u si ng a p ro ge st in -o nl y in je ct ab le a nd s ys to lic b lo od p re ss ur e is 1 60 m m H g or m or e, o r d ia st ol ic b lo od p re ss ur e is 1 00 o r m or e. - If sh e is u si ng a c om bi ne d in je ct ab le a nd s ys to lic b lo od p re ss ur e is 1 40 m m H g or m or e, o r d ia st ol ic b lo od p re ss ur e is 9 0 or m or e (2 12 ). • • • 1 G ui da nc e is fo r b ot h in tra m us cu la r a nd s ub cu ta ne ou s in je ct io n of D M PA . 2 F or h el p, s ee T ab le 3 , K ey R es ou rc es fo r P ro gr am M an ag er s an d P ro vi de rs , p . 2 2 in th e co m pa ni on is su e of P op ul at io n R ep or ts . 3 B ac ku p m et ho ds in cl ud e ab st in en ce , m al e an d fe m al e co nd om s, s pe rm ic id es , a nd w ith dr aw al . T el l h er th at s pe rm ic id es a nd w ith dr aw al a re th e le as t e ffe ct iv e co nt ra ce pt iv e m et ho ds . I f p os si bl e, g iv e he r c on do m s. 7 205402_JHU-InfoReport.indd 7205402_JHU-InfoReport.indd 7 12/12/06 10:53:07 AM12/12/06 10:53:07 AM Sources This bibliography includes citations to the materials most helpful in the preparation of this report. In the text, reference numbers for these citations appear in italics. The complete bibliography for this report and the companion Population Reports issue can be found at: http://www.populationreports.org/k6/. The links included in this report were up-to-date at the time of publication. 7. ARIAS, R.D., JAIN, J.K., BRUCKER, C., ROSS, D., and RAY, A. Changes in bleeding patterns with depot medroxyprogesterone acetate subcutaneous injection 104 mg. Contraception 74(3): 234–238. Sep. 2006. 10. BAETEN, J.M., NYANGE, P.M., RICHARDSON, B.A., LAVREYS, L., CHOHAN, B., MARTIN, H.L., JR., MANDALIYA, K., NDINYA-ACHOLA, J.O., BWAYO, J.J., and KREISS, J.K. Hormonal contraception and risk of sexually transmitted disease acquisition: Results from a prospective study. American Journal of Obstetrics and Gynecology 185(2): 380–385. Aug. 2001. 15. BEKSINSKA, M.E., SMIT, J.A., KLEINSCHMIDT, I., FARLEY, T.M., and MBATHA, F. Bone mineral density in women aged 40–49 years using depot-medroxyprogesterone acetate, norethisterone enanthate or combined oral contraceptives for contraception. Contraception 71(3): 170–175. Mar. 2005. 16. BELSEY, E.M. The association between vaginal bleeding patterns and reasons for discontinuation of contraceptive use. Contraception 38(2): 207–225. Aug. 1988. 17. BELSEY, E.M., MACHIN, D., and D’ARCANGUES, C. The analysis of vaginal bleeding patterns induced by fertility regulating methods. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction. Contraception 34(3): 253–260. Sep. 1986. 23. 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