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Progestin-Only Injectables


Q.4. Are there any age/parity restrictions on progestin-only injectables?

Recommendations

Rationales
a) No. However, young and/or childless women in particular need to understand that, on average, it takes a woman four months longer to become pregnant after discontinuing DMPA than after discontinuing COCs, IUDs or barrier methods. a) After discontinuing DMPA, about 50% of women conceive by 7 months (i.e., 10 months after the last injection). This time delay to conception is approximately 4 months longer than the time it takes for women who discontinue COCs, IUDs or barrier methods to conceive. Residual amounts of DMPA will remain in circulation for about 7 to 9 months after an injection, at which time serum levels of DMPA become undetectable. By about 2 to 3 years after discontinuation of DMPA, the proportion of women who have conceived is virtually the same as for those who have discontinued use of IUDs, diaphragms and COCs. The delay in return to fertility with NET-EN is presumed to be no more than with DMPA.
  1. Mishell DR. Long-acting contraceptive steroids: Postcoital contraceptives and antiprogestins, in Mishell DR, Davajan V, Lobo RA (eds). Infertility, Contraception, and Reproductive Endocrinology, 3rd edition. Boston, Blackwell Scientific Publications, 1991, pp 872-894.
  2. Injectable Contraceptives: Their Role in Family Planning Care. Geneva, World Health Organization, 1990.
  3. Schwallie PC, Assenzo JR. The effect of Depo-medroxyprogesterone acetate on pituitary and ovarian function, and the return of fertility following its discontinuation: A review. Contraception 1974;10(4):181-202.
  4. Pardthaisong T. Return of fertility after use of the injectable contraceptive Depo Provera: Up-dated data analysis. Journal of Biosocial Science 1984;16:23.
  5. International Center for Medical Research Task Force on Hormonal Contraception. Return to fertility following discontinuation of an injectable contraceptive - NET-EN. Contraception 1986;34(6):573-582.
  6. Depo-Provera C-150 NDA 20-246. Advisory Committee Brochure, 1992, p 37.
Older Women:  
b) Injectable progestins may be used by women through menopause. Risks for use of injectable progestins for older women appear minimal. b) DMPA confers many non-contraceptive benefits including decreased menstrual blood loss, as well as protection against endometriosis, acute pelvic inflammatory disease (PID) and ectopic pregnancy and, of particular importance to older women, protection against endometrial cancer. DMPA may also inhibit intravascular sickling - an additional benefit to women who have sickle cell disease. Other effects which may be attributed to DMPA use include a slight increase in weight and slight (non-clinically significant) alterations in plasma lipid profiles. A theoretical risk of osteoporosis is currently under study.
  1. Depot-medroxyprogesterone acetate (DMPA) and cancer: Memorandum from a WHO Meeting. Bulletin of the World Health Organization 1986;64(3):375-382.
  2. Liang AP, Levenson AG, Layde PM, Shelton JD, Hatcher RA, Potts M, Michelson MJ. Risk of breast, uterine corpus, and ovarian cancer in women receiving medroxyprogesterone injections. Journal of the American Medical Association 1983;249:2909-2912.
    3.
 
  1. Kaunitz AM. Injectable contraception. Clinical Obstetrics and Gynecology 1989;32(2):356-368.
  2. Shoupe D. Injectable contraceptives and contraceptive vaginal rings, in Shoupe D, Haseltine FP (eds). Contraception. New York, Springer-Verlag, 1993, pp 144-157.
  3. Deslypere JP, Thiery M, Vermeulen A. Effect of long-term hormonal contraception on plasma lipids. Contraception 1985;31(3):633-642.
    4.
  4. Oyelola OO. Fasting plasma lipids, lipoproteins and apolipoproteins in Nigerian women using combined oral and progestin-only injectable contraceptives. Contraception 1993;47:445-454.
  5. Solheim F. An assessment of quality of life in women treated with Depo-Provera in Sweden, in Zambrano D (ed). Depo-Provera® (medroxyprogesterone acetate) for Contraception: A Current Perspective of Scientific, Clinical & Social Issues. Kalamazoo, Michigan, The Upjohn Company, 1992, pp 61-72.
  6. De Ceulaer K, Gruber C, Hayes R, Serjeant GR. Medroxyprogesterone acetate and homozygous sickle cell disease. Lancet 1982;II:229-231.

Because women greater than 35 years of age are at increasing risk for endometrial (and ovarian) cancer, it is particularly important to:

  • carefully evaluate irregular bleeding before administering the injectable and
  • more carefully consider cancer as a possible cause if the woman returns with irregular bleeding after prolonged amenorrhea.
  1. Herbst AL, Mishell DR, Stenchever MA, Droegmueller W. Comprehensive Gynecology, 2nd edition. St. Louis, Mosby Year Book, 1992, pp 1082-1083.
  2. Parazzini F, La Vecchia C, Bocciolone L, Franceshi S. The epidemiology of endometrial cancer. Gynecologic Oncology 1991;41:1-16.
    3.
Adolescents:
c) Use of progestin-only injectables generally leads to amenorrhea (in 50% of women by the end of the first year and 66% by the end of the second year for DMPA). Some evidence suggests that a hypoestrogenic state (as evidenced by amenorrhea), within the first two years after menarche, may increase the risk of osteoporosis later in life, particularly for women with other risk factors for osteoporosis (e.g., women who are small-boned, underweight, white or Asian, smokers, or malnourished). However, for those adolescents age 15 and under, for whom progestin-only injectables are the most appropriate method, the benefits of the method generally outweigh the risks. c) Amenorrhea while on progestin-only contraceptives is evidence of lower estrogen levels, and estrogen is necessary for the development and maintenance of strong bones (to prevent osteoporosis). The peak strength (density) of spinal bone is reached by girls around age 16; the greatest increase in bone density occurs in the first two years post-menarche.
  1. Bonjour JP, Theintz G, Buchs B, Slosman D, Rizzoli R. Critical years and stages of puberty for spinal and femoral bone mass accumulation during adolescence. Journal of Clinical Endocrinology and Metabolism 1991;73:555-563.
  2. Theintz G, Buchs B, Rizzoli R, Slosman D, Clavien H, Sizonenko PC, Bonjour JP. Longitudinal monitoring of bone mass accumulation in healthy adolescents: Evidence for a marked reduction after 16 years of age at The levels of lumbar spine and femoral neck in female subjects. Journal of Clinical Endocrinology and Metabolism 1992;75:1060-1065.
  3. Dhuper S, Warren M, Brooks-Gunn J, Fox R. Effects of hormonal status on bone density in adolescent girls. Journal of Clinical Endocrinology and Metabolism 1990;71:1083-1088.

Any part of Recommendations for Updating Selected Practices in Contraceptive Use may be reproduced or adapted to meet local needs without prior permission from the TG/CWG Secretariat, provided the TG/CWG is acknowledged and the material is made available free of charge or at cost.

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