Progestin-Only Injectables

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Recommendations for Contraceptive Use

Progestin-Only Injectables

Q.9. If a woman complains of heavier menses and/or prolonged bleeding, is there a medical basis for discontinuing progestin-only injections?

Recommendations

Rationales

Not usually. Irregular and prolonged bleeding episodes are common and expected in the first 3 to 6 months of use.

a) For prolonged spotting or moderate bleeding (equivalent to normal menstruation but longer in duration), the first approach should be counseling and reassurance. It should be explained that in the absence of evidence for other diseases, irregular bleeding commonly occurs in the first few months of use of injectable progestins.

If counseling and reassurance are not sufficient for the woman and she wishes to continue the method, the following management approaches may be tried:

short term (for 7 to 21 days) COCs or estrogen, or
ibuprofen (or similar non-steroidal anti-inflammatories other than aspirin), or
if the previous injection was given more than 4 weeks ago, giving another injection at this time may be an effective approach.

a) The number of bleeding days decreases with months of injectable progestin use.

Belsey EM, Task Force on Long-Acting Systemic Agents for Fertility and Regulation. Menstrual bleeding patterns in untreated women and with long-acting methods of contraception. Advances in Contraception 1991:(7)257-270.

a-b) Management of prolonged or heavy bleeding may be achieved by:

rebuilding endometrium with COCs/estrogen, or
ibuprofen* (which blocks prostaglandin synthesis and thus decreases uterine bleeding), or
accelerating the arrival of amenorrhea with another injection. There is evidence that bleeding decreases with a subsequent injection.

Injectable Contraceptives: Their Role in Family Planning Care. Geneva, World Health Organization, 1990.

Diaz S, Croxatto HB, Davez M, Belhadj H, Stern J, Sivin I. Clinical assessment of treatments for prolonged bleeding in users of NORPLANT^Ž Implants. Contraception 1990;42(1):97-109.

Task Force on Long-Acting Agents for the Regulation of Fertility. Multinational comparative clinical trials of long-acting injectable contraceptives: Norethisterone enanthate given in two dosage regimens and Depot-medroxyprogesterone acetate: Final report. Contraception 1983;28(1):1-20.

* NOTE: Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) should be used instead of aspirin because of aspirin's stronger and longer-lasting inhibitory effects on platelet aggregation (aspirin promotes bleeding).

American Hospital Formulary Service Drug Information. Bethesda, MD, American Society of Hospital Pharmacists, 1994, p 1208.

Field CS. Dysfunctional uterine bleeding. Primary Care 1988;15(3):561-574.

b) Heavy bleeding (greater than normal menstruation) is uncommon; it can usually be controlled by administration of increased doses of COCs (or estrogen). Some women will require stopping the use of injectable progestins due to medical reasons for excessive bleeding or due to the client's preference.

c) If suspected, abnormal conditions which cause prolonged or heavy bleeding should be evaluated and treated as appropriate.

d) Some prolonged or heavy bleeding may fail to be corrected and injections may need to be discontinued.

e) Evaluate and address anemia if indicated. Give nutritional advice on the need to increase the intake of iron-containing foods.

f) Do not perform uterine evacuation unless another medical condition is suspected (vacuum aspiration is generally the preferred method of uterine evacuation).

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.

Last Updated: 09 Jul 2003

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