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Recommendations for Contraceptive Use |
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Progestin-Only Injectables |
Classification of Selected
Procedures for Progestin-Only Injectables (DMPA and NET-EN)
| Procedure |
Class |
Rationale |
| Pelvic examination (speculum and
bimanual) |
C |
- Conditions which would restrict use of injectables should
be identified by history before method initiation.
- A pelvic exam may reveal reproductive tract infections or
reproductive tract malignancies which should be treated for optimal preventive care.
Routine pelvic exam screening for asymptomatic women, in the absence of tests for cervical
cancer, however, is a low yield procedure1.
- In some cases, a pelvic exam may help evaluate the question
of pregnancy beyond 6 weeks duration: in this case it is Class A.
- A pelvic exam is not necessary to ensure safe use of
injectables as a contraceptive method.
|
| Blood pressure |
C |
- Screening for high blood pressure is part of optimal
preventive health care.
- Current evidence does not demonstrate any notable
effect of DMPA or NET-EN on blood pressure2,3.
|
| Breast examination |
C |
- For all women of reproductive age or beyond, a breast exam
is recommended for optimal preventive health care.
- Injectables do not cause breast cancer4.
Lumps that are suspicious for cancer should be evaluated. While any hormonal treatment may
in theory cause such lumps to grow, pregnancy causes much higher hormonal levels;
therefore, potential malignancies of the breast should not be a reason to delay a woman's
access to the use of this contraceptive method.
|
| Sexually transmitted disease
(STD) screening by lab tests (for asymptomatic persons) |
C |
For optimal health care, clients
at risk for STDs (by personal history or socio-demographic risk factors) should be offered
STD screening where possible. However, presence of an STD will not affect the safe use of
injectables. |
| Cervical cancer screening |
C |
- Cervical cancer screening is indicated for women at risk of
cervical carcinoma, and is recommended for optimal preventive health care for women of
reproductive age or beyond (particularly women at risk of STDs).
NOTE: Cervical cancer screening is advised for
optimal preventive care for all women at risk of cervical cancer (e.g., smokers, women
with partners having multiple partners, women with young age at first intercourse, etc.).
All women at risk should ideally have access to a practical method of cervical cancer
screening, treatment and follow up.
- Cervical screening is not needed for the safe use of
injectables5.
|
| Routine, mandatory lab tests
(e.g., cholesterol, glucose, liver function tests) |
D |
The effects of injectables on
cholesterol, blood glucose and normal liver function are slight, and of no
demonstrated clinical significance6. |
General counseling points for
progestin-only injectables use:
- efficacy
- common side effects
- correct use of method
- signs and symptoms for which to return to the clinic
- STD protection (when/as appropriate)
|
A |
- Accurate client education is essential for maximum quality
of family planning services.
- Appropriate counseling about common contraceptive side
effects at the time of method selection can lead to improved client satisfaction and
contraceptive continuation7.
|
| Counseling concerning change in
menses, including irregular or absent menstrual bleeding |
A |
Irregular or absent menstrual
bleeding is the single most common side effect of progestin-only injectables, and the
chief complaint leading to discontinuation2,3. |
KEY:
Class A = essential and mandatory or otherwise
important in all circumstances, for safe and effective use of the contraceptive method
Class B = medically/epidemiologically rational in
some circumstances to optimize the safe and effective use of the contraceptive method, but
may not be appropriate for all clients in all settings
Class C = may be appropriate for good preventive
health care, but not materially related to safe and effective use of the contraceptive
method
Class D = not materially related to either good
routine preventive health care or to the safe and effective use of the contraceptive
method
Citations:
Huber DH, Huber SC. Screening oral
contraceptive candidates and inconsequential pelvic examinations. Studies in Family
Planning 1975;6(2):49-51.
WHO Special Programme of Research, Development
and Research Training in Human Reproduction. Multinational comparative trial of
long-acting injectable contraceptives: Norethisterone enanthate given in two dosage
regimens and depot-medroxyprogesterone acetate: Final report. Contraception
1983;28(1):1-20.
WHO Task Force on Long-Acting Systemic Agents
for Fertility Regulation, Special Programme of Research, Development and Research Training
in Human Reproduction. A multi-centered phase III comparative clinical trial of
depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: I.
Contraceptive efficacy and side effects. Contraception 1986,34(3):1223-1235.
Injectable Contraceptives: Their Role in
Family Planning Care. Geneva, World Health Organization, 1990, p 69.
The WHO Collaborative Study of Neoplasia and
Steroid Contraceptives. Depot-medroxyprogesterone acetate (DMPA) and risk of invasive
squamous cell cervical cancer. Contraception 1992;45:199-312.
Injectable Contraceptives: Their Role in
Family Planning Care. Geneva, World Health Organization, 1990, p 78.
Cotten N, Standback J, Maidouka H,
Taylor-Thomas JT, Turk T. Early discontinuation of contraceptive use in Niger and The
Gambia. International Family Planning Perspectives 1992;18(4):145-149. |
