JHPIEGO TrainerNews™ |
Clinical Update: Contraceptive Pearl
(October 2002)
Checklist for Clients Who Want to Initiate DMPA (or NET-EN) [Injectable Contraceptive]
- Is your menstrual period late and do you think you could be pregnant now?
- Have you ever had a stroke, blood clot in your legs or lungs, or heart attack?
- Do you have diabetes (sugar in your blood)?
- Do you have or have you had breast cancer?
- Do you have a serious liver disease or jaundice (yellow skin or eyes)?
NO. If the client answers NO to all the above questions, continue with question 6.
YES. If the client answers YES to any of the above questions, refer her to a clinic/physician, and give her condoms to use in the meantime.
- Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse (sex)?
NO. If the client answers NO to all the questions, she can use DMPA, but to find out when she can start, continue with question 7.
YES. If the client answers YES, she can be given DMPA now, but refer her to clinic/physician for further evaluation of the bleeding. Continue with question 7.
- Are you currently breastfeeding?
NO. If client answers NO, go to question 9.
YES. If the client answers YES, go to question 8.
- Is your baby less than 6 weeks old?
NO. If client is breastfeeding a baby 6 weeks old or older and her menstrual periods have not returned, she can be given DMPA now. If her menstrual periods have returned, go to question 9.
YES. If client is breastfeeding a baby less than 6 weeks old, instruct her to return for DMPA as soon as possible after the baby is 6 weeks old.
- Has it been more than 7 days since the beginning of your last menstrual period?
NO. If the client began her last menstrual period within the past 7 days, she can be given DMPA now.
YES. If the client started her last menstrual period more than 7 days ago, and if:
- She has been using an effective method of contraception (including abstinence), 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.
OR
- She has not been using an effective method of contraception (including abstinence), she must wait until her next period to be given DMPA. Give her condoms to use in the meantime.
Explanation of DMPA Checklist Questions
- Is your menstrual period late and do you think you could be pregnant now?
This question has two parts - both of which should be asked together, and the answer "yes" must apply to both parts of the question. One or more missed periods in combination with the woman's own report that she is or might be pregnant is required before a woman should be referred to a higher-level health care provider.
- 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 who have had any of these conditions will commonly have been told that they have had this condition and will answer "yes," if appropriate.
- Do you have diabetes (sugar in your blood)?
The intention of this question is to identify women who know that they have diabetes, not to assess whether they may have an undiagnosed condition.
- Do you have or have you had breast cancer?
The intention of this question is to identify women who know they have had or currently have breast cancer.
- Do you have a serious liver disease or jaundice (yellow skin or eyes)?
The intention of this question is 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).
- Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse (sex)?
The intention of this question is to distinguish between normal bleeding changes (such as those associated with the use of another contraceptive method), and those that are different or unusual for the client, and to identify postcoital bleeding (since bleeding after intercourse may indicate an abnormality). The use of DMPA does not make these conditions worse but may change the bleeding pattern. Unusual bleeding changes can underlie a serious condition that should be evaluated by a higher-level health care provider, but DMPA use need not be delayed.
- and 8. Are you currently breastfeeding? Is your baby less than 6 weeks old?
These questions are intended to identify women who are breastfeeding babies under 6 weeks of age. A breastfeeding woman can initiate DMPA 6 weeks after her baby is born.
- Has it been more than 7 days since the beginning of your last menstrual period?
The intention of this question is to determine when the client should start DMPA. If she has just started her menstrual cycle and is within days 1 to 7 of the first day of bleeding, she can start the method immediately. If it is more than 7 days since her
first day of bleeding, she will need to wait until her next menstrual period begins before she can be given DMPA. Give her condoms to use in the meantime.