Types
| Depo-Provera® |
150 mg of depot-medroxyprogesterone (DMPA) acetate given every 3 months
and can be given up to 4 weeks (28 days) early or 4 weeks (28 days) late
|
| Noristerat® |
200 mg of norethindrone enanthate given (NET-EN) every 2 months
and can be given up to 2 weeks (14 days) early or 2 weeks (14 days) late |
Mechanisms of Action
- Thicken cervical mucus, preventing sperm penetration
- Change endometrium, making implantation less likely
- Reduce sperm transport in upper genital tract (fallopian tubes)
- Suppress ovulation
Benefits
Contraceptive
- Highly effective (0.3–1 pregnancies per 100 women during the first year of use)
- Rapidly effective (< 24 hours)
- Intermediate-term method (2 or 3 months per injection)
- Pelvic examination not required prior to use
- Do not interfere with intercourse
- Do not affect breastfeeding
- Few side effects
- No supplies needed by client
- Can be provided by trained nonmedical staff
- Contain no estrogen
Noncontraceptive
- May decrease menstrual cramps
- May decrease menstrual bleeding
- May improve anemia
- Protect against endometrial cancer
- Decrease benign breast disease
- Decrease ectopic pregnancy
- Protect against some causes of PID
- Decrease sickle cell crises
Limitations
- Cause changes in menstrual bleeding pattern (irregular bleeding/spotting/amenorrhea
initially) in most women
- User-dependent (must return for injection every 2 or 3 months)
- Weight gain (2 kg) is common, especially with DMPA
- Delay in return of fertility (DMPA only)
- Resupply must be available
- Excessive vaginal bleeding in rare instances
- Do not protect against STDs (e.g., HBV, HIV/AIDS)
Who Can Use PICs
- Women of any reproductive age
- Women of any parity including nulliparous women
- Women who want highly effective protection against pregnancy
- Women who are breastfeeding (6 weeks or more postpartum) and need contraception
- Women who are postpartum and not breastfeeding
- Women who are postabortion
- Women with desired family size who do not want voluntary sterilization
- Women with histories of ectopic pregnancy
- Women who smoke (any age, any amount)
- Women who have blood pressure < 180/110, blood clotting problems or sickle cell
disease
- Women taking drugs for epilepsy (phenytoin and barbiturates) or tuberculosis (rifampin)
- Woman who prefer not to or should not use estrogen
- Women who cannot remember to take a pill every day
Conditions Requiring Precautions
CONDITION |
RECOMMENDATION |
| Jaundice (sympotmatic viral hepatitis or cirrhosis) |
Women with viral hepatitis should avoid using PICs
unless other more appropriate methods are not available or acceptable. |
| High blood pressure (with or without vascular
problems) |
Women with BP >180/110 should avoid using PICs
unless other more appropriate methods are not available or acceptable. |
| Diabetes (> 20 years duration; vascular problems,
CNS, or visual disease) |
Women with advanced or long-standing diabetes should
avoid using PICs unless other more appropriate methods are not available or acceptable.
PICs, because of their higher daily dose, are not recommended for use in diabetics with
vascular problems because of a theoretical concern about their effect on lipid
metabolism and possible progression of the vascular disease. |
Who Should Not Use PICs
- Women who are pregnant (known or suspected)
- Women with unexplained vaginal bleeding (until evaluated)
- Women who cannot tolerate any changes in their menstrual bleeding pattern, especially
amenorrhea
- Women with current or past history of breast cancer
When To Start
- Anytime during the menstrual cycle when you can be reasonably sure the client is not
pregnant
- Days 1 to 7 of the menstrual cycle
- Postpartum:
- after 6 months if using LAM
- after 6 weeks if breastfeeding but not using LAM
- immediately or within 6 weeks if not breastfeeding
- Postabortion (immediately or within 7 days)
Management of Common Side Effects
SIDE EFFECT |
MANAGEMENT |
Amenorrhea
(absence of vaginal
bleeding or spotting) |
Check for pregnancy.
If not pregnant, no treatment is required except
reassurance. Explain that blood does not build up inside the uterus or body with
amenorrhea. The continued action of small amounts of the progestin shrinks the
endometrium, leading to decreased menstrual bleeding and, in some women, no bleeding at
all. Finally, advise client to return to clinic if amenorrhea continues to be a concern.
If intrauterine pregnancy confirmed, counsel client
regarding options. Stop the PIC if pregnancy will be continued and assure her that the
small dose of progestin will have no harmful effect on the fetus.
If ectopic pregnancy suspected, refer at once for complete
evaluation.
Do not give hormonal treatment (COCs) to induce withdrawal
bleeding. It is not necessary and usually is not successful unless 2 or 3 cycles of
COCs are given. |
| Vaginal bleeding/Spotting |
If no problem found and client not pregnant, counsel
client that bleeding/spotting is not serious and usually does not require treatment. Most
women can expect the altered bleeding pattern to become more regular after 6 to 12 months.
If the client is not satisfied after counseling and reassurance, but
wants to continue using the PIC, two treatment options are recommended:
- a cycle of COCs (30–35 µg EE), or
- ibuprofen (up to 800 mg 3 times daily for 5 days) or other NSAID.
Be sure to tell the client to expect bleeding during the week after completing
the COCs (21-pill pack) or during the last 7 pills if 28-pill pack.
For heavy bleeding give 2 COC pills per day for remainder of cycle (at
least 3 to 7 days) followed by 1 cycle of COCs or switch to 50 µg of estrogen (EE) or
1.25 mg conjugated estrogen for 14–21 days. |
| Weight gain or loss (change in appetite) |
Counsel client that
fluctuations of 1–2 kg are common with use of PICs.
Review diet if weight change is more than ±2 kg. If weight gain
(or loss) is unacceptable, even after counseling, stop use and help client choose another
method. |
Client Instructions
- Return to the health clinic for an injection every 3 months (DMPA) or every 2 months
(NET-EN).
General Information
- Changes in menstrual bleeding patterns (amenorrhea) are common, especially following the
first 2 or 3 injections. They often are temporary and rarely are a risk to health.
- Other minor side effects may include weight gain, mild headaches and breast tenderness.
These symptoms are not dangerous and gradually disappear.
- In women using DMPA, the delay in return of fertility is temporary (on average 10 months
from the last injection). DMPA, however, does not decrease fertility in the long
term.
- About 50% of women using DMPA will stop having any bleeding by the end of the first year
of use. (Not having menses is not serious and, in the absence of pregnancy symptoms, does
not require treatment.)
- PICs do not provide protection against STDs, including the AIDS virus. If either partner
is at risk, they should use condoms as well as the injectable.
WARNING SIGNS FOR
PROGESTIN-ONLY INJECTABLE CONTRACEPTIVE (PIC) USERS
- Delayed menstrual period after several months of regular cycles (may be a sign of
pregnancy)
- Severe lower abdominal pain (may be a symptom of ectopic pregnancy)
- Heavy bleeding (twice as long or twice as much as normal) or prolonged bleeding
(more than 8 days in duration)
- Pus or bleeding at the injection site
- Migraine (vascular) headaches, repeated very painful headaches or blurred vision
Contact health care provider or clinic if you develop any of the
above problems. |
Who Can Provide
- Physicians
- Nurses, Midwives, Paramedics
- Community-based Workers
- Pharmacists
Where They Can Be Provided
- Hospitals
- Clinics
- Health Posts
- Community-based Distribution Programs
 
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