Recommendations for Contraceptive Use
		Combined Injectable Contraceptives

Recommendations	Rationale
a) Not usually. Heavy bleeding (greater than normal menstrual bleeding) is common in the first 3 months of use and usually does not require discontinuation.	a) Approximately 20% of CIC users experience frequent or prolonged menstrual bleeding within the first 3 months. However, these variations from normal bleeding patterns tend to decrease with time. World Health Organization. Facts about once-a-month injectable contraceptives: memorandum from a WHO meeting. Bulletin of the World Health Organization 1993;71(6):677-89.
b) If bleeding has stopped and the woman wants to continue using CICs, she should first be reassured by informing her that these effects usually pose no threat to health and tend to improve over time.	b) Compared to women not using any contraceptive method, CIC users experience a significantly increased incidence of frequent, irregular or prolonged bleeding. World Health Organization. Facts about once-a-month injectable contraceptives: memorandum from a WHO meeting. Bulletin of the World Health Organization 1993;71(6):677-89.
c) If a woman is experiencing more days of bleeding than she was prior to starting CICs, the first approach should be counseling to provide information and reassurance. If the bleeding is intolerable to the woman but she wishes to continue CICs, then administration of supplementary short term estrogen (or combined oral contraceptives-COCs) or prostaglandin inhibitors may be tried.	c) Little research has been done on the management of heavy bleeding in CIC users. Prolonged or heavy bleeding in users of COCs or progestin-only injectables may be managed by stabilizing the endometrium with increased doses of estrogen, or by ibuprofen (or related non-steroidal anti-inflammatory drugs) which blocks prostaglandin synthesis and thus decreases uterine bleeding. Injectable contraceptives: their role in family planning care. Geneva: World Health Organization, 1990. Speroff L, Darney P. A clinical guide for contraception. Baltimore: Williams & Wilkins, 1996:179.
d) Some women may not be able to tolerate heavy or prolonged bleeding and will discontinue CICs and need another method. Evaluate and address anemia if appropriate. Give nutritional advice on the need to increase the intake of iron-containing foods.
e) Do not perform uterine evacuation unless another medical condition is suspected (vacuum aspiration is usually 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.