INJECTABLE PROGESTOGEN ONLY PILL

A slowly absorbed depot IM injection or subcutaneous injection, which provides contraceptive protection for 3
months (e.g. Depo- Provera, Sayana Press).

Indications

  • Fertile women requiring long-term contraception
  • Breastfeeding postpartum women
  • Known/suspected HIV positive women who need an effective FP method
  • Women with sickle-cell disease
  • Women who cannot use COC due to oestrogen content
  • Women who do not want more children but do not (yet) want voluntary surgical contraception
  • Women awaiting surgical contraception

Contraindications

  • As for POP above

Advantages and other health benefits/uses

  • Do not require daily action (e.g. taking pills)
  • Do not interfere with sex
  • Private method: no one else can tell that a woman is using contraception
  • Cause no monthly bleeding (for many women)
  • May help women to gain weight
  • Assists with spacing of births
  • Injections can be stopped at anytime
  • Protects against:
    • Risk of pregnancy (DMPA & NET-EN)
    • Cancer of the lining of the uterus (DMPA)
    • Uterine fibroids (DMPA)
    • Iron-deficiency anaemia (NET-EN)

Disadvantages and common side-effects

  • DOES NOT PROTECT AGAINST STI
  • Amenorrhoea
    • Often after 1st injection and after 9–12 months of use
  • Can cause heavy prolonged vaginal bleeding during first 1-2 months after injection
  • Weight gain
  • Loss of libido
  • Delayed return to fertility (Up to 10 months after stopping injection)

Complications and warning signs

  • Headaches
  • Heavy vaginal bleeding
  • Severe abdominal pain
  • Excessive weight gain

INSTRUCTIONS

  • Medroxyprogesterone acetate depot (Depo Provera) injection
    • Give 150 mg deep IM into deltoid or buttock muscle
    • Do not rub the area as this increases absorption and shortens depot effect
  • Medroxyprogesterone acetate depot (Sayana Press) injection
    • Inject 104 mg in the fatty tissue (subcutaneous) at the front of the thigh, the back of the upper arm, or
      the abdomen
    • This can be administered at community level

If given after day 1–7 of menstrual cycle

  • Advise client
    • To abstain from sex or use a back-up FP method, e.g., condoms, for the first 7 days after injection
    • To return for the next dose on a specific date 12 weeks after the injection (if client returns
      >2-4 weeks later than the date advised, rule out pregnancy before giving the next dose)
    • On likely side-effects
    • To return promptly if there are any warning signs

MANAGEMENT OF SIDE EFFECTS OF INJECTABLE POC

No Monthly Period

Assess for pregnancy:

  • If pregnant, reassure that the injectable POC will not affect her pregnancy and refer to ANC
  • If not pregnant, reassure her that this contraceptive may stop women having monthly periods, but it is not
    harmful. She can continue with the method or choose another

Irregular Bleeding

Assess for pregnancy/abortion:

  • Reassure that many women using injectable POC have irregular bleeding. It is not harmful and should lessen or stop after a few months

If irregular bleeding continues, immediately:

  • Give 400–800 mg ibuprofen every 8 hours when irregular bleeding starts
  • Or 500 mg mefenamic acid every 12 hours after meals for 5 days

If irregular bleeding continues or starts after several months of normal or no monthly bleeding:

  • Investigate other reasons (unrelated to the contraceptive) and treat accordingly
  • Help client choose another FP method if necessary

Heavy Bleeding

If heavy bleeding is between 8–12 weeks of first injection:

  • Assess for pregnancy/ abortion
  • Reassure (as for irregular bleeding)
  • Repeat progestogen-only injection and change return date to 3 months after the latest injection

Heavy bleeding after 2nd injection:

  • Assess for pregnancy/abortion
  • Reassure/comfort
  • Give 1 COC pill daily for 21 days (1 cycle)

Heavy bleeding after 3rd or later injection:

  • Assess for pregnancy/abortion
  • Reassure/comfort
  • Give 1 COC pill daily for 21 days (1 cycle) when irregular bleeding starts
  • Or 50 μg ethinyl estradiol daily for 21 days
  • And ibuprofen 800 mg every 8 hours
  • Or 500 mg mefenamic acid every 12 hours after meals for 5 days
  • Ferrous salt tablets (60 mg iron) to prevent anaemia

If bleeding persists:

  • Investigate other reasons (unrelated to injectable POC) and treat accordingly
  • Help client choose another FP method if necessary

Delayed Return to Fertility

  • A woman should not be worried if she has not become pregnant even after stopping use for 12 months
  • Reassure and counsel her about the fertile days; ovulation normally occurs 14 days before the next
    menstrual period (if woman’s cycle is 28 days and has regular menstruation)

Weight Gain

  • Rule out weight gain due to pregnancy
  • Interview client on diet, exercises, and eating habits promoting weight gain; counsel as needed. Explain to
    client that all hormonal contraceptives may have a slight effect on weight
  • If weight gain is more than 2 kg, instruct her on diet and exercises

Loss of Libido

  • Take proper history
  • Find out if she has stress, fatigue, anxiety, depression, and if she is on new medication. Explore if this is due to
    dry vagina and/or painful intercourse
  • Explore lifestyle and suggest changes where needed. Advise on foreplay and if possible, involve spouse
  • Help client choose another FP method if necessary

Headache

  • Explore possible social, financial, health, or physical causes of headaches. Ask her to keep a record of the
    timing and number of headaches for the next 2 weeks and ask her to come for follow-up
  • Evaluate cause of headache (Is blood pressure raised? Does she have sinus infection [purulent nasal discharge
    and tenderness in the area of sinuses)
  • Give pain relievers such as acetylsalicylic acid, ibuprofen, or paracetamol
    • Regardless of age, a woman who develops migraine headaches with aura or whose migraine headaches
      becomes worse while using monthly injections should stop using injectable. If migraine headaches are without aura, she can continue using the method if she wishes