Session I, Slide 1

Progestin-Only Injectable Contraceptives

Session I: Characteristics of Progestin-Only Injectables

Session I, Slide 2

ObjectivesAt the end of this session, participants will be able to:

1. Describe the characteristics of progestin-only injectables in a manner clients can understand:

a. What progestin-only injectables are and how they work (mechanism and onset of action)

b. Effectiveness

c. Side effects

d. Non-contraceptive health benefits

e. Possible health risks (complications)

f. Other characteristics (STI/HIV protection, ease of use, return to fertility, when to initiate and discontinue)

Session I, Slide 3

Objectives2. Demonstrate the ability to:

a. Screen clients for medical eligibility for injectables

b. Explain to clients the insertion, removal, and follow-up procedures

c. Explain when to return to the clinic

d. Address common concerns, misconceptions, and myths

e. Conduct follow-up for injectable clients in a way that enhances continuing safety, satisfaction, and acceptance

3. Describe when to start use of injectables.

4. Explain how to manage side effects.

5. Identify conditions that require switching to another method.

6. Identify clients in need of referral for injectable-related complications.

7. Demonstrate the preparation of supplies, equipment, and the client and the technique of administration (using a fruit or vegetable).

Session I, Slide # 4

An injection every 2 or 3 months, depending on type

• A contraceptive method given by deep intramuscular injection.

• Contains progestin (similar to the natural hormone progesterone), that is slowly released into blood from injection site.

• DMPA and NET-EN are the scientific names.

• Works mainly by stopping ovulation.

• No supplies needed at home.

Very effective and safe

• Very effective, provided client returns for injection at right time.

• Do not cause any serious health problems, cancer, or infertility, nor do they produce any significant change in blood pressure.

• For breastfeeding women, they do not affect the quality of the breast milk.

Key Points for Providers and Clients

Session I, Slide # 5

Often takes longer to get pregnant after stopping

• After stopping progestin-only injectables, there is a delay of several months before most women can get pregnant, and for some women it may be even longer.

• They do not make women permanently infertile.

Changes in monthly bleeding

• The most commonly reported side effects of progestin-only injectables are menstrual changes.

• In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding. After one year, women commonly experience infrequent bleeding, irregular bleeding and amenorrhea.

No protection against STIs or HIV/AIDS

• Provide no protection from STIs/HIV.

• For STI/HIV/AIDS protection, also use condoms.

Key Points for Providers and Clients

Session I, Slide 6

Types of Progestin-Only Injectables

• DMPA (depot medroxyprogesterone acetate)– Injection every 3 months (13 weeks)

• NET-EN (norethisterone enanthate)– Injection every 2 months (8 weeks)

• Have similar effectiveness, safety, characteristics and eligibility criteria

Source: CCP and WHO, 2010; Kingsley, 2010.

Session I, Slide 7

Effectiveness of Injectables

In this progression of effectiveness, where would you place progestin-only injectables?

Implants

Male Sterilization

Female Sterilization

Intrauterine Devices

Combined Oral Contraceptives

Male Condoms

Standard Days Method

Female Condoms

Spermicides

Less effective

More effective

Injectables

Session I, Slide 8

Relative Effectiveness of Family Planning Methods

Method # of unintended pregnancies among1,000 women in 1st year of typical use

No method 850

Withdrawal 220

Female condom 210

Male condom 180

Pill 90

Injectable 60

IUD (CU-T 380A / LNG-IUS) 8 / 2

Female sterilization 5

Vasectomy 1.5

Implant 0.5Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc.

Session I, Slide 9

Progestin-Only Injectables:

Mechanism of Action

Source: Kingsley F and Salem R, 2010.

Thicken cervical mucus to block sperm

Suppress hormonesresponsible forovulation

Note: Do not disrupt existing pregnancy

Session I, Slide 10

Characteristics of Progestin-Only Injectables

• Safe and very effective

• Easy to use; requires no daily routine

• Long-lasting and reversible

• Can be discontinuedwithout provider’s help

• Can be provided outside of clinics

• Can be used by breastfeeding women

• Use can be private

• Does not interfere with sex

• Can be used by breastfeeding women

• Provide non-contraceptive health benefits

• Have side effects

• Cause delay in return to fertility

• Effectiveness depends on user getting injections regularly

• Provide no protection from STIs/HIV

Source: CCP and WHO, 2011

Session I, Slide 11

Progestin-Only Injectables:

Health Benefits

• Help protect against:– Risks of pregnancy– Endometrial cancer– Uterine fibroids

• May help protect against symptomatic pelvic inflammatory disease (PID) and iron-deficiency anemia

• Reduce sickle cell crises in women with sickle cell anemia

• Reduce symptoms of endometriosis (pelvic pain, irregular bleeding)

Source: CCP and WHO, 2011; Manchikanti, 2007.

Session I, Slide 12

Injectables and Risk of Breast Cancer

• No effect on overall risk of breast cancer

• Older studies found a somewhat increased risk during first 5 years of use

– May be due to detection bias or accelerated growth of pre-existing tumors

• Recent large study found no increased risk in current or past DMPA users regardless of age and duration of use

• Little research has been done on NET-EN

Source: Strom et al, 2004

Session I, Slide 13

Effect of DMPA on Bone Density

• DMPA users have lower bone density than non-users

• Women initiating DMPA use as adults regain most lost bone

• Long-term effect in adolescents unknown – Concerns about reaching peak bone mass

– Long-term studies are needed

– Generally acceptable to use

Source: Cromer, 1996; Cundy, 1994; WHO, 2010.

Session I, Slide 14

Infant Exposure to DMPA/NET-ENDuring Breastfeeding

DMPA and NET-EN have no effect on:

•Onset or duration of lactation

•Quantity or quality of breast milk

•Health and development of infant

Source: Koetsawang, 1987; WHO Task Force for Epidemiological Research on Reproductive Health, 1994a and 1994b; Kapp 2010; WHO, 2008; WHO, 2010; WHO, 2004, updated 2008.

Initiation before 6 weeks postpartum is generally not recommended. (WHO/MEC)

Session I, Slide 15

Injectables: Return to Fertility

• Return to fertility depends on how fast a woman fully metabolizes the injectable

• On average, women become pregnant 9–10 months after their last injection of DMPA

• Length of time injectable was used makes no difference

Sources: Pardthaisong, 1984; Schwallie, 1974.

Session I, Slide 16

Progestin-Only Injectables:

Side Effects

Headaches and dizziness

Many women experience no side effects. Possible side effects include:

Amenorrhea (no menses)

Weight gain Changes in mood

and sex drive

Abdominal bloating and discomfort

Prolonged or heavy bleeding irregular bleeding or spotting

Session I, Slide 17

Group Activity

Injectables Fact Sheet

Review the fact sheet.

What additional questions or comments do you have about the characteristics of progestin-only injectables?