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Depo-Provera7 (DMPA): 150 mg of depot-medroxyprogesterone acetate given every 3 months

Noristerat7 (NET-EN): 200 mg of norethindrone enanthate given every 2 months

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FP TrainingJ.K.Mutua

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Suppress ovulation

Reduce spermtransport in fallopian tubes

Change endometrium

Thicken cervical mucus (prevent sperm penetration)

Highly effective (0.31 pregnancies per 100 women during first year of use)

Rapidly effective (< 24 hours) if started by day 7 of menstrual cycle

Intermediate-term method (2 or 3 months protection per injection)

Pelvic examination not required to begin use Do not interfere with intercourse

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1 Trussell et al 1998. Note: This efficacy rate refers only to DMPA.

Do not affect breastfeeding Few side effects No supplies needed by the client Can be provided by trained nonmedical staff Contain no estrogen

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May increase quantity of breastmilk Have no effect on:◦ Initiation or duration of breastfeeding◦ Quality of breastmilk◦ Growth and development of infants◦ Long-term growth and development of children through

adolescence

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Decrease ectopic pregnancy May decrease menstrual cramps May decrease menstrual bleeding May improve anemia Protect against endometrial cancer Decrease benign breast disease Decrease sickle cell crises Protect against some causes of PID

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Changes in menstrual bleeding pattern◦ Irregular bleeding/spotting initially in most women

Weight gain ( 2 kg) is common Although pregnancy is unlikely, if pregnancy

occurs, it is more likely to be ectopic than in a nonuser

Resupply must be available Must return for injections every 3 months (DMPA)

or 2 months (NET-EN) Return to fertility may be delayed for 7B9 months

(on average) after discontinuation

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Women of any reproductive age or parity who:◦ Want an effective, reversible method◦ Are postpartum and not breastfeeding◦ Are breastfeeding (6 weeks or more postpartum)◦ Are postabortion ◦ Are smokers (any age, any amount)◦ Do not mind irregular bleeding or amenorrhea

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Women of any reproductive age or parity who:◦ Have moderate to severe menstrual cramping◦ Take drugs for epilepsy or tuberculosis◦ Have high blood pressure or blood clotting problems ◦ Prefer not to or should not use estrogen◦ Cannot remember to take a pill every day◦ Prefer a method not related to intercourse

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Women who cannot tolerate any changes in their menstrual bleeding pattern, especially amenorrhea. (Changes in bleeding pattern are main reason women discontinue PICs.)

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Need for contraception Reaction of the partner to menstrual changes Interference with sexual or daily activity Religious constraints

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PICs should not be used if a woman:◦ Is pregnant (known or suspected)◦ Has unexplained vaginal bleeding (if serious problem

suspected)◦ Has breast cancer

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Source: WHO 1996.

PICs are not recommended unless other methods are not available or acceptable if a woman:◦ Is breastfeeding (< 6 weeks postpartum)◦ Is jaundiced (symptomatic viral hepatitis or cirrhosis)◦ Has high blood pressure (≥ 180/110)◦ Has ischemic heart disease (current or history)◦ Has had stroke◦ Has liver tumors (adenoma or hepatoma)◦ Has diabetes (> 20 years duration)

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Source: WHO 1996.

Initial injection:◦ Days 1 to 7 of the menstrual cycle◦ Anytime during the menstrual cycle when you can be

reasonably sure the client is not pregnant◦ Postpartum:

Immediately if not breastfeeding After 6 months if using LAM◦ Postabortion: immediately or within first 7 days

Reinjection:◦ DMPA: Up to 4 weeks early or late◦ NET-EN: Up to 2 weeks early or late

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DMPA NET-EN

Duration 3 months 2 months

Bleeding More amenorrhea More irregular

Needle/pain Smaller/less Larger/more

Reinjection window Up to 4 weeks Up to 2 weeks

Cost Cheaper More expensive

Return to ovulation Later Sooner

Amenorrhea (absence of vaginal bleeding or spotting)

Irregular or heavy bleeding Headache Nausea/dizziness/vomiting Weight gain or loss (change in

appetite)

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Give reassurance that this is a common, not serious side effect

Evaluate for pregnancy, especially if amenorrhea occurs after period of regular menstrual cycles

If no problem found, do not attempt to induce bleeding with COCs

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Prolonged spotting (> 8 days) or moderate bleeding: Reassurance Check for gynecologic problem (e.g., cervicitis) Short-term treatment:◦ COCs (30-50 µg EE) for 1 cycle1, or◦ Ibuprofen (up to 800 mg 3 times daily x 5 days)

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1Remind client to expect bleeding after completing COCs.

Bleeding twice as long or twice as much as normal: Carefully review history and check hemoglobin (if

available) Check for gynecologic problem Short-term treatment: ◦ COCs (30B50 g EE) for 1 cycle1, or ◦ Ibuprofen (up to 800 mg 3 times daily x 5 days)

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1Remind client to expect bleeding after completing COCs.

If bleeding not reduced in 3B5 days, give:◦ 2 COC pills per day for the remainder of her cycle

followed by 1 pill per day from a new packet of pills, or◦ High dose estrogen (50 µg EE COC, or 1.25 mg

conjugated estrogen) for 14B21 days

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Return to health clinic for an injection every 3 months (DMPA) or every 2 months (NET-EN).

Changes in menstrual bleeding patterns (amenorrhea) are common, especially following first 2 or 3 injections.

If using DMPA, return of fertility is temporarily delayed, but does not decrease fertility in the long term.

If using DMPA, 50% of women will stop having any bleeding by end of first year of use.

PICs do not provide protection against STDs, (e.g., HBV, HIV/AIDS).

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Delayed menstrual period after several months of regular cycles

Severe lower abdominal pain Heavy bleeding Pus or bleeding at injection site Migraine (vascular) headaches, repeated very

painful headaches or blurred vision

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Use antiseptic solution to prepare the injection site (wash area first if poor hygiene).

Use sterile (or high-level disinfected) needle and syringe.

After use, decontaminate needle and syringe and either:◦ place in puncture-proof container for disposal, or◦ clean and final process by sterilization (or high-level

disinfection).

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Adequate training in counseling and provision Steady supply (DMPA, NET-EN, antiseptics and

needles and syringes) Recommended infection prevention practices Correct disposal or processing of syringes (and

needles) for reuse System for notifying clients when to return for

injections Referral system Supervision

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Age restrictions (young and old) Parity restrictions (less than two living children) Unnecessary medical procedures (lab tests, pelvic

exams) Narrow reinjection window Inappropriate precautions (diabetes, hypertension,

smokers over age 35, etc.) “Rest” period (after 2 or more years) Poor management of side effects leading to

discontinuation of method

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