Injectable Contraceptives

This section describes the most common type of injectable contraceptive DMPA (depot - medroxy Progesterone acetate) also know as Depo - provera which is given every three months. It contains a progestin, similar to the natural hormone that woman's body makes. There are other injectable contraceptives such as NET EN (Norethisterone enanthate) which is given every two months. Other monthly injectable contraceptives include cyclofem, cycloprovera and mesigyna.

Mechanism of action of DMPA

• Mainly stops ovulation (release of eggs from ovaries).

• Also thickens cervical mucus, making it difficult for sperm to pass.

Effectiveness of DMPA

Very effective 0.3 pregnancies per 100 women in first year of use (one in every 333) when injections are regularly spaced three months apart.

Indications for DMPA

DMPA injectable can be used in any circumstances by women who: • Are breast feeding (starting as soon as 6 weeks after child birth) • Smoke cigarettes.

• Have no children.

• Are any age, including adolescents and over 40. • Are fat or thin.

• Have just had abortion or miscarriage.

• Also women with benign breast disease, headaches, high BP, iron deficiency anemia, varicouse veins, vascular heart disease, irregular menstrual periods, malaria, schistosomiasis, sickle cell disease, thyroid disease, uterine fibroids, epilepsy and tuberculosis can use DMPA in any circumstances.

Advantages

• Long-term effective contraceptive.

• Private, no one can tell that a woman is using it. • Does not interfere with sex.

• No daily pill taking.

• Allows some flexibility in return visits. Client can return from 2 to 4 weeks early (although this is not ideal) and 2 weeks and perhaps up to 4 weeks late for next injection.

• Can be used at any age.

• Can be used by nursing mothers as soon as 6 weeks after childbirth. • No estrogen side - effects.

• Helps prevent ectopic pregnancies. • Helps to prevent endometrial cancer.

Disadvantages

• Delayed return of fertility.

• Requires another injection every 3 months.

• Does not protect against STIs including HIV/AIDS.

Side - effects

• Menstrual cycle disturbance:

- Light spotting or bleeding. Most common at first. - Heavy bleeding can occur at first - Rare.

• Amenorrhea, normal, especially after first year of use.

• May cause weight gain, headaches, breast tenderness, moodiness, nausea, hair loss, less of sex drive and/or acne in some women.

Provision of DMPA

Who can provide DMPA?

Health workers who have been trained in administering injections.

Medical eligibility check list for DMPA

Ask and listen to the client for the following conditions. If the answer is NO to all of the questions/ conditions she can use DMPA if she wants.

Questions / Conditions Yes No - Breast feeding a baby less than 6 weeks ______ _________ - Certain pre - existing conditions: (Heart attack, stroke,

sever chest pain with unusual shortness of breath, diabetes for more than 20 years, or damage to vision,

kidneys, or nervous system caused by diabetes) _______ ________ - High blood pressure above 160 (systolic) and above

100 (diastolic) ______ ________

- Has she or has she ever had breast cancer? ______ ________ - Serious active liver diseases (Jaundice, painful or

enlarged liver, viral hepatitis, liver tumor). _{______ ________}

- Pregnancy ______ _________

Starting DMPA

It depends on woman's situation, • Having menstrual cycles

- Any time it is reasonably certain that she is not pregnant.

- If starting during the first 7 days after menstrual bleeding starts, no back-up method is needed for extra protection.

- If she is starting on or after day 8 of her menstrual period, she should use condoms or spermicide or avoid sex for at least the next 48 hours. If possible give her condoms or spermicide.

• Breast feeding

- As early as 6 weeks after childbirth.

- If menstrual periods have returned, she can start DMPA any time it is reasonably certain that she is not pregnant.

• After childbirth if not breast-feeding.

- Immediately or at any time in the first 6 weeks after child birth.

- After 6 weeks any time it is reasonably certain that she is not pregnant. • After miscarriage or abortion.

- Immediately or in the first 7 days after either first or second trimester miscarriage or abortion.

- Later any time it is reasonably certain that she is not pregnant. • When stopping another method.

- Immediately.

Explaining how to use

• Explain that she should receive injection of DMPA every 3 months.

• Explain to her that she has to come back any time she has questions or • Problems or wants another method.

• Mention and explain the most common side - effects.

Giving the injection

a. Equipment and supplies needed:

• One dose of DMPA (150mg = 1mL) • An antiseptic and cotton wool.

• A 2 or 5ml syringe and a 21 to 23 gauge IM needle. (All sterile).

b. Steps in giving the injection

• Wash hands and if possible wear clean gloves.

• Shake vial gently, wipe top of vial and stopper with antiseptic, and fill syringe with proper dose (150gm).

• Clean the injection site.

• Insert the sterile needle deep in to the upper arm (deltoid muscle) or glutial muscle upper outer quadrant. For DMPA the upper arm is more convenient.

Proper handling of needles and syringes

• Use disposable needles and syringes if available. • Dispose needles and syringes.

- Place used disposable needles and syringes in a puncture- proof container, - Burn or bury the container when three - quarters full.

- Do not put disposable needles in trash. Do not re-cup, bend or break needles before disposal.

- Do not re-use disposable needles and syringes. • Re-usable needles and syringes

- Use properly sterilized or high level disinfected re-usable needles and syringes if disposable are not available.

- The needles and syringes must be sterilized or high level disinfected again after each use.

Follow-up

• Tell the client the name of the injection and the date when the next Injection is due.

• A follow-up review may be performed at any of the visits during which the client obtains a repeat injection:

- up-date the client's address and how to contact her. - assess the client's satisfaction with the method.

- determine if the client has had any problems or side - effects and, if so, record them in the clinical record.

- update the medical history; measure BP and weight and perform any other examination indicated by the history.

- provide appropriate counseling and/or treatment as required.

- encourage the client to contact the clinic any time if she has any questions, complaints or problems.

• Late repeat injections:

- if the client comes 2 weeks late after the allowable time for repeat injection; to make certain she is not pregnant:

• take careful history;

• if indicated, perform a pregnancy test and/or a pelvic examination.

Management of side - effects / problems

If the client reports any of the common side - effects of DMPA:

• Do not underestimate the woman's concerns or take them lightly.

• If the woman is worried, reassure her that such side - effects are not usually dangerous or signs of danger.

• If the women is not satisfied after treatment or counseling, help her choose another method if she wishes.