Title: Injectable contraception
Course: Level 3 - Family Planning > Section: Injectable contraceptives

The contraceptive injection, also known as "the shot", contains progesterone or a combination of oestrogen and progesterone. The injectable contraceptives depot med Roxy progesterone acetate (DMPA) and norethisterone enanthate (NET-EN) each contains a progestin like the natural hormone progesterone in a woman's body. In contrast, monthly injectable contains both oestrogen and progestin. Note that combined injectable is not addressed in this module.

Progestin-Only Injectables

Progestin-only injectable contraceptives contain no oestrogen. Therefore, they can be used throughout breastfeeding and by women who cannot use methods with oestrogen. They work primarily by preventing the release of eggs from the ovaries (ovulation).

How effective are progestin-only injectables (DMPA):

Effectiveness depends on getting injections regularly: Risk of pregnancy is greatest when a woman misses an injection. As commonly used, about three pregnancies per 100 women using progestin-only injectable over the first year. This means that 97 of every 100 women using injectable will not become pregnant. When women have injections on time, less than one pregnancy per 100

Fig 7.1. DMPA injection.

Advantages of DMPA:

- Highly effective and safe.
- Long-acting (three months).
- It does not interfere with sexual intercourse.
- One of the most private and confidential methods.
- Convenient and easy to use (does not require a daily routine or supplies).
- Can be provided by a non-physician.
- Completely reversible (an average of 4 months' delay in return to fertility after discontinuing DMPA).
- Suitable for women who are not eligible to use an estrogen-containing contraceptive.
- Suitable for breastfeeding women (after six weeks postpartum).
- It provides immediate postpartum (in non-breastfeeding women) or post-abortion contraception.
- The prolonged absence of menses is an advantage for many women.
- May be used by women at any age or parity if they are at risk of pregnancy.
- Protects against ectopic pregnancy since ovulation does not occur

Disadvantages of DMPA:

- There are menstrual changes for almost all women.
- Increased appetite causing weight gain for some women (0.5 kg, on the average, in the first year).
- Women who stop using DMPA take an average of four months longer than usual to get pregnant. This is because residual levels of DMPA exist for several months after the end of contraceptive protection from the last injection.
- Since DMPA is long acting, it cannot easily be discontinued or removed from the body if a complication occurs or if pregnancy is desired immediately.
- DMPA does not provide protection against STIs/HIV.

Who can use progestin-only injectables?:

Women of any reproductive age or parity including women who:
- Have or have not had children, or are not married.
- Are of any age, including adolescents and women over 40 years old.
- Are breastfeeding (starting as soon as six weeks after childbirth).
- Have just had abortion or miscarriage.
- Smoke cigarettes, regardless of age or number of cigarettes smoked.
- Are infected with HIV, whether or not on antiretroviral medications.

Who can not use progestin-only injectables?:

Women who have the following conditions:

- Breastfeeding a baby less than six weeks old.
- Active liver disease (severe cirrhosis of the liver, a liver infection, or liver tumour).
- Systolic blood pressure 160 or higher or diastolic blood pressure 100 or higher.
- Diabetes for more than 20 years or damage to your arteries, vision, kidneys, or nervous system caused by diabetes.
- History of heart attack, heart disease due to blocked or narrowed arteries, or stroke OR current blood clot in the deep veins of the leg or the lung.
- Unexplained vaginal bleeding that suggests pregnancy or an underlying medical condition.
- Current or history of breast cancer.

Management of side-effects and problems of injectable contraceptives:

DMPA cannot be given to all women. In particular, it is not recommended for pregnant women, or those with breast cancer, or where a client has a history of diabetes (increased blood glucose level), advanced heart or liver disease, severe hypertension (increased blood pressure), or frequent severe headaches.

If a woman comes to you with concerns associated with this injection, do not underestimate or ignore her. Reassure her that the side-effects are not dangerous. Remember that counselling after side-effects has occurred is still useful, but not best practice. The best time to counsel a client about side-effects is when they make their contraceptive method choice. This is because many women encountering side-effects may not come to you at all, so it is important that you have given them the information beforehand.

First, you should advise her to wait until the effective days of the injection have passed. Then, if she is concerned about not having her monthly period, for example, she may want to change to another method. With irregular bleeding, reassure her that it is not harmful and usually reduces or stops after the first few months of use. On the other hand, if the bleeding is profuse and continuous, you should refer her for further investigation and management at the health post or hospital, as there may be another cause.

If she is suffering from headaches, suggest she takes Aspirin (500 mg), Ibuprofen (400 mg) or Paracetamol (500 mg), as needed, and provide her with the pain killer of her choice. Be aware that Aspirin and Ibuprofen may not be tolerated by a woman with gastritis or peptic ulcer diseases. In general, if her condition is severe, or if she is unhappy with your advice, refer her to the nearest health centre or hospital.

Timing and techniques for DMPA injections:

When to start DMPA injections:

- In the first seven days after menstrual bleeding starts.
- Six weeks after childbirth, or at any time once menstruation has returned, indicating the woman is not pregnant.
- Any time within four weeks after giving birth; beyond four weeks and monthly bleeding have not returned if your client is not breastfeeding.
- Immediately, or within the seventh day after a miscarriage or abortion.
- Immediately after stopping another method.

Injectable hormonal contraceptives are different from other injections because they are administered using deep intramuscular injection techniques. The vial must be shaken strongly before it is drawn into the syringe, to ensure the active ingredient is in suspension and not in the bottom of the vial. Following the procedure, the injection site should not be massaged or pressurised, because this may accelerate absorption of the drug. Infection prevention procedures are critical.

Reinjection schedule:

When the client comes to you to have her next or subsequent injection, you should check your records to see when you last gave her an injection. If it is the correct appointment date, give her the injection. If she comes to you up to two weeks before her appointment or up to one month after her scheduled appointment, you can still give her the injection. But if she is more than one month late, she can get another injection that day only if you can be sure that she is not pregnant.

She is unlikely to be pregnant if:

- She has had no sex since the day of her last injection.
- She has used condoms or another method every time she has had sex since the end of her last injection.
- She had a baby less than six months ago, is fully, or nearly fully, breastfeeding, and has not had her period since.
- She has taken emergency contraceptive pills after every sex act since her last injection.