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depot progestogen injections (contraceptive)

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Depo-Provera is an injectable contraceptive containing medroxy progesterone acetate. It is licensed for long and short term use.

Provided that it is reasonably certain that the woman is not pregnant, the use of injectable contraceptives may be started:

  • up to and including the fifth day of the menstrual cycle without the need for additional contraceptive protection
  • at any other time in the menstrual cycle, but additional barrier contraception should be used for the first 7 days after the injection
  • immediately after first- or second-trimester abortion, or at any time thereafter
  • at any time post-partum

Contraceptive efficacy

  • progestogen-only injectable contraceptives act primarily by preventing ovulation (1,2)
  • pregnancy rate associated with injectable contraceptives, when given at the recommended intervals, is very low (fewer than 4 in 1000 over 2 years) and the pregnancy rate with Depo medroxyprogesterone acetate (DMPA) is lower than that with norethisterone enantate (NET-EN)
  • DMPA should be repeated every 12 weeks and NET-EN every 8 weeks
    • an injection of DMPA can be administered up to 7 days late (up to 14 weeks after the last injection) without the need for additional contraceptive precautions (outside the product licence for IM DMPA). If necessary, an early repeat injection of DMPA can be administered from 10 weeks and from 6 weeks for norethisterone enantate (NET-EN)(outside product licence) (3)
  • may be a delay of up to 1 year in the return of fertility after stopping the use of injectable contraceptives
    • if a woman stops using injectable contraceptives but does not wish to conceive, she should start using a different contraceptive method immediately even if amenorrhoea persists

Administration

  • gluteal muscle in the buttock is the preferred site for IM DMPA administration but it can be administered into the deltoid muscle of the upper arm. In women with deep adipose tissue in the gluteal area, standard-length needles may not reach the muscle layer and SC DMPA or deltoid administration of IM DMPA should be considered (3)

Risks and possible side effects

  • DMPA use may be associated with an increase of up to 2-3 kg in weight over 1 year
    • use of DMPA appears to be associated with weight gain, particularly in women under 18 years of age with a body mass index (BMI) >30 kg/m2 (3)
    • women who gain more than 5% of their baseline body weight in the first 6 months of DMPA use are likely to experience continued weight gain (3)
  • DMPA use is not associated with acne, depression or headaches
  • DMPA use is associated with a small loss of bone mineral density, which is largely recovered when DMPA is discontinued
  • no evidence that DMPA use increases the risk of fracture
  • there is a weak association between cervical cancer and use of DMPA for 5 years or longer. Any increased risk appears to reduce with time after stopping and could be due to confounding factors (3)
  • Ulipristal acetate (UPA) has the potential to reduce the efficacy of hormonal contraception. For women using the progestogen-only injectable, additional precautions are advised for 14 days after taking UPA for emergency contraception (outside product licence) (3)
  • unscheduled bleeding - assess unscheduled bleeding as per linked item then (3):
    • women who experience unscheduled bleeding during use of a progestogen-only injectable and who are medically eligible can be offered a combined oral contraceptive (COC) for 3 months. This can be taken in the usual cyclic manner or continuously without a hormone-free interval (outside product licence). Longer-term use of the injectable and COC has not been studied and is a matter of clinical judgement (3)
    • women with unscheduled bleeding during use of a progestogen-only injectable contraceptive can be offered 500 mg mefenamic acid up to three times daily for 5 days

Possible additional benefits:

  • DMPA is a contraceptive option for women with sickle cell disease and may reduce the severity of sickle crisis pain (3)
  • amenorrhoea or reduced bleeding is common in progestogen-only injectable users and may benefit women with menstrual problems (3)

Reference:

  1. BNF 7.3
  2. NICE (September 2014). Long-acting reversible contraception
  3. FSRH (December 2014). Progestogen-only injection contraception.

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