Injectable Contraceptives: Tools for Providers ore than twice as many women are using Minjectable contraceptives today as a decade ago, and the numbers keep growing. Women choose injectables because they are highly effective, long-acting, reversible, and private. At the same time many women do not choose injectables or stop using them because of side INFO Project effects—particularly irregular bleeding, no Center for Communication monthly bleeding, and weight gain—or because Programs they have trouble returning for injections (13, 70, 135, 168). Family planning programs are meeting increasing demand while helping providers to maintain good quality of care. Attention to quality, and to counseling especially, can be the difference between successful and unsuccessful efforts to expand access to injectables (77, 78). Using the tools in this INFO Reports, providers can inform women about injectables and help them be satisfi ed users.
Table 1. Formulations and Injection Schedules of Injectable Contraceptives
Common Trade Names Formulation Injection Type and Schedule Coming Soon: Progestin-Only Injectables “Injectables Toolkit” ® ® Web site. Go to www. Depo-Provera , Megestron , Depot medroxyprogesterone acetate One intramuscular (IM) injection Contracep®, Depo-Prodasone® (DMPA) 150 mg every 3 months injectablestoolkit.org for job aids One subcutaneous injection every depo-subQ provera 104® (DMPA-SC) DMPA 104 mg and information 3 months about injectable Norethisterone enanthate (NET-EN) Noristerat®, Norigest®, Doryxas® One IM injection every 2 months contraceptives 200 mg Combined Injectables (progestin + estrogen)1 Medroxyprogesterone acetate 25 mg + Cyclofem®, Ciclofeminina®, Lunelle® 2 One IM injection every month Estradiol cypionate 5 mg (MPA/E2C) NET-EN 50 mg + Estradiol valerate Mesigyna®, Norigynon® One IM injection every month 5 mg (NET-EN/E2V) Deladroxate®, Perlutal®, Dihydroxyprogesterone (algestone) Topasel®, Patectro®, Deproxone®, acetophenide 150 mg + Estradiol One IM injection every month Nomagest® enanthate 10 mg Dihydroxyprogesterone (algestone) Anafertin®, Yectames® acetophenide 75 mg + Estradiol One IM injection every month enanthate 5 mg Chinese Injectable No. 1® 17α-hydroxyprogesterone caproate One IM injection every month, 250 mg + Estradiol valerate 5 mg except 2 injections in fi rst month
Sources: International Planned Parenthood Federation 2005 (83), Lande 1995 (99), Liggeri 2006 (103), WHO 1990 (204), WHO 1993 (205) 1Also called monthly injectables. 2The U.S. Food and Drug Administration approved Lunelle, but it is currently not available in the United States.
See companion Population Reports, “Expanding Services for Injectables” December 2006 • Issue No. 8
205402_JHU-InfoReport.indd 1 12/12/06 10:52:44 AM Checklist for Giving Intramuscular How to Use This Report Family planning providers can use the checklists Contraceptive Injections and tables in this report to: Family planning providers can use this checklist to help ensure • Counsel about injectables or answer clients’ questions (see Table 2, pp. 3–4), that injections are safe. ˛ • Identify women who may not be able to use DMPA or NET-EN for medical reasons (see Prepare equipment and supplies Checklist, pp. 5–6), • Be reasonably sure that a woman is not preg- q In advance, assemble the supplies and materials needed nant before giving the fi rst injection (see Checklist, p. 6, questions 8–13), •Single-dose vial • Review the steps required to give an injection •Sterile needle and syringe (If auto-disable (AD) or conventional disposable safely (see Checklist, this page), and syringes and needles are not available, use sterile equipment designed • Help women be informed and satisfi ed con- for steam sterilization. Do not reuse disposable equipment.) tinuing users of injectables (see Table 3, p. 7). •Cotton wool This report accompanies Population Reports, “Expanding Services for Injectables”. q Wash hands with soap and water before giving the injection, if possible. Gloves See also Population Reports, “When are not needed unless there is a chance of direct contact with blood or other Contraceptives Change Monthly body fl uids. Bleeding,” Series J, No. 54, August 2006. q Inspect the vial and check expiry date. Discard any with visible cracks or leaks. This report was prepared by Robert Lande q With injectables containing DMPA, roll the vial back and forth or gently shake to and Catherine Richey, MPH. mix contents. If the vial of NET-EN is cold, warm to skin temperature before giving Ward Rinehart, Editor. the injection. Rafael Avila and Francine Mueller, Designers. The INFO Project appreciates the assistance Intramuscular injections can be given of the following reviewers: Jacob Adetunji, in the deltoid muscle of either arm Kim Best, Richard Blackburn, Marc G. or the left or right buttock (gluteal Boulay, Steve Brooke, Gloria Coe, María muscle, upper outer portion), del Carmen Cravioto, Juan Díaz, Maxine whichever the woman prefers.1 To Eber, Douglas Huber, Barbara Janowitz, minimize the risk of injury, providers Sophie Logez, Enriquito R. Lu, Kuhu Maitra, Kavita Nanda, Fredrick Ndede, Carib should take care to deliver the Nelson, Paula Nersesian, Gael O’Sullivan, injection in the proper site. Joseph F. Perz, James Phillips, Roberto Rivera, Ruwaida Salem, Hilary Schwandt, Give the injection safely Stephen Settimi, James D. Shelton, Jenni Smit, Cathy Solter, J. Joseph Speidel, Jeff Spieler, Tara M. Sullivan, Jagdish Upadhyay, q Explain the injection procedure to the client and point out that the syringe and Ushma Upadhyay, Marcel Vekemans, Irina needle are sterile. Yacobson, and Vera Zlidar. Suggested citation: Lande, R. and Richey, C. q Ask the client her preferred site for injection: upper arm (deltoid muscle) or “Injectable Contraceptives: Tools for Provid- buttocks (gluteal muscle). To decrease discomfort, position her so that her ers,” INFO Reports, No. 8. Baltimore, Johns Hopkins Bloomberg School of muscles are relaxed. Public Health, INFO Project, Dec. 2006. q Wash the injection site with soap and water if it is visibly dirty. Swabbing clean skin Available online: http://www.infoforhealth.org/inforeports/ or wiping the skin with antiseptic before giving an injection is not necessary. q Pierce the top of the vial with the sterile needle and fi ll syringe with the proper dose. q With a smooth, steady motion, insert the needle deep into the muscle at a right angle (90°) and inject the contents of the syringe. INFO Project Center for Communication Programs q After the injection ask the client to hold cotton wool on the injection site. Instruct Johns Hopkins Bloomberg School of Public Health the client not to massage the injection site. 111 Market Place, Suite 310 Baltimore, Maryland 21202 USA q Wash hands with soap and water after giving the injection, if possible. 410.659.6300 410.659.6266 (fax) www.infoforhealth.org Dispose of waste appropriately [email protected] Earle Lawrence, Project Director, INFO Project; Do not recap, bend, cut, or break needles after use. Discard the used disposable Stephen Goldstein, Chief, Publications Division; q Theresa Norton, Associate Editor; needle and syringe immediately in an enclosed sharps container. Linda Sadler, Production Manager.
q If reusable syringes and needles are used, they must be sterilized again after INFO Reports is designed to provide an accurate and authoritative report on important developments each use. in family planning and related health issues. The opinions expressed herein are those of the authors q Seal and dispose of sharps containers when they are three-fourths full. and do not necessarily refl ect the views of the U.S. Follow program or clinic guidelines for proper waste management. Agency for International Development (USAID) or the Johns Hopkins University.
Adapted from: Hutin 2003 (80) Published with support from USAID, Global, GH/POP/PEC, 1Intramuscular injection of the combined injectable Cyclofem can also be given in the thigh (lateral muscle of the quadriceps). under the terms of Grant No. GPH-A-00-02-00003-00.
2
205402_JHU-InfoReport.indd 2 12/12/06 10:57:31 AM
cant
fi
3 rst fi
quality -
informed -
(continued on p. 4)
for Checklist
for months 2
the
women Some life. daily
well are who Women
making. -
.
Injectables Combined
28- (around patterns bleeding regular Mostly
4
(190)
injection. have still and late days 7 or early
3 After harmful. not is This use. of months 3 rst fi
7 to up come Can year). a times (12 month Every
during unpredictably patterns bleeding change to Likely
days
(67). weight in change
signi no have or weight lose users Some (68).
•year per pounds) (2 kilogram 1 of gain Average
(205). bleeding monthly no have users
of 2% about year 1 After year. 1 by intervals) day
months.
in bleeding prolonged or frequent, Irregular, •
•
next). the to bleeding monthly a of start from days 28
(around patterns regular have women most months
the
•
injection. next the for time on be to try
to Important month. a once injection an have Women •
methods. contraceptive effective most the of One •
Good contraceptive. injectable an is method that
).
that: out Point ).
).
62
202
bleed-
100
,
after than
75
,
Increasingly, .
30
(198)
injection. the after days 7 rst fi
lose users Some ).
( informed -
are episodes bleeding
23
women, Some
is bleeding monthly No 205).
).
1
but
7,
the for
( bleeding monthly no have
220
3
pills. contraceptive emergency or contraceptives oral or
,
3
87
after starting If injectables). combined to apply also questions These 8–13. questions 5–6, pp. ,
available. is treatment term -
time. on return not do users if use of year rst fi
months, 6
Important NET-EN. for months 2 every or
bleeding. monthly no or little then and rst fi
rstfi
users of 30%
time on return users if women) 1,000 per (3 use of year rst fi
).
NET-EN) (or
48
Injectables Only -
2
( EN -
Progestin
about year 1 After
seek they When 227). 55, (27, method contraceptive a choose they when important most consider women that factors the are
188). 120, (40, weight in change cant fi
with than NET
users.
short happens, it if but, common not is
4
infrequent or bleeding no then bleeding, prolonged and bleeding irregular rst,
fi
the in bleeding prolonged and Irregular EN: -
injectables. combined for month 1 and EN, -
bleeding monthly no have users of 40%–60% year 1 After (
4
( year per pounds) 4 to (2 kilograms 2 to 1 of gain Average
Appropriate partner. her or client the bother would gain weight moderate if Ask (179). age people as increase usual the be may gain weight the of Some •
gain. weight control can sometimes exercise and dieting
(22, more much gained have adolescents, overweight particularly
signi no have or weight •
bleeding Heavy •
NET
DMPA, for months 3 least off—at wears injection the until continue may and stopped be cannot changes bleeding injection, an After •
stop. injections after returns eventually bleeding Monthly • her affect would injectable an to due changes how and her to is bleeding monthly regular important how client each with Discuss
pregnant. is she that or infertile is woman a that mean not does bleeding monthly no Having • ( bleeding monthly no having like Others important. very bleeding monthly regular consider
injectable an to due changes Bleeding • illness. of sign a not and harmful not are
DMPA for than shorter
DMPA with likely more
ing. NET •
At DMPA: •
method backup a need will she bleeding, monthly her of 7 day
(see pregnant not is she sure reasonably be can provider if bleeding monthly next her during return to woman the ask to need No
method backup a using discuss late, return may client the If •
remember. to easy and convenient be will injections for clinic the to returning whether Discuss • DMPA Initiate to Want Who Clients Screening
injection. have still and late weeks 2 or early weeks 2 to up come Can •
year). a times (6 months 2 Every NET-EN: year). a times (4 months 3 Every DMPA: •
the in women 100 per pregnancy 1 than Less •
the in women 100 per pregnancies 3 about Typically, •
injectables. than other methods stopping
DMPA stopping after pregnant become to average on longer months 4 take Women •
harmful. not and common is gain weight Gradual harmful. not is This
at bleeding irregular or frequent have women Most •
injection. next the for time on be to try to
DMPA for months 3 every injection an have Women •
methods. contraceptive effective most the of One •
Contraceptives Injectable of Choice Well-Informed a Make Clients Helping 2. Table
injection rst fi
information this women Give POINTS:
guidance Counseling
change Weight
guidance Counseling
well not are who women than them using continue to likely more are injectables start they when
changes Bleeding
occur. concern and surprise avoid clients helps bleeding, monthly in changes especially effects side if effects, side on information honest and Clear
common are gain weight and bleeding monthly in Changes Effects: Side
have
immediately can women Many
injections for
guidance Counseling return to often How
time on injections having on Depends Effectiveness: Effectiveness
injectables about
choice informed an
make to information
this need Women
KEY
with women help to information decision their offers table This situation. current and preferences, needs, her suits method the if decide woman
a helps also Counseling used. is it how knows and safety, its of assured is effects, side and effectiveness its understands injectable an in interested woman a that ensure programs safety and effects, side Effectiveness,
them interests that mind in method a have already women most services, planning family
3
205402_JHU-InfoReport.indd 3 12/12/06 10:14:41 PM
9
140
≥
7
).
older, older,
212
13).
–
breastfeedinga
n.
the heart, blood vessels, vessels, blood heart, the
pregnant as before. as pregnant
).
8
eastfeeding should not use use not should eastfeeding
216
and others. and
bosis. A A woman bosis.
90), migraine headache with aura, with headache migraine 90),
≥
ables less than 3 weeks after giving birth. giving after weeks 3 than less ables
Combined Injectables Combined
arily or for reasons that lack a basis in in basis a lack that reasons for or arily
term studies of combined injectables are are injectables combined of studies term
-
ts and risks are similar to those of combined combined of those to similar are risks and ts fi
).
re over 40 years old, or have HIV/AIDS ( HIV/AIDS have or old, years 40 over re
130
handbook of family planning. family of handbook
oral contraceptives. For more information, consult a a consult information, more For contraceptives. oral
bene
limited, but most researchers expect that health health that expect researchers most but limited,
Long
combined inject combined
injectables. Women not br not Women injectables.
baby less than 6 months old should not use combined combined use not should old months 6 than less baby
current deep vein throm vein deep current
orliver and attack heart or stroke of history including
older, and certain conditions of conditions certain and older,
history of breast cancer, heavy smoking smoking and age 35 or heavy cancer, breast of history
migraine headache without aura and age 35 or or 35 age and aura without migraine headache mm Hg or diastolic diastolic or Hg mm
injectable if they have high blood pressure (systolic (systolic pressure blood high have they if injectable
Women usually should not start using a combined combined a using start not should usually Women
combined methods (12, (12, methods combined
• Little evidence available but not a concern with concern a not but available evidence Little •
methods other than injectables (153). injectables than other methods
• On average 1 month longer than for women who used used who women for than longer month 1 average On •
, “Expanding Services for Injectables.” for Services “Expanding ,
).
is not pregnant (see Checklist, p. 6, questions 8 questions 6, p. Checklist, (see pregnant not is
212
deep deep
).
6
). • Headache,221). 167, (153, tenderness breast dizziness,
.
25
term users (57, (57, users term
202
-
ng or spotting episodes in 3 months; infrequent bleeding is fewer than 2 bleeding bleeding 2 than fewer is bleeding infrequent months; 3 in episodes spotting or ng
216)
riosis are reported for subcutaneous DMPA (37,170). (37,170). DMPA subcutaneous for reported are riosis
han han
, 64). ,
.
Population Reports Population
ts
10
term and long and term
-
on issue of of issue on
.
1
more than 4 bleedi 4 than more
and pain of sickle cell crises (43). crises cell sickle of pain and
after stopping NET-EN and combined injectables. combined and NET-EN stopping after
Population Repor Population
ciency anemia (73, 222). (73, anemia ciency fi
.
s
de
). Little evidence available. evidence Little ).
-
bleeding is is bleeding
ammatory disease ( disease ammatory fl
15
only injectable if they have very high blood blood high very have they if injectable only
49 ( 49
Population Reports Population
-
–
thdrawal. Tell her that spermicides and withdrawal are the least effective contraceptives. If possible, give her condoms. her give possible, If contraceptives. effective least the are withdrawal and spermicides that her Tell thdrawal.
s; frequent frequent s;
ts, only reduced symptoms of endomet of symptoms reduced only ts, fi
100), history of breast cancer, unexplained vaginal vaginal unexplained cancer, breast of history 100),
Only Injectables Only -
≥
).
). These are averages so a woman should not be be not should woman a so averages are These ).
otect against iron against otect
broids (106). broids
fi
212
, DMPA reduces the frequency the reduces DMPA ,
lying medical condition (until diagnosed), and certain conditions conditions certain and diagnosed), (until condition medical lying
Progestin
16, 17, 219 17, 16,
, 171, 171, ,
start using a progestin a using start
130
EN may help pr help may EN
). Providers can use a checklist to be reasonably sure that a woman woman a that sure reasonably be to checklist a use can Providers ).
-
T
160 mm Hg or diastolic diastolic or Hg mm 160
215
≥
he eye, often before a migraine headache begin headache migraine a before often eye, he
with sickle cell disease disease cell sickle with
only injectables (see Checklist, pp. 5–6). 5–6). pp. Checklist, (see injectables only
-
Managers and Providers, p. 22 in the companion issue of of issue companion the in 22 p. Providers, and Managers
EN: May have no effect on women age 40 age women on effect no have May EN:
EN: On average 1 month longer than for women using methods other than injectables ( injectables than other methods using women for than longer month 1 average On EN:
-
-
ted times; prolonged bleeding is longer than 8 day 8 than longer is bleeding prolonged times; ted
• Both DMPA and NE and DMPA Both •
intercourse, and pelvic pain and tenderness (37, 170, 199). 170, (37, tenderness and pain pelvic and intercourse,
• For women with endometriosis, DMPA reduces pain during menstrual periods, pain during during pain periods, menstrual during pain reduces DMPA endometriosis, with women For •
• For women For •
• DMPA may help protect against symptomatic pelvic in pelvic symptomatic against protect help may DMPA •
• DMPA helps protect against uterine uterine against protect helps DMPA •
• Do not prevent transmission of STIs, including HIV. Women at risk for STIs should also use condoms to prevent STI transmissio STI prevent to condoms use also should STIs for risk at Women HIV. including STIs, of transmission prevent not Do •
• DMPA helps protect against cancer of the lining of the uterus (endometrial cancer) ( cancer) (endometrial uterus the of lining the of cancer against protect helps DMPA •
• Help the woman decide if she might be at risk of STIs. If she might be at risk, help her decide how she will protect herself herself protect will she how decide her help risk, at be might she If STIs. of risk at be might she if decide woman the Help •
• None necessary ( necessary None •
progestin
vein thrombosis. Also, a woman breastfeeding a baby less than 6 weeks old should not use use not should old weeks 6 than less baby a breastfeeding woman a Also, thrombosis. vein bleeding that suggests an under an suggests that bleeding
of the heart, blood vessels, or liver including history of stroke or heart attack and current and attack heart or stroke of history including liver or vessels, blood heart, the of pressure (systolic (systolic pressure
Women usually should not should usually Women
• Programs need to decide if providers should mention loss of bone density with DMPA. with density bone of loss mention should providers if decide to need Programs •
• NET •
• Tell women that these may occur but are not common. common. not are but occur may these that women Tell •
• DMPA: Small loss of bone density during use. Usually regained after use stops ( stops use after regained Usually use. during density bone of loss Small DMPA: •
• Headache, dizziness, abdominal discomfort, mood changes, less sex drive (174, (174, drive sex less changes, mood discomfort, abdominal dizziness, Headache, • • Injectables do not cause permanent infertility or spontaneous abortions. spontaneous or infertility permanent cause not do Injectables •
• It may take a few months after a woman stops using DMPA, but monthly bleeding eventually returns, and she will be able to get to able be will she and returns, eventually bleeding monthly but DMPA, using stops woman a after months few a take may It •
• The length of the delay in becoming pregnant is the same for short for same the is pregnant becoming in delay the of length The •
• NET • would have been given ( given been have would
worried if she has not become pregnant after 12 months. 12 after pregnant become not has she if worried injectables—10 months from the last injection, or 7 months from when the next injection injection next the when from months 7 or injection, last the from months injectables—10
• DMPA: On average 4 months longer than for women who used methods methods used who women for than longer months 4 average On other• DMPA: t
5
ts: Injectables help protect against some health conditions health some against protect help Injectables ts: fi
should try to give each client the family planning method she wants and to avoid denying women their choice of a method arbitr method a of choice their women denying avoid to and wants she method planning family the client each give to try should
8
Consult a a Consult
infections (STIs) infections
Sexually transmitted transmitted Sexually
Health Bene Health Counseling guidance Counseling
Tests
less safe less
make use of injectables injectables of use make
conditions that may that conditions
on screening women for women screening on
handbook for guidance guidance for handbook
criteria:
Medical eligibility eligibility Medical
evidence. For example, women can safely use injectables even if they have not had children, are not married, are adolescents, a adolescents, are married, not are children, had not have they if even injectables use safely can women example, For evidence.
Programs
Safety: Injectables are safe for most women most for safe are Injectables Safety:
Counseling guidance Counseling
Bone density Bone
physical change: change: physical
Other possible possible Other
Counseling guidance Counseling
Other side effects side Other
Counseling guidance Counseling
become pregnant) become
(amongwho women stop injections to to injections stop
Return to fertility fertility to Return
See Table 3, Key Resources for Program for Resources Key 3, Table See t in vision lost of area bright a usually is aura An
Reported by at least 5% of users. of 5% least at by Reported compani the in 21 p. Injectables, About Answers and Questions see loss, bone about information more For of issue companion the in 21 p. Injectables, Use Can HIV/AIDS With Women box, See
Backup methods include abstinence, male and female condoms, spermicides, and wi and spermicides, condoms, female and male abstinence, include methods Backup unexpec at is bleeding Irregular
Includes intramuscular and subcutaneous injection of DMPA. Among health bene health Among DMPA. of injection subcutaneous and intramuscular Includes pregnant become to delay one-month the about know to need women whether decide can Programs
7 8 9
5 6
episodes in 3 months; heavy bleeding is twice the usual amount ( amount usual the twice is bleeding heavy months; 3 in episodes
2 3 4 1
Table 2 (continued) Table
4
2205402_JHU-InfoReport.indd05402_JHU-InfoReport.indd 4 112/12/062/12/06 110:14:450:14:45 PPMM a i r e t i r Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) C Research fi ndings have established that depot medroxyprogesterone acetate (DMPA) and norethisterone enantate (NET-EN) y
t are safe and eff ective for use by most women, including those who are at risk of sexually transmitted infections (STIs) i
l and those living with or at risk of HIV infection. For some women, DMPA and NET-EN are usually not recommended or are i contraindicated because of the presence of certain medical conditions such as liver tumors and breast cancer. b i
g This checklist (see next page) is designed for use by both clinical and nonclinical health care providers, including i
l community health workers, to help screen clients who were counseled about contraceptive options and made an
E informed decision to use DMPA. It consists of 13 questions designed to identify medical conditions that would prevent safe
l DMPA use or require further screening, as well as to provide further guidance and directions based on clients’ responses. a Clients who are ruled out because of their response to some of the medical eligibility or pregnancy questions may still c
i be good candidates for DMPA after the suspected condition is excluded through appropriate evaluation. The checklist is d based on recommendations by the World Health Organization in the Medical Eligibility Criteria for Contraceptive Use (212). e This checklist is part of a series of provider checklists developed by Family Health International (FHI), with support M from the U.S. Agency for International Development (USAID). The checklist is included in this issue of INFO Reports as a
O collaborative distribution service of the INFO Project. For more information, please visit www.fhi.org. H
W Assessing Medical Eligibility for DMPA women with blood pressure levels of 160/100 mm Hg or more
e should not initiate DMPA. 1. Have you ever had a stroke, blood clot in your legs or h t lungs, or heart attack? 6. Do you have bleeding between menstrual periods, which
e This question is intended to identify women with already is unusual for you, or bleeding after intercourse (sex)? s
u known serious vascular disease, not to determine whether This question is intended to identify women who may have women might have an undiagnosed condition. Women with s an underlying pathological condition. While DMPA use does r these conditions may be at somewhat increased risk of blood not make these conditions worse, it may change the bleeding e clots if they use DMPA. Women who have had any of these pattern and mask a serious underlying condition. Unusual d i conditions will commonly have been told that they have had bleeding changes may indicate pregnancy or tumor that should v this condition and will answer “yes,” if appropriate. be evaluated soon or treated by a higher-level health care o
r provider. DMPA use should be delayed until the condition can be
p 2. Have you ever been told you have breast cancer? evaluated. In contrast, women for whom it is not unusual to have
p This question is intended to identify women who know they heavy or prolonged bleeding, or irregular bleeding patterns, may l have had or currently have breast cancer. These women are e safely initiate DMPA use.
h not good candidates for DMPA because breast cancer is a hormone-sensitive tumor, and DMPA use may adversely 7. Are you currently breastfeeding a baby less than six o
t affect the course of the disease. weeks old? l This question is included because of the theoretical concern a 3. Do you have a serious liver disease or jaundice (yellow that hormones in breastmilk can have an adverse effect on a n skin or eyes)?
o newborn during the fi rst six weeks after birth. A breastfeeding i
t This question is intended to identify women who know that woman can initiate DMPA six weeks after her baby is born.
a they currently have a serious liver disease and to distinguish
n between current severe liver disease (such as severe cirrhosis Note: Clients with multiple risk factors for cardiovascular disease r (e.g., a combination of older age, smoking, and diabetes even without e or liver tumors) and past liver problems (such as treated t hepatitis). Women with serious liver disease should not complications) generally are not good candidates for DMPA. n I generally use DMPA because it is processed by the liver Determining Current Pregnancy
h and hence its use may adversely affect women whose liver t Questions 8–13 of the checklist are intended to help a provider l function is already weakened by the disease.
a determine, with reasonable certainty, whether a client is not e 4. Have you ever been told you have diabetes (high sugar pregnant. If a client answers “yes” to any of these questions and
H in your blood)? there are no signs or symptoms of pregnancy, it is highly likely
y This question is intended to identify women who know that that she is not pregnant. The client can start DMPA now. l i they have diabetes, not to assess whether they may have an If the client is within 7 days of the start of her menstrual bleeding,
m undiagnosed condition. Women who have had diabetes for she can start the method immediately. No back-up method is needed.
a 20 years or longer or those with vascular complications should
F generally not use DMPA because of the increased risk of blood If it has been more than 7 days since her fi rst day of bleeding, clots. Evaluate or refer for evaluation as appropriate and, if she can start DMPA immediately but must use a back-up m these complications are absent, the woman may still be a good method (i.e., using a condom or abstaining from sex) for 7 days o
r candidate for DMPA. to ensure adequate time for the DMPA to become effective. f
l 5. Have you ever been told you have high blood pressure? If you cannot determine with reasonable certainty that your o client is not pregnant (using the checklist) and if you do not
o This question is intended to identify women who may have
t have access to a pregnancy test, then she needs to wait until high blood pressure. These women should be evaluated or her next menstrual period begins before starting DMPA. She
A referred for evaluation as appropriate. Based on evaluation, should be given condoms to use in the meantime.
5
2205402_JHU-InfoReport.indd05402_JHU-InfoReport.indd 5 112/12/062/12/06 110:53:040:53:04 AAMM Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN) To determine if the client is medically eligible to use DMPA, ask questions 1–7. As soon as the client answers YES to any question, stop, and follow the instructions below.
NO 1. Have you ever had a stroke, blood clot in your legs or lungs, or heart attack? YES
NO 2. Have you ever been told you have breast cancer? YES
NO 3. Do you have a serious liver disease or jaundice (yellow skin or eyes)? YES
NO 4. Have you ever been told you have diabetes (high sugar in your blood)? YES
NO 5. Have you ever been told you have high blood pressure? YES
Do you have bleeding between menstrual periods, which is unusual for you, or NO 6. YES bleeding after intercourse (sex)?
NO 7. Are you currently breastfeeding a baby less than 6 weeks old? YES
If the client answered YES to any of questions 1Ð3, she is not a good candidate for DMPA. Counsel about other available methods or refer. If the client answered NO If the client answered YES to any of questions 4Ð6, DMPA cannot be initiated to all of questions 1Ð7, without further evaluation. Evaluate or refer as appropriate, and give condoms to the client can use DMPA. use in the meantime. See explanations on p. 5 for more instructions. Proceed to questions 8–13. If the client answered YES to question 7, instruct her to return for DMPA as soon as possible after the baby is six weeks old.
Ask questions 8–13 to be reasonably sure that the client is not pregnant. As soon as the client answers YES to any question, stop, and follow the instructions below.
YES 8. Did your last menstrual period start within the past 7 days? NO
Did you have a baby less than 6 months ago, are you fully or nearly-fully YES 9. NO breastfeeding, and have you had no menstrual period since then? Have you abstained from sexual intercourse since your last menstrual period or YES 10. NO delivery?
YES 11. Have you had a baby in the last 4 weeks? NO
YES 12. Have you had a miscarriage or abortion in the last 7 days? NO
YES 13. Have you been using a reliable contraceptive method consistently and correctly? NO
If the client answered YES to at least one of questions 8Ð13 and she is free of signs or symptoms of pregnancy, you can be reasonably sure If the client answered NO to all of that she is not pregnant. The client can start DMPA now. questions 8Ð13, pregnancy cannot be ruled out. If the client began her last menstrual period within the past 7 days, she can start DMPA immediately. No additional contraceptive She must use a pregnancy test or wait protection is needed. until her next menstrual period to be given DMPA. If the client began her last menstrual period more than 7 days ago, she can be given DMPA now, but instruct her that she must Give her condoms to use in the use condoms or abstain from sex for the next 7 days. Give her meantime. condoms to use for the next 7 days.
© 2006 6
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7
205402_JHU-InfoReport.indd 7 12/12/06 10:53:07 AM Sources
This bibliography includes citations to the materials 83. INTERNATIONAL PLANNED PARENTHOOD most helpful in the preparation of this report. In the FEDERATION (IPPF). Directory of hormonal text, reference numbers for these citations appear in contraceptives.
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