Injectable Contraceptives: Tools for Providers

• Injectable Contraceptives: Tools for Providers
• Table 2. Helping Clients Make a Well-Informed Choice of Injectable Contraceptives
• Table 3. Helping Clients Be Informed Users of Injectable Contraceptives
• Checklist for Giving Intramuscular Contraceptive Injections
• Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), part a
• Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), part b
• Sources
• Subscription and Ordering Information
• Credits

Assessing Medical Eligibility for DMPA

1. Have you ever had a stroke, blood clot in your legs or lungs, or heart attack?
   This question is intended to identify women with already known serious vascular disease, not to determine whether women might have an undiagnosed condition. Women with these conditions may be at somewhat increased risk of blood clots if they use DMPA. Women who have had any of these conditions will commonly have been told that they have had this condition and will answer "yes," if appropriate.
2. Have you ever been told you have breast cancer?
   This question is intended to identify women who know they have had or currently have breast cancer. These women are not good candidates for DMPA because breast cancer is a hormone-sensitive tumor, and DMPA use may adversely affect the course of the disease.
3. Do you have a serious liver disease or jaundice (yellow skin or eyes)?
   This question is intended to identify women who know that they currently have a serious liver disease and to distinguish between current severe liver disease (such as severe cirrhosis or liver tumors) and past liver problems (such as treated hepatitis). Women with serious liver disease should not generally use DMPA because it is processed by the liver and hence its use may adversely affect women whose liver function is already weakened by the disease.
4. Have you ever been told you have diabetes (high sugar in your blood)?
   This question is intended to identify women who know that they have diabetes, not to assess whether they may have an undiagnosed condition. Women who have had diabetes for 20 years or longer or those with vascular complications should generally not use DMPA because of the increased risk of blood clots. Evaluate or refer for evaluation as appropriate and, if these complications are absent, the woman may still be a good candidate for DMPA.
5. Have you ever been told you have high blood pressure?
   This question is intended to identify women who may have high blood pressure. These women should be evaluated or referred for evaluation as appropriate. Based on evaluation, women with blood pressure levels of 160/100 mm Hg or more should not initiate DMPA.

6. Do you have bleeding between menstrual periods, which is unusual for you, or bleeding after intercourse (sex)?
   This question is intended to identify women who may have an underlying pathological condition. While DMPA use does not make these conditions worse, it may change the bleeding pattern and mask a serious underlying condition. Unusual bleeding changes may indicate pregnancy or tumor that should be evaluated soon or treated by a higher-level health care provider. DMPA use should be delayed until the condition can be evaluated. In contrast, women for whom it is not unusual to have heavy or prolonged bleeding, or irregular bleeding patterns, may safely initiate DMPA use.
7. Are you currently breastfeeding a baby less than six weeks old?
   This question is included because of the theoretical concern that hormones in breastmilk can have an adverse effect on a newborn during the first six weeks after birth. A breastfeeding woman can initiate DMPA six weeks after her baby is born.
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   Note: Clients with multiple risk factors for cardiovascular disease (e.g., a combination of older age, smoking, and diabetes even without complications) generally are not good candidates for DMPA.

Determining Current Pregnancy

Questions 8–13 of the checklist are intended to help a provider determine, with reasonable certainty, whether a client is not pregnant. If a client answers "yes" to any of these questions and there are no signs or symptoms of pregnancy, it is highly likely that she is not pregnant. The client can start DMPA now.

If the client is within 7 days of the start of her menstrual bleeding, she can start the method immediately. No back-up method is needed.

If it has been more than 7 days since her first day of bleeding, she can start DMPA immediately but must use a back-up method (i.e., using a condom or abstaining from sex) for 7 days to ensure adequate time for the DMPA to become effective.

If you cannot determine with reasonable certainty that your client is not pregnant (using the checklist) and if you do not have access to a pregnancy test, then she needs to wait until her next menstrual period begins before starting DMPA. She should be given condoms to use in the meantime.