Table 2. Helping Clients Make a Well-Informed Choice of Injectable Contraceptives

	Injectable Contraceptives: Tools for Providers
December 2006 Issue No. 8	The INFO Project • Johns Hopkins Bloomberg School of Public Health • Center for Communication Programs • 111 Market Place, Suite 310 • Baltimore, Maryland 21202, USA • 410-659-6300 • 410-659-6266 (fax) • www.infoforhealth.org • infoproject@jhuccp.org

PDF version of the INFO Reports, December 2006, Number 8, Injectable Contraceptives: Tools for Providers

Table 2. Helping Clients Make a Well-Informed Choice of Injectable Contraceptives Effectiveness, side effects, and safety are the factors that women consider most important when they choose a contraceptive method (27, 55, 227). When they seek family planning services, most women already have a method in mind that interests them (198). Increasingly, that method is an injectable contraceptive. Good-quality programs ensure that a woman interested in an injectable understands its effectiveness and side effects, is assured of its safety, and knows how it is used. Counseling also helps a woman decide if the method suits her needs, preferences, and current situation. This table offers information to help women with their decision-making.

	Progestin-Only Injectables¹	Combined Injectables
KEY POINTS: Give women this information
Women need this information to make an informed choice about injectables	One of the most effective contraceptive methods. Women have an injection every 3 months for DMPA or every 2 months for NET-EN. Important to try to be on time for the next injection. Most women have frequent or irregular bleeding at first and then little or no monthly bleeding. This is not harmful. Gradual weight gain is common and not harmful. Women take 4 months longer on average to become pregnant after stopping DMPA than after stopping methods other than injectables.²	One of the most effective contraceptive methods. Women have an injection once a month. Important to try to be on time for the next injection. Likely to change bleeding patterns unpredictably during the first 3 months of use. This is not harmful. After 3 months most women have regular patterns (around 28 days from start of a monthly bleeding to the next).
Effectiveness: Depends on having injections on time
Effectiveness	Typically, about 3 pregnancies per 100 women in the first year of use if users do not return on time. Less than 1 pregnancy per 100 women in the first year of use (3 per 1,000 women) if users return on time (190).
How often to return for injections	DMPA: Every 3 months (4 times a year). NET-EN: Every 2 months (6 times a year). Can come up to 2 weeks early or 2 weeks late and still have injection.	Every month (12 times a year). Can come up to 7 days early or 7 days late and still have injection.
Counseling guidance	Discuss whether returning to the clinic for injections will be convenient and easy to remember. If the client may return late, discuss using a backup method³ or oral contraceptives or emergency contraceptive pills.
Many women can have first injection immediately	No need to ask the woman to return during her next monthly bleeding if provider can be reasonably sure she is not pregnant (see the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), questions 8–13. These questions also apply to combined injectables). If starting after day 7 of her monthly bleeding, she will need a backup method³ for the first 7 days after the injection.
Side Effects: Changes in monthly bleeding and weight gain are common
Clear and honest information on side effects, especially changes in monthly bleeding, helps clients avoid surprise and concern if side effects occur. Women who are well-informed when they start injectables are more likely to continue using them than women who are not well-informed (30, 75, 100).
Bleeding changes	DMPA: At first, irregular bleeding and prolonged bleeding, then no bleeding or infrequent bleeding.⁴ After 1 year 40%–60% of users have no monthly bleeding (7, 205). No monthly bleeding is more likely with DMPA than with NET-EN (48). NET-EN: Irregular and prolonged bleeding in the first 6 months, but bleeding episodes are shorter than for DMPA users. After 1 year about 30% of users have no monthly bleeding (202).	Irregular, frequent, or prolonged bleeding in first 3 months.⁴ Mostly regular bleeding patterns (around 28-day intervals) by 1 year. After 1 year about 2% of users have no monthly bleeding (205).
Counseling guidance	Discuss with each client how important regular monthly bleeding is to her and how changes due to an injectable would affect her daily life. Some women consider regular monthly bleeding very important. Others like having no monthly bleeding (62). Point out that: Bleeding changes due to an injectable are not harmful and not a sign of illness. Having no monthly bleeding does not mean that a woman is infertile or that she is pregnant. Monthly bleeding eventually returns after injections stop. After an injection, bleeding changes cannot be stopped and may continue until the injection wears off—at least 3 months for DMPA, 2 months for NET-EN, and 1 month for combined injectables. Heavy bleeding⁴ is not common but, if it happens, short-term treatment is available.
Weight change	Average gain of 1 to 2 kilograms (2 to 4 pounds) per year (87, 220). Some women, particularly overweight adolescents, have gained much more (22, 23). Some users lose weight or have no significant change in weight (40, 120, 188).	Average gain of 1 kilogram (2 pounds) per year (68). Some users lose weight or have no significant change in weight (67).
Counseling guidance	Some of the weight gain may be the usual increase as people age (179). Ask if moderate weight gain would bother the client or her partner. Appropriate dieting and exercise sometimes can control weight gain.
Return to fertility (among women who stop injections to become pregnant)	DMPA: On average 4 months longer than for women who used methods other than injectables—10 months from the last injection, or 7 months from when the next injection would have been given (130, 171, 212). These are averages so a woman should not be worried if she has not become pregnant after 12 months. NET-EN: On average 1 month longer than for women using methods other than injectables (212).	On average 1 month longer than for women who used methods other than injectables (153).
Counseling guidance	It may take a few months after a woman stops using DMPA, but monthly bleeding eventually returns, and she will be able to get pregnant as before. The length of the delay in becoming pregnant is the same for short-term and long-term users (57, 130). Injectables do not cause permanent infertility or spontaneous abortions.
Other side effects⁵	Headache, dizziness, abdominal discomfort, mood changes, less sex drive (174, 202).	Headache, dizziness, breast tenderness (153, 167, 221).
Counseling guidance	Tell women that these may occur but are not common.
Other possible physical change: Bone density	DMPA: Small loss of bone density during use. Usually regained after use stops (216). NET-EN: May have no effect on women age 40–49 (15). Little evidence available.	Little evidence available but not a concern with combined methods (12, 216).
Counseling guidance	Programs need to decide if providers should mention loss of bone density with DMPA.⁶
Safety: Injectables are safe for most women
Programs should try to give each client the family planning method she wants and to avoid denying women their choice of a method arbitrarily or for reasons that lack a basis in evidence. For example, women can safely use injectables even if they have not had children, are not married, are adolescents, are over 40 years old, or have HIV/AIDS (212).⁷
Medical eligibility criteria: Consult a handbook for guidance on screening women for conditions that may make use of injectables less safe⁸	Women usually should not start using a progestin-only injectable if they have very high blood pressure (systolic ≥160 mm Hg or diastolic ≥100), history of breast cancer, unexplained vaginal bleeding that suggests an underlying medical condition (until diagnosed), and certain conditions of the heart, blood vessels, or liver including history of stroke or heart attack and current deep vein thrombosis. Also, a woman breastfeeding a baby less than 6 weeks old should not use progestin-only injectables (see Checklist).	Women usually should not start using a combined injectable if they have high blood pressure (systolic ≥140 mm Hg or diastolic ≥90), migraine headache with aura,⁹ migraine headache without aura *and* age 35 or older, history of breast cancer, heavy smoking *and* age 35 or older, and certain conditions of the heart, blood vessels, or liver including history of stroke or heart attack and current deep vein thrombosis. A woman breastfeeding a baby less than 6 months old should not use combined injectables. Women not breastfeeding should not use combined injectables less than 3 weeks after giving birth.
Tests	None necessary (215). Providers can use a checklist to be reasonably sure that a woman is not pregnant (see Checklist, questions 8–13).
Sexually transmitted infections (STIs)	Do not prevent transmission of STIs, including HIV. Women at risk for STIs should also use condoms to prevent STI transmission.
Counseling guidance	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 and others.
Health Benefits: Injectables help protect against some health conditions
	DMPA helps protect against cancer of the lining of the uterus (endometrial cancer) (25). DMPA helps protect against uterine fibroids (106). DMPA may help protect against symptomatic pelvic inflammatory disease (10, 64). For women with sickle cell disease , DMPA reduces the frequency and pain of sickle cell crises (43). For women with endometriosis, DMPA reduces pain during menstrual periods, pain during intercourse, and pelvic pain and tenderness (37, 170, 199). Both DMPA and NET-EN may help protect against iron-deficiency anemia (73, 222).	Long-term studies of combined injectables are limited, but most researchers expect that health benefits and risks are similar to those of combined oral contraceptives. For more information, consult a handbook of family planning.⁸
¹Includes intramuscular and subcutaneous injection of DMPA. Among health benefits, only reduced symptoms of endometriosis are reported for subcutaneous DMPA (37, 170). ² Programs can decide whether women need to know about the one-month delay to become pregnant after stopping NET-EN and combined injectables. ³Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptives. If possible, give her condoms. ⁴Irregular bleeding is at unexpected times; prolonged bleeding is longer than 8 days; frequent bleeding is more than 4 bleeding or spotting episodes in 3 months; infrequent bleeding is fewer than 2 bleeding episodes in 3 months; heavy bleeding is twice the usual amount (16, 17, 219). ⁵Reported by at least 5% of users. ⁶For more information about bone loss, see Questions and Answers About Injectables, in the companion issue of Population Reports, "Expanding Services for Injectables." ⁷See box, Women With HIV/AIDS Can Use Injectables, in the companion issue of Population Reports. ⁸See Table 3, Key Resources for Program Managers and Providers, in the companion issue of Population Reports. ⁹An aura is usually a bright area of lost vision in the eye, often before a migraine headache begins.

Johns Hopkins Bloomberg School of Public Health: The INFO Project

Injectable Contraceptives: Tools for Providers