Tables

Table 1. Formulation, Injection Schedule, and Availability of Injectable Contraceptives
Table 2. Knowledge and Current Use of Injectable Contraceptives Among Married Women of Reproductive Age, Survey Findings, 1984–1994
Table 3. Progestin-Only Injectables: When to Give the Injection
Table 4. Investigating Injectables: Study Findings
Table 5. Menstrual Patterns Among Users of Injectable Contraceptives, WHO Multicenter Studies, 1983–1988
Table 6. Risk of Various Cancers and Use of DMPA

Table 1. Formulation, Injection Schedule, and Availability of Injectable Contraceptives
Formulation Developer Brand Name/
Manufacturer		 Injection Schedule Availability
Progestin only: 150 mg depot medroxyprogesterone acetate (DMPA) The Upjohn Company Depo-Provera/Upjohn
Megestron/Organon		 Every 3 months, 12 weeks, or 90 days Registered in over 100 countries; available in both public and private sectors.
Progestin-only: 200 mg norethindrone (norethisterone) enanthate (NET EN) Schering AG Noristerata/Schering AG
Doryxus/Richter Gedeon Ltd.		 Every 2 monthsb Registered in over 60 countries; available in both public and private sectors.
Progestin + estrogen: 25 mg DMPA + 5 mg estradiol cypionate Upjohn, WHO Cyclofem/Aplicaciónes Farmaceuticas (Mexico); Upjohn (US)
Cyclo Geston/PT Tunggal, PT Triyasa Nagamas Farma (Indonesia)		 Every month Registered in Guatemala, Indonesia, Mexico, Peru, and Thailand
Progestin + estrogen: 50 mg NET EN + 5 mg estradiol valerate WHO Mesigyna/Schering AG Every month Registered in Argentina, Brazil, and Mexico
Progestin + estrogen: 150 mg dihydroxyprogesterone acetophenide + 10 mg estradiol enanthate


Half-dose: 75 mg dihydroxyprogesterone acetophenide + 5 mg estradiol enanthate		 Squibb Pharmaceutical Company Perlutan, Topasel, Agurin, Horprotal, Uno-Ciclo/Various manufacturers in Latin America

Anafertin, Yectames/Various manufacturers in Latin America		 Every month





Every month		 Available in pharmacies in many Latin American countries ans Spain; generally not available in public family planning programs.
Progestin + estrogen: 250 mg 17a-hydroxyprogesterone caproate + 5 mg estradiol valerate Chinese researchers; Squibb Pharmaceutical Company Chinese Injectable No. 1 Every month; 2 injections in first month China
a Called Norigest in Pakistan
b Alternative schedule: every 2 months for 6 months and then every 3 months
Sources: Warner-Rowe (318), WHO 1990 (333), WHO 1993 (331)

Return to Chapter 1.4


Table 2.
Knowledge and Current Use of Injectable Contraceptives Among Married Women of Reproductive Age, Survey Findings, 1984–1994
Region, Country
& Year of Survey		 % Aware of % Currently Using % of Contraceptive Users Who Use Injectables
Any Modern Method Injectables Any Modern Method Injectables
AFRICA
Botswana 1988 96 91 33 6 18
Burkina Faso 1993 63 41 4 <1 <25
Burundi 1987 65 58 1 1 100
Cameroon 1991 63 40 4 0 0
Ghana 1988 77 48 4 0 0
Kenya 1993 97 93 27 7 26
Liberia 1986 68 43 5 0 0
Madagascar 1992 62 48 5 2 40
Malawi 1992 92 68 7 2 29
Mali 1987 30 18 1 0 0
Mauritius 1991 100 94 49 4 8
Namibia 1992 90 85 26 8 31
Niger 1992 58 39 2 1 50
Nigeria 1990 42 34 4 1 25
Senegal 1992-93 70 34 5 <1* <20
South Africa 1987-89 NA NA 56 23 41
   Black NA NA 49 27 55
   White NA NA 79 3 4
Sudan 1989-90 71 46 6 0 0
Swaziland 1988 NA 75 17 4 24
Tanzania 1991-92 72 40 7 0 0
Togo 1988 82 61 3 0 0
Uganda 1988-89 79 41 3 0 0
Zambia 1992 87 38 9 0 0
Zimbabwe 1994 99 87 42 3 7
ASIA & PACIFIC
Bangladesh 1993-94 100 97 36 5 14
China 1988 NA NA 71 <1 <1
India 1992-93 96 19 36 0 0
Indonesia 1994 96 91 52 15 29
Nepal 1991 93 65 24 2 8
Pakistan 1990-91 77 62 9 1 11
Philippines 1993 97 54 25 <1 <4
Sri Lanka 1987 99 85 41 3 7
Thailand 1991 NA NA 69 12 18
Vietnam 1994 NA NA 65 <1 <1
LATIN AMERICA & CARIBBEAN
Belize 1991 NA 86 42 4 10
Bolivia 1989 69 44 13 1 8
Brazil 1986 100 58 57 1 2
   Northeast 1991 100 85 54 <1 <2
Colombia 1990 100 92 55 2 4
Costa Rica 1986 NA 90 58 1 2
Dominican Rep. 1991 100 57 52 0 0
Ecuador 1989 92 72 42 0 0
El Salvador 1988 NA 81 44 1 2
Guatemala 1987 72 46 19 1 5
Haiti 1989 NA 61 9 2 20
Jamaica 1993 NA NA 58 6 10
Mexico 1987 93 87 46 3 7
Panama 1984 NA 86 53 1 2
Paraguay 1990 98 89 35 5 14
Peru 1991-92 95 82 33 2 6
Trinidad & Tobago 1987 99 80 46 1 2
NEAR EAST & NORTH AFRICA
Egypt 1992 100 82 45 <1 <2
Jordan 1990 99 51 27 0 0
Morocco 1992 99 63 36 0 0
Tunisia 1988 99 60 41 1 2
Turkey 1993 99 39 35 <1 <1
Yemen 1991-92 53 32 6 1 17
* Includes Norplant
NA = Not available
Sources : Robey et al. 1992 (268) except: El-Zanaty et al. 1993 (73) (Egypt) ; Ferraz et al. 1992 (82) (Brazil) ; IIPS 1994 (135) (India); Indonesia et al. 1994 (131) ; Katjiuanjo et al. 1993 (153) (Nambia) ; Kenya & DHS 1994 (156) ; Knodel 1995 (163) (Thaïland, Vietnam) ; Konaté et al. 1994 (170) (Burkina Faso); McFarlane et al. 1994 (202) (Jamaica); Malawi & DHS 1994 (191) ; Mostert 1990 (213) (South Africa); Ndiaye et al. 1994 (219) (Senegal); Niport et al. 1994 (218) (Bangladesh); NIV 1992 (220) (Nepal); Philippines & DHS 1994 (249); Refero et al. 1994 (266) (Madagascar); Turkey & DHS 1994 (310); Zimbabwe CSO & DHS 1995 (358)

Return to Chapter 2 First Reference | Second Reference


Table 3. Progestin-Only Injectables: When to Give the Injection
QuestionRecommendation
When can the first injection be given? Any time the provider can be reasonably sure that a woman is not pregnanta—for example, during any of the 7 days that begin with the onset of menses (days 1 through 7 of the menstrual cycle).

Use of backup methods: For a woman having menstrual cycles, no backup method is needed if she is in the first 7 days of her menstrual cycle and is still menstruating. If she is in the first 7 days of her cycle but is not menstruating, some programs may recommend use of a backup method for 1 week. If injections are started after day 7 of a regular cycle, a backup method (or abstinence) for up to 1 week may be recommended.
Postpartum: When can the first injection be given? For breastfeeding women: If she does not rely on the Lactational Amenorrhea Method (LAM) or another nonhormonal method, ideally wait until 6 weeks postpartum. If the woman relies on LAM, she can start DMPA or NET EN when her menses return, or when she is no longer fully or nearly fully breastfeeding, or at 6 months postpartum, whichever comes first.
For women who are not breastfeeding: The first DMPA or NET EN injection can be given immediately postpartum or whenever the provider can be reasonably sure that the woman is not pregnant.a
After spontaneous or induced abortion: When can the first injection be given? Within the next 7 days, because fertility returns almost immediately.
Where should the injection be given? Into the muscle of the arm or the buttock. The choice is best left to the client.
Grace period: How late or early can users come for subsequent injections? DMPA: Up to 2 weeks late and possibly up to 4 weeks late depending on the population. Up to 4 weeks early although not ideal.
NET ENb: Up to 1 week late and possibly up to 2 weeks late depending on the population. Up to 2 weeks early although not ideal.
Monthly injections: Up to 3 days late and up to 3 days early.
If a woman returns after the grace period, she can receive the injection if the provider is reasonably sure that she is not pregnant.a If she may be pregnant, she should use a barrier method until it is clear whether or not she is pregnant.
Cumulative effect? Does a woman have to stop using injectables at any point to give her body a rest? No. There is no cumulative effect of injectables, and extended amenorrhea is not a medical problem. It may be an advantage in areas where anemia is common. Counseling can reassure the user who is worried about amenorrhea.
a










b		 A provider can be reasonably sure that a woman is not pregnant if she has no symptoms or signs of pregnancy and she:
  • has not had intercourse since her last normal menses; or
  • has been correctly and consistently using a reliable contraceptive; or
  • is within the first 7 days after normal menses; or
  • is within 4 weeks postpartum (for nonlactating women); or
  • is within the first 7 days postabortion; or
  • is fully breastfeeding, amenorrheic, and less than 6 months postpartum.
    If available, a pregnancy test may be helpful, but it is not required.
    2-month schedule
    • Source: Technical Guidance Working Group 1994 (299)

    Return to Chapter 3.1 | Return to Chapter 4.4


    Table 4. Investigating Injectables: Study Findings
      DMPA and NET EN Monthly Injectables
    Findings Ref. Nos. Findings Ref. Nos.
    Blood pressure Most studies find no effect. 75, 122, 129, 276, 338 No significant effects 108, 271, 336
    Blood coagulation Most studies find no effect. 77, 122, 123, 124, 201, 208, 209, 309 No significant effects 86, 94, 208, 271, 331
    Cholesterol Most studies find higher levels of low-density lipoprotein (LDL) cholesterol and lower levels of high-density lipoprotein (HDL) cholesterol.a 6, 75, 77, 78, 122, 158, 200, 334 Most studies find no significant effects on total, LDL, or HDL cholesterol. 86, 94, 108, 331
    Carbohydrate metabolism Do not induce diabetes in normal women but may significantly increase glucose and insulin levels. 7, 47, 76, 105, 122, 184 No significant effects 86, 94, 108, 331
    Liver function Most studies find no effect.b 7, 47, 276, 280 No significant effects 108
    Lactation Increase or no effect on milk volume.
    No effect or possibly beneficial effect on quality of breast milk.c
    Lengthening or no effect on duration of lactation.d
    No effect on nursing infants.e    		 126, 165, 197, 329
    52, 56, 72, 197, 329
    42, 143, 279, 347, 354, 356
    61, 126, 143, 152, 168, 237, 279, 347, 348    		 Not studied. (With combined oral contraceptives, the estrogen component decreases the quantity and quality of breast milk (329).)  
    a
    b
    c
    d


    e    		 Three studies find no changes in LDL or HDL cholesterol (93, 122, 300).
    One study of DMPA reported a possible enhancing effect through induction of liver enzymes (79).
    Measured by fat concentration, calories, minerals, protein, lactose, and immunoglobulin.
    One review concluded that DMPA and Norplant implants had little effect on women whose breastfeeding was partial or token but shortened the duration of breastfeeding among women who practiced full breastfeeding (175).
    Nursing infants ingest a small amount of hormone if their mothers use injectables—up to 10 mg of DMPA or 2 mg of NET EN per day (56). Studies have examined children's weight, height, movement, skills and general health from ages 1 to 15 years.

    Return to Chapter 4 | Return to Chapter 4.2


    Table 5. Menstrual Patterns Among Users of Injectable Contraceptives, WHO Multicenter Studies, 1983–1988
    Type of Injectable or Untreated Months Number of Diaries % Experiencing Bleeding Patterns
    Regular Patterns Amenorrhea Infrequent Bleeding Irregular Bleeding Frequent Bleeding Prolonged Bleeding Total Variations from Regular Patternsa
    DMPA 0-3
    4-6
    7-9
    10-12    		 509
    406
    311
    241    		 9.0
    6.9
    6.4
    8.3    		 10.6
    23.9
    37.0
    38.6    		 15.7
    25.8
    24.8
    27.8    		 46.0
    35.7
    27.7
    17.9    		 17.7
    10.5
    8.3
    6.6    		 43.4
    27.7
    17.3
    16.5    		 91.0
    93.1
    93.6
    91.7
    Cyclofem 0-3
    4-6
    7-9
    10-12    		 1,001
    885
    802
    730    		 43.0
    63.2
    61.3
    70.0    		 0.1
    0.2
    1.1
    2.3    		 0.1
    3.4
    5.4
    3.7    		 39.6
    23.5
    25.4
    13.6    		 22.3
    3.3
    2.8
    6.5    		 20.8
    13.3
    9.4
    10.1    		 57.0
    36.8
    38.7
    30.0
    Mesigyna 0-3
    4-6
    7-9
    10-12    		 1,000
    860
    766
    713    		 47.2
    62.8
    63.3
    68.4    		 0.2
    0.6
    1.3
    2.0    		 0.1
    2.2
    2.9
    5.0    		 34.6
    25.2
    24.8
    14.6    		 29.6
    5.5
    4.9
    6.2    		 16.2
    11.1
    12.6
    12.7    		 52.8
    37.2
    36.7
    31.6
    Untreatedb 0-3
    4-6
    7-9
    10-12    		 3,893
    3,893
    3,893
    3,893    		 90.3
    90.8
    90.1
    85.1    		 1.3
    1.5
    1.3
    1.6    		 3.4
    2.9
    2.8
    3.1    		 4.5
    5.8
    5.4
    8.6    		 0.2
    0.3
    0.1
    0.3    		 2.6
    2.3
    2.6
    4.3    		 9.7
    9.2
    9.9
    14.9
    Note: Patterns are defined for 90-day observation periods:
    Regular patterns—Three episodes of bleeding or spotting each lasting about five days.
    Amenorrhea—No bleeding
    Infrequent bleeding—Fewer than two bleeding or spotting episodes
    Frequent bleeding—More than four bleeding or spotting episodes
    Irregular bleeding—A pattern in which the difference between the longest and shortest bleeding-free intervals is more than 17 days.
    Prolonged bleeding—At least one bleeding or spotting episode lasting 10 days or more (30, 31, 331)
    A bleeding episode is defined as requiring the use of a pad or other protection. A spotting episode does not require protection. No comparable data for NET EN are available.
    a Some subjects appear in more than one category.
    b From Treloar et al. 1967 (308)
    Source: WHO 1993 (331)

    Return to Chapter 4.1 First Reference | Second Reference


    Table 6. Risk of Various Cancers and Use of DMPA
    Site of Cancera Ref. No. No. of Cases Who Used DMPA/All Cases No. of Controls Who Used DMPA/All Controls Relative Risk for Women Who Ever Used DMPA (95% Confidence Intervals)b Worldwide Incidence Among Women, 1985c
    Breast 719,000
       WHO Study 301 109/869 (13%) 1,452/11,890 (12%) 1.2 (0.96-1.52)  
       WHO +
       New Zealandd    		 284 219/1,768 (12%) 1,725/13,905 (12%) 1.1 (0.97-1.4)  
    Cervix
       Invasive 303 338/2,009 (17%) 1,415/9,583 (15%) 1.1 (0.96-1.29) 437,000
       In situ 304 168/727 (22%) 1,375/8,942 (15%) 1.25 (1.02-1.52)e  
    Endometrium 302 3/122 (2%) 84/939 (9%) 0.2 (0.1-0.8) 140,000
    Ovary 291 22/224 (10%) 229/1,781 (13%) 1.1 (0.6-1.8) 162,000
    Liverf 101,000
       Kenya 269 4/22 (18%) 12/142 (9%) 1.64 (0.4-6.6)  
       Thailand 269 4/492 (8%) 65/388 (17%) 0.33 (0.1-1.0)  
    a


    b



    c
    d
    e
    f    		 WHO study data for breast and invasive cervical cancer come from Kenya, Mexico, and Thailand; for cervical carcinoma in situ and ovarian cancer, from Mexico and Thailand; for endometrial cancer, from Thailand.
    Relative risk is statistically significant if range of 95% confidence interval does not include 1.0 . Among relative risks reported here, relative risk of cervical carcinoma in situ is significantly increased, while risk of endometrial cancer is significantly decreased (protective effect). All others are not significant.
    Source: Parkin et al. 1993 (239)
    Pooled data from WHO and New Zealand studies (243)
    Women with symptoms only. Relative risk statistically significant at p<.05.
    Results for Kenya and Thailand are presented separately because risk of liver cancer among DMPA users differed significantly between the two countries.

    Return to Chapter 5 | Return to Chapter 5.1
    Return to Chapter 5.2 | Return to Chapter 5.3


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