Injectable contraception Flashcards
When may injectable contraceptives not be suitable?
- Cardiovascular or cerebrovascular disease
- Significant multiple risk factors for arterial cardiovascular disease
- Current or recent breast cancer
- Severe decompensating cirrhosis or liver tumours
- Unexplained vaginal bleeding
- A high risk of developing osteoporosis
What is the MOA of DMPA?
- Inhibits ovulation
- Alters cervical mucus, preventing sperm penetration
- Prevent implantation by inducing endometrial atrophy
- Modifies sperm function and motility
What is the efficacy of the Injectables?
Fewer than 4 women become pregnant out of every 1000 over a 2 year period.
With imperfect use the typical failure rate is 4 in 100 women over 1 year.
How often are the injectables given?
Depo-provera = 12 weeks
Sayana Press = 13 weeks
Noristerat = 8 weeks
What are the advantages of the injectables?
- Effective and discreet method
- Sayana Press can be self administered
- If pregnancy was to occur during DMPA use, no evidence of harm to the pregnancy or fetus
- Non-intercourse related contraceptive method
- Very safe with no reported attributable deaths
- Safe for breastfeeding mothers
- Can be used in sickle cell disease with possible reduction in sickle crisis pain
- Helpful for women with ovulation pain
- Can be used for treatment of HMB and pain associated with endometriosis
- Protection against PID, extra-uterine pregnancies, functional ovarian cysts, fibroid formation
- May reduce risk of ovarian and endometrial cancer
- Minimal metabolic effects occur
What are the disadvantages of the injectables?
- Need to return for subsequent injections
- Irregular, prolonged vaginal bleeding
- Weight gain in about one-third of women
- Mood changes, headaches, loss of libido, bloating, breast tenderness - although no causal association has been found
- Can cause short delay in return to normal fertility
- Small increase in risk of breast cancer
- Possible increased in risk of cervical cancer
- Cannot be removed if side-effects occur
- Injection site reactions can occur
- Small reduction in bone mineral density
Are injectables effected by enzyme inducers?
No
There is no evidence that enzyme inducers affect the efficacy of DMPA
Which EC should you avoid giving DMPA with?
Ulipristal acetate
If Ulipristal acetate given for EC, DMPA should not be administered for 5 days. Additional contraceptive precautions should be used for these 5 days and for the next 7 days after the injection has been given.
What to advise if 14 weeks or more has lapsed since the last injection?
- If within 14 weeks of receiving her late injection then the next injection is administered and no further action needs to be taken
- If >14 weeks since last injection, but no unprotected sex has occurred from 14 weeks onwards, the next injection is given and additional contraception or abstinence advised for the next 7 days
- If > 14 weeks since last injection and UPSI has only occurred in the last 5 days, exclude the risk of pregnancy, consider EC, give the next injection and advise additional contraception or abstinence for the next 7 days. Repeat UPT in 3/52.
When are additional contraceptive precautions not required for 7 days when starting injectables?
- Up to and including D5 of natural menstrual cycle
- Before and including day 21 following childbirth
- Within 5 days following abortion, miscarriage, ectopic pregnancy or gestational trophoblastic disease
- Switching from a CHC, D1-2 of HFI or week 2-3 of CHC
- Anytime switching from only progestogen-only anovulatory methods
- Switching from IUD, up to and including day 5 of cycle
How long is the delay of return to fertility from the injectables?
- Mean time to ovulation being 5.3 months after the preceding injection
- Fertility rates by 2 years are similar to those discontinuing non-hormonal contraceptive methods
How to manage prolonged and frequent bleeding with injectables?
- Exclude gynaecological pathology
- Perform pelvic examination if irregular bleeding has occurred for more than 3 months, other symptoms present, previous medical treatment has failed or woman is anxious
- Exclude pregnancy
- Perform STI screening
- Review cervical screening
What treatment can you offer for prolonged and frequent bleeding with injectables?
- COC for up to 3 months cyclically or continuously if there are no CIs
- Tranexamic acid 250mg QDS for 5 days
- Mefenamic acid 500mg TDS for up to 5 days
- Reduce injection interval by 2 weeks if bleeding occurs towards the end of the injection cycle
How should you counsel about weight gain with DMPA?
- Advise women that 2/3 women do not gain weight with DMPA
- More likely to occur in women with a previous history of labile weight changes
- Keep to healthy Mediterranean diet
- Women who gain more than 5% of their baseline body weight in the first 6 months are likely to continue to gain weight
A 24 year old woman has been using DMPA for 3 years. She wants a baby and stopped having DMPA injections 18 months ago but has still not had a period. What should you do?
1) As it has been 12 months since her last injection, check other causes for secondary amenorrhoea including undertaking blood tests to check FSH, LH, oestradiol, thyroid function tests, prolactin
2) Check her BMI
3) Perform a pregnancy test
4) If all investigations are normal refer her to a gynaecologist who specialized in fertility issues because she may need ovulation induction
