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8.0 Injectable Contraception

8.1 Methods

Injections containing hormone formulation are given periodically to women to prevent pregnancy.

Depot-medroxy progesterone acetate (DMPA)

This is the commonest type of injectable contraceptive. It is given in a dose of 150 mg intra-muscularly every three months. It is marketed as Depo-Provera in India. It can be prescribed in women where oestrogen is contraindicated.

Norethindrone Enanthate (NET-EN)

It is given in a dose of 200 mg intra-muscularly every 2 months. Currently, it is not available in India.

Combined Estrogen and Progestin (monthly Injections)

It is marked as cyclofem, cycloprovera or mesogyna. These are monthly injections containing 25mg depomedroxyprogesterone acetate and 5mg estradiol cypionate. These are yet not available in India.

8.2 Mechanism of action (DMPA)

blocks LH surge and therefore prevents ovulation

thickens cervical mucus

alters the endometrial receptivity for implantation

suppression of FSH is not intense, thus allowing follicular growth sufficient to produce estrogen levels comparable to early follicular phase of a normal menstrual cycle

8.3 When to start injectable contraceptive (DMPA)

after excluding pregnancy, injectable contraceptives can be started at any time of the menstrual cycle, preferably within first 5 days of menstrual bleeding when no back-up method is needed. If given later in the cycle a back-up method like condoms or spermicide should be used for at least the next 48 hours.

it can be started as early as 6 weeks after childbirth when the woman is fully or partially breast-feeding her baby. In non-lactating mothers it can be given immediately after childbirth or any time within 6 weeks without waiting for return of menses.

after an abortion, it can be started immediately, or in the first 7 days, or any time later after excluding pregnancy.

women discontinuing the use of other contraceptives can use injectables without any delay.

8.4 Advantages

very effective, long acting, reversible

easy to maintain privacy

not a coitus-related method

no daily pill-taking is required

allows some flexibility in return visits. Client can return as much as 2 weeks early or late than due date for injection

quantity and quality of breast milk is not affected. Can be used by nursing mothers as soon as 6 weeks after childbirth

no estrogen side-effects like dyslipidemia and increased risk of heart attack etc.

prevent ectopic pregnancies, endometrial cancer, uterine fibriods

may help in preventing ovarian cancer and iron-deficiency anemia

may make seizures less frequent in women with epilepsy

make sickle cell crises less frequent and less painful

8.5 Disadvantages

changes in menstrual bleeding pattern, like irregular spotting or bleeding, scanty periods are common, rarely heavy bleeding may occur. Amenorrhoea, especially after first year of use, may be disturbing in some women

breast tenderness, weight gain, acne and depression are bothersome side-effects

return of fertility may take up to 9 months after the last injection which is longer than other reversible contraceptive methods

requires another injection every 1-3 months

does not protect against sexually transmitted diseases including HIV/AIDS

8.6 Contraindications

lactating mothers less than 6 weeks post-partum

current or past history of breast cancer

current or past history of ischaemic heart disease, severe hypertension, diabetes mellitus for than 20 years or associated with damage to vision, kidneys or nervous system

current deep vein thrombosis or pulmonary embolism

active viral hepatitis, severe cirrhosis, benign or malignant liver tumors

Emergency Contraception should be used as a ‘back up’ if more than 2 week late for DMPA injection and more than 3 days late for combined monthly injection.

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