Note from the Faculty of Sexual & Reproductive Healthcare (FSRH) and the National Guideline Clearinghouse (NGC): The print version of this Clinical Effectiveness Unit (CEU) Guidance Document (issued in November 2008) contained some inconsistencies that the CEU has corrected in the June 2009 version. These corrections are to Table 1: United Kingdom (UK) Medical Eligibility Criteria for Contraceptive use for progestogen-only injectable use (page 2 in the original guideline document), Timing of repeat injections (page 6 in the original guideline document), and Table 3: Summary of indications for emergency contraception following late progestogen-only injections (page 7 in the original guideline document). The recommendations below are unchanged.
The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
Which women are eligible to use progestogen-only injectable contraception?
Health professionals should be familiar with the United Kingdom Medical Eligibility Criteria (UKMEC) for progestogen-only injectable contraceptive use. (Good Practice Point)
Table: Definitions of UK Medical Eligibility Criteria for Contraceptive Use Categories
| UKMEC Definition of Category |
| Category |
|
| UKMEC 1 |
A condition for which there is no restriction for the use of the contraceptive method. |
| UKMEC 2 |
A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. |
| UKMEC 3 |
A condition where the theoretical or proven risks usually outweigh the advantages of using the method.a |
| UKMEC 4 |
A condition which represents an unacceptable health risk if the contraceptive method is used. |
aThe provision of a method to a woman with a condition given a UKMEC Category 3 requires expert clinical judgement and/or referral to a specialist contraceptive provider since use of the method is not usually recommended unless other methods are not available or not acceptable.
What should clinicians assess when a woman is considering progestogen-only injectable contraception?
A medical history (including sexual history), together with consideration of the UKMEC recommendations, should be used to assess the appropriateness of progestogen-only injectable contraception. (Good Practice Point)
What information should be given to women considering progestogen-only injectable contraception?
Mode of Action
Women should be informed that progestogen-only injectable contraception acts primarily by inhibition of ovulation. (Grade C)
Contraceptive Efficacy
Women should be advised that the failure rate with the progestogen-only injectable given within license every 12 weeks is very low (<4 in 1000 over 2 years). (Grade A)
Return of Fertility
Women should be advised that there can be a delay of up to 1 year in the return of fertility after discontinuation of progestogen-only injectable contraception. (Grade C)
Women who do not wish to conceive should be advised to start another contraceptive method before or at the time of the next scheduled injection even if amenorrhoeic. (Good Practice Point)
Side Effects
Bleeding Changes
Women should be informed about the altered bleeding patterns that usually occur with the use of a progestogen-only injectable contraceptive. (Good Practice Point)
Up to 70% of depot medroxyprogesterone acetate (DMPA) users are amenorrhoeic at 1 year of use. (Grade B)
Weight Change
Women should be advised that there is an association between DMPA use and weight gain. (Grade C)
Mood Change, Libido and Headache
Women should be advised that there is no evidence of a causal association between the use of progestogen-only injectable contraceptives and mood change, libido or headache. (Grade C)
Discontinuation
Women should be informed that up to 50% of progestogen-only injectable contraceptive users will discontinue by 1 year, and that the most common reason for discontinuation is changes to bleeding pattern. (Grade B)
Women should be informed about the main reasons for discontinuation of progestogen-only injectable contraception and be given appropriate oral and written advice. (Grade A)
Health Concerns
Bone Mineral Density (BMD)
Women should be informed that progestogen-only injectable contraceptive use is associated with a small loss of BMD, which is usually recovered after discontinuation. (Grade B)
Women should be advised that there is no available evidence on the effect of depot medroxyprogesterone acetate (DMPA) on long-term fracture risk. (Good Practice Point)
In women aged under 18 years DMPA can be used as first-line contraception after consideration of other methods. (Grade C)
Women using DMPA who wish to continue use should be reviewed every 2 years to assess individual situations and discuss the benefits and potential risks, and be supported in their choice of whether or not to continue. Use may continue to age 50 years. (Good Practice Point)
Drug Interactions
Women should be informed that the efficacy of progestogen-only injectable contraception is not reduced with concurrent use of medication (including antibiotics and liver enzyme-inducing drugs) and the injection intervals do not need to be reduced. (Grade C)
Symptoms Requiring Medical Attention
Women should be advised to return if they experience any signs or symptoms of infection at the site of injection. (Good Practice Point)
When can progestogen-only injectable contraceptives be started?
Initiation of Progestogen-Only Injectable Contraceptives in Special Circumstances
Postpartum
Women can start a progestogen-only injectable contraceptive up to Day 21 postpartum to provide immediate contraceptive protection. If started after that time another method of contraception or abstinence is required for 7 days. (Grade C)
Progestogen-only injectable contraception can be safely used by women who are breastfeeding. (Grade B)
Following Abortion or Miscarriage
Progestogen-only injectable contraception may be given following surgical abortion (or second part of) medical abortion or miscarriage. If administered within 5 days after the abortion or miscarriage then additional contraceptive protection or abstinence is not required. (Grade C)
Practical Procedures for Administering a Progestogen-Only Injectable Contraception
Emergency Equipment for Administering Progestogen-Only Injectable Contraceptive
Emergency resuscitation equipment must be available in all settings where progestogen-only injectable contraception is administered and local referral protocols must be in place for women who require further medical input. (Grade C)
Ongoing Use and Follow-Up of Progestogen-Injectable Contraception and Follow-Up
Timing of Repeat Injections
Women should be advised to return every 12 weeks for a repeat injection of DMPA (or every 8 weeks for norethisterone enanthate [NET-EN]). (Grade C)
If necessary, a repeat progestogen-only injectable contraceptive can be given up to 2 weeks early (i.e., 10 weeks for DMPA and 6 weeks for NET-EN). (Grade C)
A repeat injection of progestogen-only injectable contraception can be given up to 2 weeks late (i.e., 14 weeks since the last DMPA and 10 weeks for NET-EN) without additional contraception (unlicensed). (Grade C)
The decision to provide a further DMPA injection and advice regarding the need for additional contraception should be considered individually, assessing the risk of pregnancy, the duration of use and the method (e.g., one previous injection or using DMPA for the last 5 years). (Good Practice Point)
Managing Common Problems Associated with DMPA Use
Unacceptable Bleeding
Clinicians managing women who experience unacceptable bleeding while using a progestogen-only injectable contraceptive should take a sexual history, establish risk of sexually transmitted infections (STIs) and consider possible gynaecological pathology. (Grade C)
Women using progestogen-only injectable contraception who have unacceptable bleeding but wish to continue with this method may consider the use of a combined oral contraceptive (COC) pill (if appropriate) as a short-term treatment. (Grade C)
Definitions:
Grades of Recommendations
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the multidisciplinary group
