Injectable Contraceptives Overview
Depo-Provera is the only injectable contraceptive available in the United States. It comes in two forms: intramuscular (IM, Depo-Provera) and subcutaneous (SC, Depo-Sub Q 104). Currently, the IM form is available in a generic form, making it much more widely used despite the fact that the SC product can be self-administered. The risks and benefits of the different forms of Depo-Provera are essentially the same, although the SC product is used at a lower dose. For purposes of these protocols, we will focus on the IM delivery system. Please contact the manufacturer for information on SC administration and teaching protocols for self-administration.
Depo-Provera is often the first choice of women who are not good at remembering to take oral contraceptives and who find NuvaRing and Ortho Evra undesirable. The convenience of an injection every 3 months is preferable to many women. It provides safe contraception while nursing and excellent contraception in general. However, as with all methods, proper patient selection and patient education are the keys to successful and continued use.
Patients need to know to be prepared for some predictable side effects. Bleeding irregularities are high on the list of patient complaints and are the most common reason for patients discontinuing use of the method. Amenorrhea becomes common with continued Depo-Provera use and may be a desired side effect. Another patient complaint is weight gain, which may be attributable to an actual increase in appetite rather than due to fluid retention. According to the package insert available with each Depo-Provera injection, an average weight gain of 13.8 lb during a 4-year period of use has been reported.
There may be a delay in return to menstruation after the cessation of Depo-Provera injections, often reported as a 6- to 12-month interval, until the return of fertility. This needs to be taken into account when planning for pregnancy, and patients should be questioned as to their reproductive plans when choosing this method to allow for adequate time for return to fertility.
Long-term users of Depo-Provera need to be counseled about the potential risk for decreased bone density. There is no current standard for evaluating or treating this potential problem. Some clinicians may order bone density testing (dual energy X-ray absorptiometry [DEXA]) or estradiol levels after 2 or more years of use and may recommend estrogen supplementation if levels fall below an agreed-on standard. It is important when ordering bone density tests in adolescents to ascertain the calibration standards for the facility you recommend. Many DEXA machines are calibrated for bone density
readings in women age 20 years and older and are not reliable below that age. All patients on Depo-Provera or Depo-Sub Q 104 should be advised to take 1200 mg of calcium daily and exercise for a minimum of 30 minutes five times per week in order to support bone health.
readings in women age 20 years and older and are not reliable below that age. All patients on Depo-Provera or Depo-Sub Q 104 should be advised to take 1200 mg of calcium daily and exercise for a minimum of 30 minutes five times per week in order to support bone health.
Some women using Depo-Provera may complain of vaginal dryness. In such cases, the provider may recommend a small amount of estrogen cream as an “add back” to remedy this complaint.
» BASIC TRIAGE ASSESSMENT FORM FOR INJECTABLE CONTRACEPTIVES
When was your last menstrual period? _______________ (Remind patients they may not have normal menstruation while using this method.)
How long have you been using Depo-Provera? __________________________________
What was the date of your last injection? ___________________________________
Are you having any health problems at this time? ____________________________
Do you use a backup method of contraception? Method type: ___________________
Are you planning a pregnancy in the next 2 years? ___________________________
Amenorrhea With Depo-Provera Use
» Key Questions
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» Actions
STEP A: Pregnancy Possible
Confirm pregnancy status before proceeding. If the patient is uncertain of her pregnancy status, have her take a home pregnancy test or come in for a blood or urine pregnancy test.
For patients desiring to continue pregnancy, assuming they have no risk factors for abnormal 1st trimester pregnancy (see protocols in Chapters 7 and 8) and no medical problems, do the following:
Because the patient probably will be uncertain of the date of her last menses, she should be scheduled for an initial visit with an obstetric care provider or at least have a sonogram to confirm dates; either should occur within 1 week.
Call in a prescription for prenatal vitamins or suggest an approved over-the-counter (OTC) prenatal vitamin if the patient is not already taking them.
If the patient has a risk factor for an abnormal 1st trimester pregnancy (prior ectopic pregnancy, prior abdominal surgery or ruptured appendix, or repeated miscarriages) or has medical problems, do the following:
Notify an on-call physician if the situation is urgent. If no physician is available and the patient has symptoms accompanied by abdominal pain, have the patient seek evaluation in the emergency room (ER).
Schedule an evaluation within 24 to 48 hours if no problems are noted by the patient.
Call in a prescription for prenatal vitamins or suggest an approved OTC prenatal vitamin if appropriate.
For patients desiring pregnancy termination, refer as appropriate.
STEP B: Pregnancy Unlikely
Determine the patient’s method compliance.
Reassure her that amenorrhea is an expected side effect.
If the patient has been noncompliant with the timing of method administration, encourage her to have a sensitive urine pregnancy test.
If the patient is concerned about the possibility of a pregnancy and has been compliant, encourage her to take a home pregnancy test for reassurance and for building confi dence in her method compliance.
Determine the patient’s comfort with the method.
» Patient Education
Although pregnancy is unlikely in a patient compliant with her Depo-Provera regimen, it is best to be suspicious of pregnancy in a sexually active woman rather than miss an opportunity for the patient to explore her options for pregnancy continuation and optimal pregnancy health.
Patients using Depo-Provera need to be comfortable with this expected side effect. Those who are not should consider switching to a different method at a convenient time.
Use this opportunity to encourage consistent condom use in women at risk for sexually transmitted infections (STIs).
Bleeding and Depo-Provera Use
» Key Questions
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