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RCFP_ Injectables FAQ English |
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1 Pages 1-10 |
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1.1 Page 1 |
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INJECTABLES
FREQUENTLY
ASKED QUESTION
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1.2 Page 2 |
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1.3 Page 3 |
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AMENORRHOEA
IS A BIG CONCERN
HOW TO MANAGE IT?
Amenorrhoea* is the effect of a Progesteron only drug which does not
require treatment with any drug.The provider’s responsibility is to give
supportive counselling and reassure the women when they develop the
aforesaid condition. All women should be properly counselled and
informed that amenorrhoea can be expected before they select
injectables.
About 80% of women will develop amenorrhoea by the end of the
second year of DMPA use.
Providers should reassure women that this is not a sign of pregnancy, but
rather indicates that the DMPA is working effectively.The condition can
be described as similar to ‘no monthly’ bleeding during pregnancy/
lactation. It is not bad for a woman’s health and may be very good for
women at risk of anemia. Some women may feel uncomfortable – as
they are not sure if they are pregnant or not when their menstrual cycle
stops.
*Amenorrhoea is the absence of menstruation. Menstruation is a woman's monthly
period.
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The only tool that may be helpful is proper method specific counselling,
which should be provided at the time that they are choosing the DMPA.
It should particularly focus on menstrual changes, including amenor-
rhoea, before it develops; and include supportive counselling to reassure
them after it does. However, if it is still unacceptable, discontinue the
DMPA and help her to choose another method.
WHAT ABOUT
WEIGHT GAIN POST- DMPA?
On an average, a woman can gain about 1-2 kg during the first year of
DMPA use.
Some women don’t gain weight at all and
some gain more than 2 kg.The weight gain
is mostly due to other reasons like diet and
lack of physical activity. They should be
counselled about ways to manage the
weight by adjusting the diet and taking
exercise.
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1.5 Page 5 |
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WHAT IS THE
FAILURE RATE OF DMPA?
DMPA is a highly effective contraceptive method. With perfect use
(when women always come on time for the re-injection), the failure
rate is only 0.3%. However, the failure rate increases in typically
common situations, (when women are sometimes late for the re-injec-
tion), when it may be as high as 3%.
HOW MUCH TIME DOES IT TAKE FOR
THE MENSTRUATION TO RESUME
AFTER INJECTION OF THE DMPA?
DMPA causes a delay in the return of menstruation/fertility, which
takes an average of 7 to 10 months after the last injection.
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WHEN SHOULD
DMPA BE STARTED?
DMPA can be started at any time if it is reasonably certain that the
woman is not pregnant. However, depending on her situation, the first
dose of DMPA can be started over the following time periods:
Post delivery: If the woman is breastfeeding then start DMPA 6 weeks
after childbirth. If not, it can be given earlier than 6 weeks.
Immediately post abortion: On the very same day or within the first 7
days, or else any time after ruling out pregnancy. If it is past 7 days, then
they should use an additional contraceptive for 7 days.
Post menses: It can be started any day within 7 days of the menstrual
cycle with no need for a backup method.
It can also be started any time later in the menstrual cycle (after 7
days) if it is reasonably certain that the woman is not pregnant (no
history of unprotected sex since LMP). She will need a backup
method (e.g. condom) for the first 7 days after the injection.
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WHAT IS CONSIDERED TO BE A
TIMELY ADMINISTRATION
OF DMPA?
DMPA clients need repeat injection every three months.
The World Health Organization’s (WHO) practice recommendations
state that a woman may be up to two weeks early or two weeks late,
the so called “grace period,” and still be eligible to receive her DMPA or
NET-EN re-injection. However, the GoI guidelines state that the next
injection can be administered up to two weeks earlier and four weeks
later from the scheduled date. If delayed by more than 4 weeks, then
pregnancy has to be ruled out prior to the re-injection. If the woman is
not menstruating then ruling out pregnancy may involve a pregnancy
test and/or pelvic examination. Women must be counselled about the
importance of coming on time for the re-injection
CAN NULLIPAROUS WOMEN
(WOMEN WHO NEVER GAVE
BIRTH) USE DMPA?
DMPA as a contraceptive option can safely be given to nulliparous
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1.8 Page 8 |
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women. However, the nulliparous couple needs to be counselled about
the delay in the return to fertility by about 4 to 6 months or even slightly
longer after stopping DMPA.They need to plan their pregnancy accord-
ingly. It takes about 12 months for the fertility to return and it may also
take the woman an extra year to become pregnant.
WHAT ARE THE CONCERNS THAT ARE
RELATED TO THE DELAY IN THE
RETURN TO FERTILITY?
The return to fertility may be important for women who want to get
pregnant on schedule. DMPA is known to cause a delay in this regard.
Couples should therefore plan the duration of its use depending on
when they plan to have their child. Studies have shown that at the end of
two years1, the return to fertility is almost the same in DMPA and IUCD
users.
1 Return of fertility after discontinuation of depot medroxyprogesterone acetate and intra-uter-
ine devices in Northern Thailand. Pardthaisong T, Gray RH, McDaniel EB. 1980 Mar 8. Lancet. ,
1980 Mar 8, Lancet, pp. 1(8167):509-12.
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WHAT IS MORE RELIABLE – NET-EN
(ANOTHER INJECTABLE
CONTRACEPTIVE) OR DMPA?
There is very little difference between NET-EN OR DMPA. They are
equally effective.
The main difference is that NET-EN is given every 2 months and
DMPA every 3 months. NET-EN causes somewhat less pronounced
bleeding changes and slightly less delay in the return to fertility. Some
women may prefer NET-EN because of that. But other women prefer
DMPA because they don’t need to come to the clinic as often for the
re-injection.
HOW IMPORTANT IS CLIENT’S
COMPLIANCE WITH DMPA?
Compliance with DMPA use at the scheduled intervals is very important
so as to have effective contraceptive benefits. If the woman is late for the
DMPA injection by more than 4 weeks, it may be difficult to rule out
pregnancy in order to provide the re-injection (as many women don’t
have their menses while on DMPA). Also, few women may become
pregnant soon after the re-injection window ends (even if the return to
fertility is delayed for the majority of women).
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HOW LONG
CAN ONE USE DMPA?
It can be used for as long as one wants and needs protection from
pregnancy. Some caution should be exercised when the woman is
approaching menopause (WHO MEC category 2). This is because
menopause itself increases a risk for osteoporosis* and women may not
be able to regain the bone mass they loose while using DMPA. Some
may want to stop it and switch to another method at this stage. This way
they will have enough time to regain the bone mass before they reach
full menopause.
DOES DMPA CAUSE
BONE LOSS?
Women using DMPA may experience a decrease in bone mineral
density, which is believed to be due to it’s interference with the produc-
tion of oestrogen, an important hormone for bone mineral density
development. Studies confirm that bone loss occurring with DMPA use
is reversible and is not likely to be an important risk factor for low bone
density and fractures in older women.
*Osteoporosis is a disease which makes your bones weak and more likely to break.
Anyone can develop osteoporosis, but it is common in older women
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2 Pages 11-20 |
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2.1 Page 11 |
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However, the advantages of DMPA use as a contraceptive generally
outweigh the theoretical concerns regarding skeletal harm.
Accordingly, studies conclude that skeletal
health concerns should not restrict
initiation or continuation of DMPA in
adolescent girls or older reproductive-age
women (aged 45 years).
There is no increase in fractures. Routine
bone mineral density monitoring is not
recommended in any population using
DMPA.
Moreover, the available evidence does not
justify the requirement of a limit regarding
the duration of DMPA therapy, even in
adolescents.
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WOULD THERE BE A PROBLEM
IN BREASTFEEDING MY BABY?
The use of DMPA has no adverse effects
on the quality, amount and composition of
breast milk or on the duration of lactation,
once the breast milk formation and breast
feeding has been established. Moreover,
infant growth and psychomotor develop-
ment, milestones, health problems, infant
height are not affected with the small
amount of progesterone passed into the
infant’s body through breast milk.
DOES DMPA
COMPROMISE IMMUNITY?
One of the studies show that DMPA increased CD3+ T cells and
HLA-DR+ cells. These findings were consistent with another large
longitudinal study that found that white blood cells (WBCs) and
polymorphonuclear monocytes (PMNs) were increased in the cervico-
vaginal fluid lavage (CVL) of women using hormonal contraception.
This suggests that DMPA does not compromise immunity.
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DOES DMPA CAUSE
MOOD CHANGES?
There is no definite evidence to substantiate the effect of DMPA on
women’s mood and behaviour.
A cohort study (in USA) reported no significant differences in mood
and depression scores in adolescents (aged 16 to 21 years) who used
DMPA, compared with non-users of hormonal contraception at 1 year.
Another cohort study (in USA) of adolescents (n = 199) reported no
significant differences in depression between users of DMPA and
combined oral contraceptives (53 per cent versus 57 per cent) at 6
months.
DOES DMPA CAUSE A
LOSS OF LIBIDO?
There is no definitive evidence to substantiate that DMPA causes a loss
of libido. Studies on this have so far been inconclusive.
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DOES DMPA CAUSE
CANCER ?
DMPA does not cause cancer.
In fact DMPA use helps to protect the lining of the uterus (endometri-
um) and ovary against cancer.
A WHO collaborative study of neoplasia and steroidal contraceptives
found no overall increased risk of breast cancer, no increased risk of
invasive cervical cancer and no increased risk of ovarian or liver cancer.
DOES USE OF DMPA INCREASE THE RISK
OF STIs INCLUDING HIV INFECTION?
DMPA does neither. It neither protects the
women from STIs and/or HIV infection and
nor does it increase the risk of acquiring
them. However, women using DMPA and
who are at risk of acquiring STIs and/or
HIV infection should ensure that the
partner consistently uses a condom during
each act of sexual intercourse.
“Reference Manual for Injectable Contraceptive (DMPA),Family Planning Division, MoHFW,
Government of India.”
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ABOUT PFI
Population Foundation of India is a national NGO, which promotes and
advocates for the effective formulation and implementation of gender
sensitive population, health and development strategies and policies. The
organisation was founded in 1970 by a group of socially committed industri-
alists under the leadership of the late JRD Tata and Dr Bharat Ram.
PFI addresses population issues within the larger discourse of empowering
women and men, so that they are able to take informed decisions related to
their fertility, health and well-being. It works with the government, both at
the national and state levels, and with NGOs, in the areas of community
action for health, urban health, scaling up of successful pilots and social and
behaviour change communication. PFI is guided by an eminent governing
board and advisory council comprising distinguished persons from civil
society, the government and the private sector.
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