What Are Progestin-Only Injectables?
- The injectable contraceptives depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) each contain a progestin like the natural hormone progesterone in a woman’s body.
- Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.
- DMPA, the most widely used progestin-only injectable, is also known as “the shot,” “the jab,” the injection, Depo, Depo-Provera, Megestron, and Petogen.
- NET-EN is also known as norethindrone enanthate, Noristerat, and Syngestal.
- Given by injection into the muscle (intramuscular injection). The hormone is then released slowly into the bloodstream. A different formulation of DMPA can be injected just under the skin (subcutaneous injection).
- Work primarily by preventing the release of eggs from the ovaries (ovulation).
Effectiveness depends on getting injections regularly: Risk of pregnancy is greatest when a woman misses an injection.
- As commonly used, about 3 pregnancies per 100 women using progestin-only injectables over the first year. This means that 97 of every 100 women using injectables will not become pregnant.
- When women have injections on time, less than 1 pregnancy per 100 women using progestin-only injectables over the first year (3 per 1,000 women).
Return of fertility after injections are stopped: An average of about 4 months longer for DMPA and 1 month longer for NET-EN than with most other methods.
Protection against sexually transmitted infections (STIs): None
Side Effects, Health Benefits, and Health Risks
Some users report the following:
- Changes in bleeding patterns including, with DMPA:
First 3 months:
– Irregular bleeding
– Prolonged bleeding
At one year:
– No monthly bleeding
– Infrequent bleeding
– Irregular bleeding
- Weight gain
- Аbdominal bloating and discomfort
- Mood changes
- Less sex drive
Other possible physical changes:
- Other possible physical changes:
Known Health Benefits
Helps protect against:
- Risks of pregnancy
- Cancer of the lining of the uterus (endometrial cancer)
- Uterine fibroids
May help protect against:
- Symptomatic pelvic inflammatory disease
- Iron-deficiency anemia
- Sickle cell crises among women with sickle cell anemia
- Symptoms of endometriosis (pelvic pain, irregular bleeding)
Known Health Risks:
Who Can and Cannot Use Progestin-Only Injectables
Safe and Suitable for Nearly All Women
Nearly all women can use progestin-only injectables safely and effectively, including women who:
- Have or have not had children
- Are not married
- Are of any age, including adolescents and women over 40 years old
- Have just had an abortion or miscarriage
- Smoke cigarettes, regardless of woman’s age or number of cigarettes smoked
- Are breastfeeding (starting as soon as 6 weeks after childbirth;
- Are infected with HIV, whether or not on antiretroviral therapy
Women can begin using progestin-only injectables:
- Without a pelvic examination
- Without any blood tests or other routine laboratory tests
- Without cervical cancer screening
- Without a breast examination
- Even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant
- Can stop monthly bleeding, but this is not harmful. It is similar to not having monthly bleeding during pregnancy. Blood is not building up inside the woman.
- Do not disrupt an existing pregnancy.
- Do not make women infertile.
Managing Any Problems
Problems Reported as Side Effects:
- No monthly bleeding
- Irregular bleeding (bleeding at unexpected times that bothers the client)
- Weight gain
- Abdominal bloating and discomfort
- Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)
- Ordinary headaches (nonmigrainous)
- Mood changes or changes in sex drive
New Problems That May Require Switching Methods:
- Migraine headaches
- Unexplained vaginal bleeding (that suggests a medical condition not related to the method)
- Certain serious health conditions (suspected blocked or narrowed arteries, serious liver disease, severe high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, or damage to arteries, vision, kidneys, or nervous system caused by diabetes).
- Suspected pregnancy
Contact your doctor if you have any of the problems listed above.
Questions and Answers About Progestin-Only Injectables
1. Can women who could get sexually transmitted infections (STIs) use progestin-only injectables?
Yes. Women at risk for STIs can use progestin-only injectables. The few studies available have found that women using DMPA were more likely to acquire chlamydia than women not using hormonal contraception. The reason for this difference is not known. There are few studies available on use of NET-EN and STIs. Like anyone else at risk for STIs, a user of progestin-only injectables who may be at risk for STIs should be advised to use condoms correctly every time she has sex. Consistent and correct condom use will reduce her risk of becoming infected if she is exposed to an STI.
2. If a woman does not have monthly bleeding while using progestin-only injectables, does this mean that she is pregnant?
Probably not, especially if she is breastfeeding. Eventually most women using progestin-only injectables will not have monthly bleeding. If she has been getting her injections on time, she is probably not pregnant and can keep using injectables. If she is still worried after being reassured, she can be offered a pregnancy test, if available, or referred for one. If not having monthly bleeding bothers her, switching to another method may help.
3. Can a woman who is breastfeeding safely use progestin-only injectables?
Yes. This is a good choice for a breastfeeding mother who wants a hormonal method. Progestin-only injectables are safe for both the mother and the baby starting as early as 6 weeks after childbirth. They do not affect milk production.
4. How much weight do women gain when they use progestin-only injectables?
Women gain an average of 1–2 kg per year when using DMPA. Some of the weight increase may be the usual weight gain as people age. Some women, particularly overweight adolescents, have gained much more than 1–2 kg per year. At the same time, some users of progestin-only injectables lose weight or have no significant change in weight. Asian women in particular do not tend to gain weight when using DMPA.
5. Do DMPA cause abortion?
No. Research on progestin-only injectables finds that they do not disrupt an existing pregnancy. They should not be used to try to cause an abortion. They will not do so.
6. Do progestin-only injectables make a woman infertile?
No. There may be a delay in regaining fertility after stopping progestinonly injectables, but in time the woman will be able to become pregnant as before, although fertility decreases as women get older. The bleeding pattern a woman had before she used progestin-only injectables generally returns several months after the last injection even if she had no monthly bleeding while using injectables. Some women may have to wait several months before their usual bleeding pattern returns.
7. How long does it take to become pregnant after stopping DMPA ?
Women who stop using DMPA wait about 4 months longer on average to become pregnant than women who have used other methods. This means they become pregnant on average 10 months after their last injection. These are averages. A woman should not be worried if she has not become pregnant even as much as 12 months after stopping use. The length of time a woman has used injectables makes no difference to how quickly she becomes pregnant once she stops having injections. After stopping progestin-only injectables, a woman may ovulate before her monthly bleeding returns—and thus can become pregnant. If she wants to continue avoiding pregnancy, she should start another method before monthly bleeding returns.
8. Does DMPA cause cancer?
Many studies show that DMPA does not cause cancer. DMPA use helps protect against cancer of the lining of the uterus (endometrial cancer). Findings of the few studies on DMPA use and breast cancer are similar to findings with combined oral contraceptives: Women using DMPA were slightly more likely to be diagnosed with breast cancer while using DMPA or within 10 years after they stopped. It is unclear whether these findings are explained by earlier detection of existing breast cancers among DMPA users or by a biologic effect of DMPA on breast cancer. A few studies on DMPA use and cervical cancer suggest that there may be a slightly increased risk of cervical cancer among women using DMPA for 5 years or more. Cervical cancer cannot develop because of DMPA alone, however. It is caused by persistent infection with human papillomavirus.
9. Can a woman switch from one progestin-only injectable to another?
Switching injectables is safe, and it does not decrease effectiveness. If switching is necessary due to shortages of supplies, the first injection of the new injectable should be given when the next injection of the old formulation would have been given. Clients need to be told that they are switching, the name of the new injectable, and its injection schedule.
10. How does DMPA affect bone density?
DMPA use decreases bone density. Research has not found that DMPA users of any age are likely to have more broken bones, however. When DMPA use stops, bone density increases again for women of reproductive age. Among adults who stop using DMPA, after 2 to 3 years their bone density appears to be similar to that of women who have not used DMPA. Among adolescents, it is not clear whether the loss in bone density prevents them from reaching their potential peak bone mass.
11. Do progestin-only injectables cause birth defects? Will the fetus be harmed if a woman accidentally uses progestin-only injectables while she is pregnant?
No. Good evidence shows that progestin-only injectables will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using progestin-only injectables or accidentally starts injectables when she is already pregnant.
12. Do progestin-only injectables change women’s mood or sex drive?
Generally, no. Some women using injectables report these complaints. The great majority of injectables users do not report any such changes, however. It is difficult to tell whether such changes are due to progestinonly injectables or to other reasons. Providers can help a client with these problems. There is no evidence that progestin-only injectables affect women’s sexual behavior
13. What if a woman returns for her next injection late?
In 2008 WHO revised its guidance based on new research findings. The new guidance recommends giving a woman her next DMPA injection if she is up to 4 weeks late, without the need for further evidence that she is not pregnant. Some women return even later for their repeat injection, however. Whether a woman is late for reinjection or not, her next injection of DMPA should be planned for 3 months later.
Where to address?
For a family planning consultation:
- Ask your family doctor at your health care facility in your area of residence (see here). WARNING: if you belong to one of the socially vulnerable groups (see here) you can benefit from free contraceptives!
- Ask Youth Friendly Health Centers
- Call the RHTC Hotline (free and confidential call) – 0800-088-08
- Call RHTC – 022355072 / 060903782 / 078306973
- Write to RHTC e-mail – firstname.lastname@example.org