Transcript Injectable Contraception

Progestogen Only Injectable (POI)
/
https://www.fsrh.org/documents/cec-ceu-guidance-injectables-dec-2014
Most commonly used in UK is
 Depot Medroxyprogesterone
Acetate (150mgs in 1ml).
 Sub cut version developed (2005)
but not currently available in UK.
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Norethisterone Enantate
(Noristerat/ Neto) (200mgs in 1ml
Neto short term licensed only.
Vasectomy
Rubella
Mode Of Action
Inhibits ovulation abolishes
peak levels of LH and FSH
maintains basal levels of both
hormones
 Thickens cervical mucus
 Suppression of endometrium
 30+ million users worldwide
 About 3% users in UK (ONS
2007)
 Efficacy: <4 in 1000 in 2 years
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UK MECS:
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Current VTE on
anticoagulants.
CVA
Significant multiple risk
factors for arterial
cardiovascular disease.
Gestational Trophoblastic
Neoplasia
Diabetes: > 20yrs of
duration/”opathies”
Active Viral Hepatitis
UK MEC 3
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Current Breast Cancer:
within last 5 yrs)
Review 1&2
UK MEC 4
Dose
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Steady dose
Much higher level initially
Declining thereafter
Individual variation less marked than oral
methods because variable absorption from
the gut and variable 1st pass metabolism
not involved.
No maximum duration of use.
Blood levels seem to decline more rapidly
in thin women
Administration: Depot
Depo-provera available in pre-filled syringe
150mg in 1ml
 Needs to be shaken vigorously as drug is
in suspension
 Deep intramuscular injection into gluteal or
deltoid muscle usually in buttock
 The site should not be massaged after
injection as this accelerates absorption
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Administration: Noristerat
Noristerat supplied in 200mg ampoules
 8 weekly
 The solution is oily and should be
warmed to body temperature to facilitate
administration
 Injection given into gluteal muscle
without massaging site afterwards
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Advantages
Highly effective 0.1-0.6%
failure and convenient
 Independent of SI
 Independent of users
memory apart from 12 week
appts
 Secrecy for some, under
women's control
 Reversible
 Less menorrhagia,
dysmenorrhoea,anaemia,
PMS and ovulation pain
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Advantages cont.
Less ectopics, ovarian cysts, fibroids,
endometriosis
 Lactation not suppressed
 Fewer crises for sickle cell (although WHO 2 for
coc now)
 No effect on BP
 Reduction in endometrial cancer
 Less PID
 Ok for women on liver enzyme inducing
medication and antibiotics
 Free from side effects due to oestrogen
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Disadvantages
Amenorrhoea
Menstrual disturbances (menstrual chaos) (80% over 1st 3
yrs))
 Fertility Delay( up to 1 yr BUT no evidence of long term
fertility reduction)
 Weight Gain – 3kgs at 2yrs mean average (Cochrane
Review)
 Galactorrhoea
 Cannot be stopped once given
 Risk of osteoporosis
 Subjective minor side effects
 Local complications –abscess, haematoma
 Libido
 Headches/mood changes.
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Health Concerns:
Cardiovascular Disease:
 No association.
Bone Mineral Density:
 Concern in the under
20yrs & over 40s.
 Assess family history
 Assess lifestyle
 Re-evaluate every 2
yrs
Drug Interactions:
 Not reduced with
concurrent drug use of
medications.
Medical Attention:
 Migraine with aura
 Abscess/Haematoma.
 Rash, swelling, pain,
redness.
Clinical Management:
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Those who received repeated structured
evidenced information were less likely to
discontinue in the 1st yr.
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General medical history esp those related
to arterial disease and osteoporosis
Baseline measurements BP, Wt
Possible side effects fully discussed
Theoretical long term risks
Usually given day 1-5 of menstrual cycle
then every 12 weeks thereafter
If given any other time of menstrual cycle
need 7 days EP- REASONABLY CERTAIN
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Initiation:
General
Days 1–5 (inclusive) of a normal
menstrual cycle.
No additional contraception is
required.
Injections may also be initiated
at any other time, key word
reasonably certain that the
woman is not pregnant and that
there is no risk or conception.
EP for 7/7
If the woman is amenorrhoeic,
the clinician must be reasonably
certain that the woman is not
pregnant and there is no risk of
conception. EP 7/7
Postpartum
Miscarriage/Abortion
Progestogen-only injectables
may be initiated up to Day 21
postpartum with immediate
contraceptive cover.
After Day 21; EP 7/7
Initiate on day of surgical or
second part of medical abortion or
immediately following miscarriage:
no additional contraception is
required.
After 5 days: EP 7/7
Switching:
CHC
POP
Can be initiated immediately if
CHC has been used consistently
and correctly or if the clinician
is reasonably certain that the
woman is not pregnant and that
there has been no risk of
conception.
No additional contraception is
needed.
Can be initiated immediately if
POP has been used consistently
and correctly or if the clinician is
reasonably certain that the woman
is not pregnant and that there has
been no risk of conception.
No additional contraception is
needed.
SDI
POI
Can be initiated immediately if
implant has been used consistently
and correctly or if the clinician
is reasonably certain that the
woman is not pregnant and that
there has been no risk of
conception. No additional
contraception is needed.
If the woman’s previous method was
another injectable, she should have
the injection before or at
the time the next injection was due. No
additional contraception is needed.
IUS (LNG)
IUD
Can be initiated immediately if
the LNG-IUS was used
consistently and correctly or if
the clinician
is reasonably sure that the
woman is not pregnant. As
bleeding with the LNG-IUS may
not reflect
ovarian activity, the LNG-IUS
should be continued for at least
7 days.
Can be initiated immediately if the
IUD was used consistently and
correctly or if the clinician is
reasonably sure that the woman is
not pregnant. The IUD should be
continued for at least 7 days
unless the first injection occurs
between Days 1–5 (inclusive) of a
normal menstrual cycle.
Management of bleeding
Annoying bleeding
common in first 3
injections
 Check for unrelated
cause e.g. retained
products of conception,
polyps, chlamydia or
carcinoma
 Give oestrogen if not
contraindicated e.g
microgynon 30
 Some give depo earlier
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Future Management
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Check in time!
Check for any bleeding problems
Any change in personal, family medical
history
BP once a year probably sufficient-(depo
no effect on BP)
Review and reassess every 2 yrs.
Indications for EC & Late POIs
Timing
UPSI
Injection
EC
EP
PT
Up to
14/52
N/A
Yes
No
No
No
14+1 or
more
No
Yes
No
Yes
No (if
abstained)
Yes if barrier
(21/7)
(abstained
/barriers)
(next 7/7)
Yes in last Yes
Yes or
Yes in last Yes
Yes
No if opts
copper IUD for copper
IUD
Yes (21/7)
Yes more
than 5/7
No
Yes
3/7
4-5/7
NO
Yes
copper IUD (Next 7/7)
Yes 21/7
PLUS 7/7
Yes (21/7)
at
presentation
and 21/7
104mgs every 13 weeks.
Subcut
Self administration?
References:
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FFPRHC(2002) Depo-provera & bone density Journal of Family Planning &
Reproductive Health Care 28(1) 7-11.
Westhoff C (2003) Depot-medroxyprogesterone acetate injection: a highly
effective contraceptive option with proven long term safety. Contraception
68 75-87.
Task Force for Epidemiological Research on Reproductive Health, UN,
(1998) Effects of Contraception on Hemoglobin and Ferritn Contraception
58 261-273.
FSRH (2008) FSRH Guidance Progestogen only injection FSRH Website