1. Session III: Providing Progestin-Only Injectables
Progestin-Only Injectable Contraceptives
Session III: Providing Progestin-Only Injectables

2. When Can A Woman Start Injectables (part 1)
Anytime – if you are sure woman is not pregnant. May be started without a pelvic exam or routine lab tests, without cervical cancer screening, and without a breast exam
During the first seven days after your client’s period starts you can assume that she is not pregnant.
You can give an injection now. There is no need for her to abstain or use condoms.
Injectables may be initiated without a pelvic exam; without blood tests or routine lab tests; without cervical cancer screening; without a breast exam.
Explain to participants that DMPA and NET-EN can be started anytime during the menstrual cycle as long as the provider can be reasonably sure the woman is not pregnant. You can be reasonably certain that a woman is not pregnant if any of these situations apply:
Her menstrual bleeding started within the past seven days.
The woman is fully breastfeeding, has no menses, and her baby is less than six months old.
She has abstained from intercourse since her last menses or since delivery.
She has given birth in the past four weeks.
She had a miscarriage or an abortion in the past seven days.
She has been using a reliable contraceptive method consistently and correctly.
Reference:
1. World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva: WHO, 2004; updated 2008.
After day eight of her cycle, you must rule out pregnancy before giving an injection.
If she is not pregnant, give the injection and tell her to abstain from sex or use condoms for the next seven days.

3. When Can A Woman Start Injectables (part 2)
Postpartum and breastfeeding: wait 6 weeks (follow checklist instructions). (WHO/MEC)
Postpartum and not breastfeeding: anytime within 4 weeks after delivery (after 4 weeks, rule out pregnancy)
If DMPA or NET-EN are initiated during the first seven days of the menstrual cycle—where day one is the first day of bleeding—no backup contraceptive method is necessary. If progestin-only injectables are initiated more than seven days after the start of woman’s monthly bleeding, advise her to use a backup contraceptive method such as condoms for the first seven days following the injection.Ideally, postpartum women who are breastfeeding generally should not start using injectables until six weeks postpartum because of concerns the newborn infants will be exposed to DMPA or NET-EN received in breast milk. This represents the international consensus on the initiation of progestin-only injectables and breastfeeding as reflected in the WHO MEC. For further information on the initiation of implants and breastfeeding, see slide 10 in Session II.  This consideration was more fully discussed at that time. Women who are exclusively breastfeeding a baby less than six months old and whose menses have not returned are protected from pregnancy by the lactational amenorrhea method (LAM). Refer to slide #10 in session II for a more detailed description about use of progestin only methods with postpartum breastfeeding women.Postpartum women who are not breastfeeding may start progestin-only injectables immediately after giving birth. If a woman who is not breastfeeding wants to start using progestin-only injectables more than four weeks after she has given birth, it is necessary to rule out pregnancy before giving the injection. Progestin-only injectables can be initiated immediately following an abortion or miscarriage without need for a backup method. If it is more than seven days after a first- or second-trimester miscarriage or abortion, a woman can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first seven days after the injection. If a woman is switching to injectables from another hormonal method, she can have an injection of DMPA or NET-EN immediately, provided that she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. There is no need for her to wait for her next monthly bleeding. There is no need for her to use a backup method. If she is switching from another injectable, she can have the new injectable when the repeat injection would have been given. No need for a backup method. She can start injectables on the same day that she uses emergency contraceptive pills (ECPs), or, if she prefers, within seven days after the start of her monthly bleeding. She will need a backup method for the first seven days after the injection. She should return if she has signs or symptoms of pregnancy other than not having monthly bleeding.Illustration credits: Ambrose Hoona-Kab, Salim Khalaf, Institute for Reproductive HealthReference:
1. World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva: WHO, 2004; updated 2008.
Switching from another method: start immediately
Miscarriage or abortion: anytime within 7 days (after day 7 rule out pregnancy).

4. Counseling about Progestin-Only Injectables: Describing Side Effects
If you choose this method, you may have some side-effects. They are not usually signs of illness.
Very common:
Changes to monthly bleeding
Adapted from WHO’s Decision-making tool for family planning clients and providers.
Counseling—both prior to the first injection and for women already using injectables—is the best way to help women manage the side effects associated with progestin-only injectables.
Before giving the injection, ensure that the client understands the most common side effects of progestin-only injectables, especially changes in bleeding patterns.
Irregular bleeding: For the first several months: irregular bleeding (bleeding at unexpected times), prolonged bleeding, frequent bleeding. Later (after 12 months of use) no monthly bleeding at all.
Weight gain: Gaining about 1–2 kg per year is also commonly experienced.
Other side effects: Headaches, dizziness, abdominal bloating/discomfort, mood changes, and changes in sex drive are examples of less common side effects associated with progestin-only injectables.
Women who are considering using progestin-only injectables should be counseled that menstrual changes are expected and that these and other side effects are not signs of disease or health problems. Some women may not have any side effects.
After giving the injection, the practitioner should tell clients to come back if they have any questions or concerns. Ongoing counseling and reassurance should be provided if needed.
If the user continues to be concerned or if she finds the side effects unacceptable, it may be necessary to treat the side effects or advise the client to choose a different method.
Very common:
Weight gain
Less common:
Some others

5. Counseling about Progestin-Only Injectables: Getting Your Injection
Insertion and removal should be quick and easy
Either in your hip, arm or your buttock
Don’t rub the injection site afterwards
Expect menstrual bleeding changes
Seek help for problems or concerns at a health care facility
No protection from STIs and HIV
When to come back:
For DMPA: every 3 months (13 weeks)
For NET-EN: every 2 months (8 weeks)
Come back even if you are late
Adapted from WHO’s Decision-making tool for family planning clients and providers.
After a client has made an informed choice to use an injectable contraceptive, it is imporant that she know what will happen during insertion:
Injectables usually only take a few minutes to insert, but can sometimes take longer.
Complications related to the insertion are rare.
The provider will carefully clean the area on the arm, hip, or buttock and will use sterile gloves and equipment.
The client will receive a small injection under the skin so that she will not feel the implant being inserted. The injection may sting a bit and the client will be awake during the procedure.
The client should not massage or rub the injection site after the injection, because that can cause the DMPA or NET-EN to be absorbed too quickly.
The client should expect menstrual bleeding changes such as longer periods of bleeding, bleeding at unexpected times, or no bleeding at all.
The client seek help from a provider at a health care facility if she is concerned that there is something seriously wrong with her health, such having severe headaches, severe abdominal pain, heavy or long bleeding (bleeding taht is more than eight days long or twice as heavy as usual), or yellow skin or eyes that may indicate a serious liver condition.The client should keep in mind that injectables do not protect against STIs, including HIV, and should therefore consider using condoms to avoid infection.
The client should return for next injection on time. If she is late for reinjection, she should use condoms or abstain if she does not want to become pregnant.

6. Counseling about Progestin-Only Injectables: Post-Injection Messages
What to remember:
Name of your injectable:
When to come for next injection:
Bleeding changes and weight gain are common. Come back if they bother you.
See a nurse or doctor if:
Unusually heavy or long bleeding
Yellow skin or eyes
A bright spot in your vision before bad headaches
Adapted from WHO’s Decision-making tool for family planning clients and providers.
After giving a client an injection of DMPA or NET-EN, counsel her about the following:
Remember the type of injectable she received (DMPA or NET-EN).
Do not massage the injection site, as that can cause the DMPA or NET-EN to be absorbed too quickly.
Expect bleeding changes, such as prolonged, irregular or frequent bleeding for the first several months and, later, no monthly bleeding at all. These changes are not harmful to her health.
Set a date for a reinjection. It is important to return on time, no more than four weeks late; always return for reinjection no matter how late.
Return if she has problems or concerns, especially if she develops new serious health problems or experiences bad headaches which follow a bright area of lost vision in one eye, also known as a migraine aura; or notices yellow skin or eyes that may indicate jaundice.
Keep in mind that injectables do not protect against STIs including HIV and consider using condoms to avoid infection.

7. Counseling about Progestin-Only Injectables: Counseling Reduces Discontinuation
Women who receive appropriate counseling more likely to continue using injectables.
After injections begin, counseling and reassurance should be provided as needed.
Providers must be sure that the woman has made an informed choice to use injectables and carefully considered these factors:
Safety and effectiveness of injectables and how it helps her achieve her reproductive goals
Anticipated menstrual bleeding and other potential side effects
The timing of return to fertility after injections are discontinued
The need for regular, timely injections
Need for STI protection (use of condoms for dual protection)
Characteristics of the injectable and how its use might affect her lifestyle, including her relationship with her partner
Ask participants: what do you think is the most common reason that women stop using injectables? <accept responses from several participants>
Although knowing how to give an injection safely is a very important skill, knowing how to counsel your clients appropriately is equally important.
A client’s satisfaction with any contraceptive method depends greatly on counseling. With injectable contraceptives, the quality of counseling has a large effect on whether women discontinue the method because of side effects. Women’s concerns over prolonged or heavy bleeding should never be disregarded or considered unimportant. Changes in menstrual bleeding–such as prolonged, irregular, or frequent bleeding resulting from DMPA or NET-EN use–are the most common reason for discontinuation. Women who are considering using DMPA or NET-EN should be counseled that such changes in bleeding are normal and expected; they are not signs of disease or health problems. After injections begin, counseling and reassurance should be provided as needed. Providers should encourage women to return to clinic if they have questions or concerns about side effects.Women are much more likely to continue using DMPA or NET-EN if they have received adequate counseling about the possibility and meaning of side effects. Researchers found that women who had been counseled about side effects were more than three times as likely to continue using the method as women who had not been counseled. The sites that provided better counseling had lower discontinuation rates.When a woman chooses an injectable contraceptive, the provider must be sure that she has made an informed choice to use the method and has carefully considered the factors listed on the slide.
If a DMPA or NET-EN user is experiencing severe bleeding, medical treatment or discontinuation of the injectable may be necessary, especially in cases where the woman has anemia.

8. Correcting Rumors and Misunderstandings
Progestin-only injectables:
Can stop monthly bleeding, but this is not harmful
Blood is not building up inside the woman
It is similar to not having menses during pregnancy
Usually not a sign of pregnancy
Does not cause an abortion/disrupt an existing pregnancy.
Do not make women infertile
What are some common misconceptions about progestin-only injectables? <accept responses from several participants; click the mouse to reveal the answers>
Explain that rumors are unconfirmed stories that are transferred from one person to another by word of mouth. In general, rumors arise when:
An issue or information is important to people, but it has not been clearly explained. There is nobody available who can clarify or correct the incorrect information. The original source is perceived to be credible. Clients have not been given enough options for contraceptive methods.
People are motivated to spread them for political reasons.
A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
Discuss methods for counteracting rumors and misinformation:
When a client mentions with a rumor, always listen politely. Don't laugh.
Define what a rumor or misconception is.
Find out where the rumor came from and talk with the people who started it or repeated it. Check whether there is some basis for the rumor.
Explain the facts.
Use strong scientific facts about FP methods to counteract misinformation.
Always tell the truth. Never try to hide side effects or problems that might occur with various methods.
Clarify information with the use of demonstrations and visual aids.
Give examples of people who are satisfied users of the method (only if they are willing to have their names used). This kind of personal testimonial is most convincing.
Reassure the client by examining her and telling her your findings.
Counsel the client about all available FP methods.

9. Management of Side Effects: Bleeding Changes
Counseling and reassurance are key
Problem
Action/Management
Irregular bleeding
(spotting or light bleeding at unexpected times that bothers the client)
Reassure client that this is common and not harmful
Recommend a 5-day course of mefenamic acid (500 mg 2 times per day after meals)
Or 40 mg valdecoxib daily for 5 days, beginning when irregular bleeding starts
If side effects persist and are unacceptable to the client, help her choose another method
Amenorrhea
Reassure client: no medical treatment necessary
The best way to reduce the anxiety some women feel when they experience side effects is to provide reassurance and address her concerns through follow-up counseling.
Irregular bleeding:
For complaints about irregular bleeding, which may be defined as spotting or light bleeding at unexpected times that bothers the client, the provider should explain that this bleeding is common in the first few months of using injectables and reassure the client that it is not harmful and that it usually becomes less or stops after the first few months of use.
If the irregular bleeding is unacceptable, the provider may recommend 500 mg of mefenamic acid two times daily after meals, or 40 mg of valdecoxib daily, for five days. <use local brand names of these medications> Note that these are short-term treatments that are only mildly effective. Women who are experiencing irregular bleeding should not take aspirin, since it may increase bleeding.
Amenorrhea:
Amenorrhea is another common side effect of injectables. Some women consider amenorrhea to be an advantage of using injectables, but others may be concerned about this side effect. Amenorrhea associated with DMPA and NET-EN use does not present a health risk or require medical treatment.
If the provider has no reason to suspect pregnancy, counseling and reassurance are the only tools needed for management of amenorrhea. Women need to be reassured that amenorrhea is normal for DMPA and NET-EN users. Women should understand that in this case amenorrhea does not indicate pregnancy. Women may also need to be reassured that the absence of menses does not mean that toxic blood is building up inside their bodies, that they have become infertile, or that they have reached premature menopause.
Source: CCP and WHO, 2011.

10. Management of Side Effects: Bleeding Changes, continued
Problem
Action/Management
Heavy or prolonged bleeding
(twice as much as usual or longer than 8 days)
Reassure client that this is common, not harmful
Recommend 5-day course of mefenamic acid (500 mg 2 times per day after meals); or 40 mg valdecoxib daily for 5 days; or COCs daily for 21 days; beginning when heavy bleeding starts
Suggest iron tablets and foods high in iron to prevent anemia
Consider underlying conditions if heavy bleeding continues or starts after several months
If bleeding becomes a health threat, of if the woman wants, help her choose another method
If a client complains about heavy or prolonged bleeding, the provider should first reassure her that some women using progestin-only injectables experience heavy or prolonged bleeding, and that it is not harmful and usually becomes less or stops after a few months.
For modest, short term relief, she can try (one at a time), beginning when heavy bleeding starts:
500 mg of mefenamic acid two times daily after meals for five days
40 mg of valdecoxib daily, for five days
COCs once a day for 21 days. (50 µgm of ethinyl estradiol daily for 21 days)
Women who are experiencing heavy bleeding should not take aspirin, since it may increase bleeding, not decrease it.
If bleeding is very prolonged or heavy—twice as much as usual or longer than eight days—the provider can suggest that the woman take iron tablets to help prevent anemia.
If irregular or heavy bleeding continues to bother the client beyond the first six months of injectables use, or starts after several months of normal monthly bleeding or amenorrhea, the provider should rule out a possible underlying condition unrelated to method use, such as uterine fibroids, a sexually transmitted infection, genital cancer, or pregnancy.
If side effects persist and are unacceptable to the client, the provider should help her choose another contraceptive method.
Source: CCP and WHO, 2011.

11. Management of Side Effects: Other Side Effects
Problem
Action/Management
Common headaches, dizziness
Reassure and suggest pain relievers; evaluate headaches that worsened after starting injectables.
Dizziness: consider local remedies.
Abdominal bloating/ discomfort
Reassure; suggest local remedies.
Refer for care if abdominal pain is severe.
Changes in mood or sex drive
Ask about changes in life that could affect mood or sex drive, including relationship changes.
Give support as appropriate.
For serious mood changes, refer for care.
Weight gain
Review diet and counsel as needed.
There are several other side effects that clients who are using progestin-only injectables may experience, including headaches, abdominal bloating, changes in mood or sex drive, and weight gain.
Common headaches, dizziness: If a client experiences frequent headaches that are not migraines, reassure her that ordinary headaches do not indicate dangerous conditions and usually diminish over time. Standard doses of painkillers such as ibuprofen, paracetamol, or other pain relievers may be used to alleviate symptoms. However, evaluate headaches that get worse or occur more often after starting to use injectables. For dizziness, consider locally available remedies, such as <give example of a locally available remedy for dizziness>.
Abdominal bloating/discomfort: For abdominal bloating and discomfort, reassure the client that other injectables users have reported this and that it is not serious, and suggest locally available remedies. However, if abdominal pain becomes severe, refer at once for immediate diagnosis and care. This is especially true if the severe abdominal pain occurs with other signs or symptoms of ectopic pregnancy—abnormal vaginal bleeding or no monthly bleeding (especially if this is a change from her usual bleeding pattern), light-headedness, dizziness, or fainting. Ectopic pregnancy is rare but can be life-threatening.
Changes in mood or sex drive: For a client who experiences changes in mood or sex drive, ask about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give support as appropriate. Clients who have serious mood changes, such as major depression, should be referred for care.
Weight gain: In case of weight gain, review the client’s diet and counsel her about healthy eating habits and exercise as a way to better control her weight.
If side effects persist and the client wants to stop using injectables, health providers should counsel her about non-hormonal options, and help the woman choose another method.
Source: CCP and WHO, 2011.

12. Problems That May Require Switching from Injectables to Another Method
Action/Management
Unexplained vaginal bleeding
Refer or evaluate by history and pelvic exam.
If an STI is diagnosed, she can continue using injectables during treatment.
If no cause can be found, consider stopping injectables to make diagnosis easier.
Migraines
If client has migraines without aura, she can continue to use injectables.
If she has migraine aura, do not give the injection. Help her choose a method without hormones.
Certain serious health conditions
Do not give next injection.
Give client backup method to use until condition is evaluated.
Refer for diagnosis and treatment..
There are some serious health problems which may require that a client stop using progestin-only injectables.
Unexplained vaginal bleeding: If a client experiences unexplained vaginal bleeding or heavy or prologned bleeding that is suggestive of a medical condition not related to the method, she may need to discontinue injectables. Refer the client or evaluate by taking her medical history and doing a pelvic examination. Diagnose and treat as appropriate. If no cause of bleeding can be found, consider stopping injectables to make the diangosis easier. Provide the client with another contraceptive method of her chocie until the condition is evaluated and treated. The alternative method should be something other than progestin-only implants or a copper-bearing or hormonal IUD. If the bleeding is caused by a sexually transmitted infection or PID, the client can continue using injectables during treatment.
Migranes: Women with migraine headaches without aura can continue using injectables. Although women who have migraine headaches with an aura can initiate injectables, if a women develops migraines with aura after starting injectables, do not give the next injection. Help her choose a non-hormonal method.
Certain serious health conditions: If a woman develops a serious health condition (susptected blocked or narrowed arteries, serious liver disease, severe high blood pressure, blood clots in the deep veins of the legs or lungs, severe liver disease, stroke, or damage to arteries, vision, kidneys or nervous system cause by diabetes), do not give the next injection. Help her choose a non-hormonal method.
Finally, if a woman is pregnant, stop injections. However, there are no known risks to a fetus conceived while a woman is using injectables.
Source: CCP and WHO, 2011.

13. DMPA Injection Schedule
150 mg DMPA
Injection every 13 weeks (or 3 months)
Can be up to 2 weeks early or 4 weeks late
A woman should receive an injection of 150 mg DMPA once every three months or 13 weeks.
However, there is a safe window (“grace period”) for repeat injections—that is, how early or late the injection can be given while maintaining effective contraception.
For DMPA, this window is up to two weeks before or four weeks after a scheduled reinjection date. For example, <pick up a calendar or point to one displayed in the room> let’s say a client named Gloria had her first DMPA injection on September 1. Her scheduled reinjection date would be 13 weeks after that, or December 1. Ask participants: When would the safe reinjection window start and end for Gloria? <allow for participant responses, and affirm the correct answer> It would begin November 17 and close December 29.
If Gloria returns more than four weeks late, or after December 29, she can still receive an injection if the provider can rule out pregnancy. If pregnancy is ruled out and she receives the injection, Gloria should use a backup method for the next seven days, and she should be counseled that delaying injections increases the risk of pregnancy.
Source: WHO, 2010

14. NET-EN Injection Schedule
Injection every 8 weeks (every 2 months)
Can be up to 2 weeks early or 2 weeks late
A woman should receive an injection of 200mg NET-EN once every eight weeks (or two months).
However, there is a safe window for repeat injections (“grace period”)—that is, how early or late the injection can be given while maintaining effective contraception.
The safe window for repeat injections for NET-EN is up to two weeks before or two weeks after a scheduled reinjection date
For DMPA, this window is up to two weeks before or four weeks after a scheduled reinjection date. For example, <pick up a calendar or point to one displayed in the room> let’s say a client named Martha had her first NET-EN injection on September 2. Her scheduled reinjection date would be eight weeks after that, or October 28. Ask participants: When would the safe reinjection window start and end for Martha? <allow for participant responses, and affirm the correct answer> It would begin October 14 and close on November 11. If Martha returns more than two weeks late, or after November 11, she can still receive an injection if the provider can rule out pregnancy. If pregnancy is ruled out and she receives the injection, Martha should use a backup method for the next seven days, and she should be counseled that delaying injections increases the risk of pregnancy.
Women who take certain medications, such as ARV therapy, or anti-seizure or TB medications, should be encouraged to receive the next injection by the end of the eight week period.
Source: WHO, 2010

15. Managing Late Injections
Rule out pregnancy using one of following:
Option 1: Modified pregnancy checklist
Option 2: Pregnancy test
Option 3: Bimanual pelvic exam for comparison at follow-up
Option 4: Abdominal exam
Assess if returning within reinjection window may remain a problem, if yes, discuss other method options
Ask participants: What should you do when a DMPA client returns more than four weeks late, or a NET-EN client returns more than two weeks late? <allow participants to respond>
There are two things you should do: First, rule out pregnancy and second, assess if returning within the reinjection window might remain a problem. If it will, discuss other method options that might be more suitable for the client.
To rule out pregnancy in this situation, providers have these four options, which are also described on page two of the DMPA and NET-EN job aids for reinjection (Handouts #14 and 15):
Use the modified pregnancy checklist.
Use a pregnancy test.
If a pregnancy test is not available, conduct a bimanual pelvic examination to determine the size of the uterus for comparison at a follow-up visit.
If a pregnancy test or bimanual pelvic examination are not available, do an abdominal examination and give her a backup method to use until her return visit for another abdominal examination in 12 to 14 weeks to see if the uterus could be located through the abdominal wall, or during her next menses, whichever comes first.

16. Injectables: Summary Safe and highly effective Easy to use
Most women can use
Bleeding changes may be a concern for some women
Can be provided in both clinical and non-clinical settings
Need appropriate counseling
See Facilitator’s Guide for instructions on roleplays and case studies
In conclusion, progestin-only injectables have characteristics that make them a desirable method for many women.
They are safe.
They are highly effective.
They are easy to use correctly.
They can be delivered in both clinical and nonclinical settings.
Appropriate counseling plays a key role in the provision of injectable contraceptives.
While it is relatively simple to administer injectables correctly, providers also need to counsel clients about the characteristics of progestin-only injectable contraceptives, with special attention to side effects, and be able to manage side effects.
Family planning programs that offer progestin-only injectable contraceptives give their clients more options for contraception.