Presentation on theme: "Session I: Characteristics of Progestin-Only Injectables"— Presentation transcript:
1 Session I: Characteristics of Progestin-Only Injectables Progestin-Only Injectable ContraceptivesSession I: Characteristics of Progestin-Only InjectablesPhoto credit: FHI (packaging from socially marketed DMPA in Kenya and Uganda)
2 Objectives At the end of this session, participants will be able to: Describe the characteristics of progestin-only injectables in a manner clients can understand:What progestin-only injectables are and how they work (mechanism and onset of action)EffectivenessSide effectsNon-contraceptive health benefitsPossible health risks (complications)Other characteristics (STI/HIV protection, ease of use, return to fertility, when to initiate and discontinue)By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud>.Progestin-only injectable contraceptives are safe and highly effective, and many women find that they are convenient to use.Injectables can be provided in different settings by a wide range of providers. Providers find that injectables are easy to provide, and many women find that they are easy to use.The session is designed to address the objectives for this method listed in the Facilitator’s Guide and on the slide set.This presentation provides an overview of the characteristics of this method. It also provides training on how to counsel, screen, and provide follow-up to clients who are interested in using progestin-only injectables as a way to regulate their fertility.During this training you will learn and demonstrate these skills during role plays and other activities. You will also be encouraged to think about what it will be like to perform these tasks on-the-job.Review objectives with participants.Solicit input about whether the planned objectives match participant’s expectations of the training.
3 Objectives Demonstrate the ability to: Screen clients for medical eligibility for injectablesExplain to clients the insertion, removal, and follow-up proceduresExplain when to return to the clinicAddress common concerns, misconceptions, and mythsConduct follow-up for injectable clients in a way that enhances continuing safety, satisfaction, and acceptanceDescribe when to start use of injectables.Explain how to manage side effects.Identify conditions that require switching to another method.Identify clients in need of referral for injectable-related complications.Demonstrate the preparation of supplies, equipment, and the client and the technique of administration (using a fruit or vegetable).By the end of this training session, participants will be able to: <click the mouse to advance through the objectives, reading each objective aloud>.
4 Key Points for Providers and Clients An injection every 2 or 3 months, depending on typeA contraceptive method given by deep intramuscular injection.Contains progestin (similar to the natural hormone progesterone), that is slowly released into blood from injection site.DMPA and NET-EN are the scientific names.Works mainly by stopping ovulation.No supplies needed at home.Very effective and safeVery effective, provided client returns for injection at right time.Do not cause any serious health problems, cancer, or infertility, nor do they produce any significant change in blood pressure.For breastfeeding women, they do not affect the quality of the breast milk.Adapted from WHO’s Decision-making tool for family planning clients and providers.Progestin-only injectables are contraceptives that are given by deep intramuscular injection.They contain the synthetic hormone progestin, similar to the hormone progesterone in a woman’s body.The hormone is released into the blood gradually from the injection site, thereby providing contraception over a period of time.Note to facilitator: If participants also provide combined injectables (contain both estrogen and progestin and given monthly), clarify that although both are given by injection, they have many important differences. This presentation addresses only progestin-only injectables.
5 Key Points for Providers and Clients Often takes longer to get pregnant after stoppingAfter stopping progestin-only injectables, there is a delay of several months before most women can get pregnant, and for some women it may be even longer.They do not make women permanently infertile.Changes in monthly bleedingThe most commonly reported side effects of progestin-only injectables are menstrual changes.In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding. After one year, women commonly experience infrequent bleeding, irregular bleeding and amenorrhea.No protection against STIs or HIV/AIDSProvide no protection from STIs/HIV.For STI/HIV/AIDS protection, also use condoms.Adapted from WHO’s Decision-making tool for family planning clients and providers.
7 Effectiveness of Injectables In this progression of effectiveness, where would you place progestin-only injectables?ImplantsMale SterilizationFemale SterilizationIntrauterine DevicesCombined Oral ContraceptivesMale CondomsStandard Days MethodFemale CondomsSpermicidesMore effectiveAsk participants: Where would you put progestin-only injectables, or DMPA, on this list? After participants respond, click the mouse to reveal the answer.The purpose of this discussion is to emphasize the effectiveness of progestin-only injectables.The list on this slide categorizes contraceptive methods from most effective to least effective as commonly used. In this list, spermicides are the least effective method and the most effective methods are sterilization and implants.Ask participants: Where would you put progestin-only injectables on this list? <after participants respond, click the mouse to reveal the answer>Conduct Counseling Role Plays conveying information about method effectivness.Conclude by emphasizing that progestin-only injectables are at the top of the second tier of methods, as they are very effective methods of contraception. Only the intrauterine device (IUD), male and female sterilization, and implants are more effective than progestin-only injectables.InjectablesLess effective
8 Relative Effectiveness of Family Planning Methods # of unintended pregnancies among1,000 women in 1st year of typical useNo method850Withdrawal220Female condom210Male condom180Pill90Injectable60IUD (CU-T 380A / LNG-IUS)8 / 2Female sterilization5Vasectomy1.5Implant0.5Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) , Elsevier Inc.Explain that there is another way to look at effectiveness. In this slide we look at how effective FP methods are as they are commonly used.The slide shows the number of women who would get pregnant if 1,000 women used a method for one year. So, if 1,000 fertile women who were having sex, but not using any protection from pregnancy, 850 of them would become pregnant.But, if the same 1,000 women were using an injectable, 60 would become pregnant.As a part of good counseling, it is important to inform clients about how effective each method is.Ask participants:What if these same women were using the pill? How many would become pregnant?
9 Progestin-Only Injectables: Mechanism of Action Thicken cervical mucus to block spermSuppress hormonesresponsible forovulationNote: Do not disrupt existing pregnancyExplain that progestin-only injectables prevent pregnancy in two ways:The primary mechanism of action is to suppress ovulation. Progestin causes the hypothalamus and the pituitary gland to reduce production of the hormones that are necessary for ovulation. Without ovulation, there is no egg to be fertilized.Progestin also thickens the cervical mucus. The thickened mucus makes it more difficult for sperm to enter the uterine cavity. In the unlikely event that a woman does ovulate, this mucus barrier greatly reduces the chance that the egg will be fertilized.Other contraceptive methods that work this way are implants and combined oral contraceptives (COCs).Progestin-only injectables do not disrupt an existing pregnancy and do not harm a fetus if a woman is accidentally given this method when she is already pregnant. However, if it is determined that a woman who is using injectables is, indeed, pregnant, she should stop receiving injections.Note to facilitator: In many places it is a common myth that injectables will abort an existing pregnancy or harm a fetus, so it is important to counter this belief and emphasize the fact that progestin-only injectables do not disrupt an existing pregnancy or harm a fetus if a woman is already pregnant when she has receives an injection. More information about misconceptions and rumors about injectables will be discussed further in Session III.Source: Kingsley F and Salem R,
10 Characteristics of Progestin-Only Injectables Safe and very effectiveEasy to use; requires no daily routineLong-lasting and reversibleCan be discontinued without provider’s helpCan be provided outside of clinicsCan be used by breastfeeding womenUse can be privateDoes not interfere with sexCan be used by breastfeeding womenProvide non-contraceptive health benefitsHave side effectsCause delay in return to fertilityEffectiveness depends on user getting injections regularlyProvide no protection from STIs/HIVInstructions for facilitator:Ask participants to brainstorm first a list of positive characteristics (advantages) and then negative characteristics (limitations) of progestin-only injectables. Write these suggested characteristics on a flip chart. Then show the slides of characteristics of progestin-only injectables and compare them to the list generated through brainstorming.If you use the terms advantages and limitations, mention that the same characteristic of a FP method may be an advantage for one person and a limitation to another.Discuss and correct any misconceptions and counter any myths that may arise about progestin-only injectables.Remind participants that people with similar characteristics in similar situations may have very different reasons for making choices about contraceptive methods. When counseling clients it is important to help them consider how these method characteristics fit with their lifestyles and reproductive health goals and desires.Source: CCP and WHO, 2011
11 Progestin-Only Injectables: Health Benefits Help protect against:Risks of pregnancyEndometrial cancerUterine fibroidsMay help protect against symptomatic pelvic inflammatory disease (PID) and iron-deficiency anemiaReduce sickle cell crises in women with sickle cell anemiaReduce symptoms of endometriosis (pelvic pain, irregular bleeding)In addition to preventing pregnancy, progestin-only injectables provide a number of health benefits to users including:They help protect against endometrial cancer and uterine fibroids.They may help protect against symptomatic pelvic inflammatory disease (PID) and iron-deficiency anemia.They reduce sickle cell crises in women with sickle cell anemia2They also reduce the symptoms of endometriosis, including pelvic pain, and irregular bleeding.Source: CCP and WHO, 2011; Manchikanti, 2007.
12 Injectables and Risk of Breast Cancer No effect on overall risk of breast cancerOlder studies found a somewhat increased risk during first 5 years of useMay be due to detection bias or accelerated growth of pre-existing tumorsRecent large study found no increased risk in current or past DMPA users regardless of age and duration of useLittle research has been done on NET-ENProgestin-only injectables have no effect on a client’s overall risk of breast cancer. Older studies had found a somewhat increased risk of breast cancer among current users. But this finding was probably due to detection bias or accelerated growth of pre-existing tumors.A recent large study found no increased cancer risk in current or past DMPA users regardless of age and duration of use.No studies were done for NET-EN.Source: Strom et al, 2004
13 Effect of DMPA on Bone Density DMPA users have lower bone density than non-usersWomen initiating DMPA use as adults regain most lost boneLong-term effect in adolescents unknownConcerns about reaching peak bone massLong-term studies are neededGenerally acceptable to useMost studies have found that DMPA users have lower bone density than non-users, especially women age 21 or younger. A woman’s bones normally reach their maximum density during adolescence, but the use of DMPA during adolescence may affect peak bone mass.Women who start using DMPA as adults appear to regain most of the lost bone after they stop using DMPA.However, it is not yet known whether bone loss in adolescents and young women is completely reversible. One study found that adolescent NET-EN users recovered bone mass density after discontinuing.4 However, long-term studies are needed to determine whether DMPA use increases the risk of fracture, especially in women who begin using DMPA during adolescence.5 Currently, DMPA use is considered to be generally acceptable for adolescent clients, because preventing risks associated with unwanted pregnancy at a young age outweigh the theoretical risk of fracture later in life.Source: Cromer, 1996; Cundy, 1994; WHO, 2010.
15 Injectables: Return to Fertility Return to fertility depends on how fast a woman fully metabolizes the injectableOn average, women become pregnant 9–10 months after their last injection of DMPALength of time injectable was used makes no differenceReturn to fertility for injectables users depends on how long it takes a woman to fully metabolize the DMPA or NET-EN from her last injection. Because women differ in how they metabolize DMPA and NET-EN, there is considerable variability in how long it takes to become pregnant after discontinuation.In the case of DMPA, on average, women can become pregnant nine to 10 months after their last DMPA injection. Some women may become pregnant as soon as four months after the last injection, but a small percentage may take as long as 18 months. The average time it takes to become pregnant after discontinuing injectables is about four months longer for DMPA users and about one month longer for NET-EN users than for women who use other modern methods. The difference in fertility between former DMPA users and former users of other contraceptives disappears approximately 16 months after discontinuation.The length of time a woman has used DMPA or NET-EN makes no difference in return to fertility.Because of the delay in return to fertility, women should be counseled to consider discontinuing DMPA or NET-EN several months before the time they want to conceive.Sources: Pardthaisong, 1984; Schwallie, 1974.
16 Progestin-Only Injectables: Side Effects Many women experience no side effects. Possible side effects include:Abdominal bloating and discomfortAmenorrhea (no menses)Headaches and dizzinessIllustration credit: Ambrose Hoona-KabMany women experience no side effects, but some users of injectables experience side effects.The most commonly reported side effects of DMPA and NET-EN are menstrual changes, including prolonged, heavy or irregular bleeding, spotting, and amenorrhea.In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding.After one year, women commonly experience infrequent bleeding, irregular bleeding, and amenorrhea.Less than 10% of DMPA users have normal cycles in the first year of use (90% of users will have bleeding changes in the first year).Menstrual bleeding changes for any one client are unpredictable.About 47 percent of women, nearly half, develop amenorrhea and have no monthly bleedings after one year of DMPA useDMPA and NET-EN users also commonly report weight gain, although some injectables users report weight loss while others report no change in weight.Less commonly reported side effects are headaches; dizziness; abdominal bloating and discomfort; mood changes, such as anxiety; and changes in sex drive. It is difficult to determine wither a change in a woman’s mood or reduced sex drive is related to DMPA or NET-EN or to other reasons; there is no evidence that injectables affect a woman’s sexual behavior.Typically, nine out of ten of injectables users report at least one side effect during the first year of use. In most cases, none of these side effects result in health risks. Nonetheless, some side effects, such as changes in bleeding, may have serious practical and social consequences for women.About one third of users discontinue in the first year due to side effects.It is important to reassure clients that side effects are experienced by many women who use injectables and they are not signs of illness.Weight gainChanges in mood and sex driveProlonged or heavy bleeding irregular bleeding or spotting
17 Group Activity Injectables Fact Sheet Review the fact sheet.What additional questions or comments do you have about the characteristics of progestin-only injectables?Introduce the fact sheet and ask participants to review the first page.Ask participants if there are any additional comments or questions about the characteristics of implants.Discuss and clarify as needed.Ask participants to consider how they might be able to use the fact sheet in their work. Remind participants that although it might be useful for helping providers to remember important information to share with clients, the fact sheet is not intended to be used as a brochure to be distributed to clients.Ask participants to review page two of the fact sheet. Inform the participants that the next segment of the training will address the issues outlined on page two of the fact sheet.