Sunday 5 February 2017

Injectable

Injectable

Description

Depo-Provera® (depot medroxyprogesterone acetate, or DMPA) is a progestin-only method. It is a 3-month injectable that delivers either 104 mg (in the subcutaneous formulation) or 150 mg (in the intramuscular formulation) of medroxyprogesterone acetate to inhibit ovulation. DMPA is a good contraceptive choice for women who cannot use estrogen.

Use

A provider administers the DMPA injection to the patient

Injectable (Depo-provera)

subcutaneously or intramuscularly every 3 months. DMPA can be administered up to 2 weeks early or 2 weeks late (i.e., 10 to 14 weeks after the last injection) without the need for a protective back-up contraceptive method. If it is more than 2 weeks late, the injection can be administered if the woman is reasonably certain that she is not pregnant. Additional contraceptive protection should be used for the next 7 days.39

Effectiveness

This method is very effective.40 The failure rate with perfect use is 0.2 percent and with typical use is 6 percent.19 The convenience and high efficacy rate of DMPA have made this contraceptive method increasingly popular with teens.41

Risks

Effects on bone (see box) 
Dispelling Myths About DMPA and Bone Health
  • In 2004, the FDA approved a "black box" warning regarding use of DMPA and loss of bone mineral density, based on clinical data showing a significant loss of BMD among women using DMPA.42 Ample research evidence suggests that the effects of DMPA on bone health may be less concerning that originally believed.
  • Premenopausal women who use DMPA for up to 5 years experience BMD loss similar to that associated with breastfeeding, and the loss is substantially reversed after cessation of DMPA.43
  • The reliance on surrogate markers of bone loss may have heightened the concern about the effects of DMPA on bone; use of a surrogate endpoint (i.e., BMD) rather than a clinical endpoint (i.e., fracture) may have led to an inaccurate or overestimated assessment of the risks associated with DMPA.44 
  • Longer-term studies suggest that BMD may not be as affected by DMPA as suggested in studies of shorter duration. A 3-year observational study of established DMPA users > age 35 years (i.e., women who had attained peak bone mass) found that despite increased levels of bone turnover markers, BMD was not reduced in the hip or spine.45 
  • Experts have called for removal of the black box warning. 
  • The American Congress of Obstetricians and Gynecologists (ACOG) and the World Health Organization support long-term contraceptive use of DMPA for women 18–45 years old.46
  • In an opinion published in October 2008, ACOG recommended that clinicians not allow concerns about the effects of DMPA on BMD to prevent their prescribing the contraceptive or limit use to 2 years.47 Instead, clinicians should inform women about the relative benefits and risks so they can weigh the risk of fracture with the risk of unintended pregnancy. The opinion piece noted that the reduction in BMD associated with DMPA use is similar to that seen during pregnancy and breastfeeding (approximately 3 to 5 percent per year).
  • Data on the effects of DMPA on bone health in individuals who have not yet attained peak bone health are not clear. The use of DMPA is designated category 1 or 2 for adolescents and perimenopausal women.5

Side Effects

Side effects include weight gain and menstrual cycle changes. Nearly all women experience alterations in the menstrual cycle—irregular bleeding, spotting, or rarely, heavy bleeding. After 6 months, fewer women experience excessive or frequent bleeding, and more women experience amenorrhea. By 1 year, up to 70 percent of women have amenorrhea.48

Contraindications and Precautions

Medical Eligibility Criteria for DMPA
Category 4
(unacceptable health risk if the contraceptive method is used)
  • Current breast cancer
Category 3
(theoretical or proven risks usually outweigh the advantages of using the method)
  • Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
  • Hypertension (systolic >160 mm Hg or diastolic >100 mm Hg)
  • Vascular disease
  • Ischemic heart disease or stroke (current or history of)—for initiating or continuing method
  • SLE (positive for antiphospholipid antibodies or status unknown; or if severe thrombocytopenia)
  • Rheumatoid arthritis (designated category 2 if not on long-term corticosteroid treatment with a history of or risk factors for non-traumatic fractures)
  • Migraine with aura—for continuing method (i.e., if migraines worsen in a woman who is already using DMPA)
  • Unexplained vaginal bleeding prior to evaluation
  • Breast cancer in past; no evidence of disease for 5 years
  • Diabetes (only if nephropathy, retinopathy, neuropathy, or other vascular disease is present, or the duration of diabetes is >20 years)
  • Severe cirrhosis
  • Malignant liver tumor
  • Certain antiretroviral and anticonvulsant medications (some are designated category 2)
Source: Reference 5

Advantages

  • Convenient, requires only four shots per year
  • Discreet
  • Very effective
  • Reversible
  • Amenorrhea (may improve conditions such as menorrhagia, dysmenorrhea, and iron deficiency anemia); may be a desired lifestyle change; can also decrease the risk of dysfunctional menstrual bleeding in women who are overweight
  • Lack of estrogen in DMPA makes it appropriate for smokers older than age 35, postpartum breastfeeding women, and others who have contraindications to estrogen
  • Reduces the risk of endometrial cancer by up to 80 percent, with continuing protection after discontinuation49
  • Reduces risk of PID 50 and uterine leiomyomata51
  • Can decrease the number and severity of crises in patients who have sickle cell anemia52
  • Can decrease frequency of seizures and does not interact with anti-epileptic medications53

Disadvantages

  • Requires visit to clinician for quarterly injection
  • Initial irregular bleeding
  • Weight gain may occur in some women due to increased appetite, particularly those who are sedentary or overweight when they begin to use DMPA54 (Weight gain of 5 percent or more in the first 6 months of use may signal risk of continued weight increase while on DMPA55)
  • Short-term, reversible BMD loss
  • Delayed return to fertility: the median time to conception for those who do conceive is 10 months after the last injection, much longer than with other hormonal methods
  • No protection against STIs

Counseling Messages


  • Bleeding profile improves over time; amenorrhea, which occurs in about half of users after 1 year of use, may be an advantage or disadvantage, depending on the woman.56
  • It is important to consider genetic and lifestyle factors that contribute to osteoporosis when weighing the benefits and risks of DMPA.
  • It is important to promote bone health with weight-bearing exercise, intake of calcium and vitamin D, avoidance of tobacco, and limits on alcohol.
  • Non-hormonal back-up contraception is needed for the first 7 days.
  • This method does not protect against STIs.
  • The CDC updated its recommendations in 2012 to indicate that data are inconclusive as to whether women using DMPA might be at increased risk for HIV acquisition, and that these women should be strongly advised to always also use either female or male condoms and take other HIV prevention measures.57
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ORAL CONTRACEPTIVES

Some medicines are not suitable for people with certain conditions, and sometimes a medicine may only be used if extra care is taken. For these reasons before you start taking a combined hormonal contraceptive, it is important that your doctor knows:
  • If you are breast-feeding or think you may be pregnant.
  • If you or a close family member have ever had a clot in a blood vessel, or any circulation problems.
  • If you have ever had a problem with your veins (such as superficial thrombophlebitis).
  • If you smoke.
  • If you have high blood pressure.
  • If you have a breast lump or have had breast cancer.
  • If you have any problems with the way your liver works, or if you have gallstones.
  • If you have heart problems, migraine, or diabetes.
  • If you have any vaginal bleeding other than your normal monthly period.
  • If you are not fully mobile for any reason.
  • If you have ever had depression.
  • If you have had a transient ischaemic attack (TIA), sometimes called a 'mini-stroke'.
  • If you or a close relative have ever had high blood levels of fats (lipids).
  • If during a pregnancy you have had problems such as severe itching and blistering of your skin, jaundice, or any involuntary jerky movements.
  • If you have been told you have high levels of prolactin.
  • If you have an inflammatory bowel condition.
  • If you have systemic lupus erythematosus (often called SLE).
  • If you have sickle cell disease, porphyria, or if you have had haemolytic uraemic syndrome (these are blood disorders).
  • If you have ever had an allergic reaction to a medicine.
  • If you are taking any other medicines. This includes any medicines you are taking which are available to buy without a prescription, such as herbal and complementary medicines. This is important because some medicines may stop combined hormonal contraceptives from working properly.

If you are taking 'the pill'

  • Before you start taking the pill, read the manufacturer's printed information leaflet from inside your pack. It will give you more information about your specific brand of pill and will provide you with a full list of the side-effects which you may experience from taking it.
  • Take one tablet each day. Most pills are taken for 21 days of each menstrual cycle, leaving a seven-day pill-free interval. If you find it difficult to remember which weeks to take your tablets, your doctor may have given you the type of pill which is taken every day of the month. If you are unsure how to take the tablets, ask your doctor or pharmacist for advice.
What to do if you forget to take a pill
  • You should take your pill at the same time each day. If you forget to take it on time, take it as soon as you remember, and then the next dose at your usual time. Note: if you are taking Qlaira® or Zoely® and you are more than 12 hours late taking a pill, your protection against pregnancy may be reduced and you may need to use additional precautions such as a condom. Follow the instructions on the 'missed pill chart' in the leaflet from your pack of pills, which tell you what you need to do, as the following points do not apply to you.
  • If you miss one dose (this means you are 24-48 hours late taking a dose), take a pill as soon as you remember and then take the next dose at your usual time even if this means taking two pills together.
  • If you miss two or more doses, the pill may not work and you may not be protected from becoming pregnant. As soon as you remember, take a pill and then continue taking the tablets as normal. In addition, for the following seven days you must either use another method of contraception such as a condom, or avoid sex. If these seven days run beyond the end of your packet of pills, start the next packet straightaway without any tablet-free days. This means you may not have a period until the end of the two packets. If you are using an everyday (ED) pill, miss out the seven inactive pills (the pills you take while you are having a period). If you are not sure which these are or if you are unsure about the advice, speak with your doctor or pharmacist.
  • Important: if you miss two or more pills from the first seven tablets in the pack and you have had unprotected sex recently, ask your doctor or pharmacist for advice on what to do.

If you are using patches

  • Before you start using the patches, read the manufacturer's printed information leaflet from inside the pack. It will give you more information about the patches and will provide you with a full list of the side-effects which you may experience from using them.
  • Apply a patch on the first day of your period, and call this 'Day 1'. Change the patch for a fresh patch on the same day of the following week, and the week after that (that is, on 'Day 8' and 'Day 15' of your cycle). On 'Day 22' remove the patch and follow it with seven patch-free days before beginning a new cycle.
What to do if the patch comes loose or if you forget to change the patch
  • If a patch becomes detached and you notice this within 24 hours, you can either reapply the same patch, or replace it with a fresh patch. Then continue as before, applying your next patch on your usual 'change day'.
  • If a patch has been detached for more than 24 hours or if you do not know when it came off, start a new cycle by applying a new patch. You will also need to use another method of contraception such as a condom during the following seven days. This new patch is now your 'Day 1' patch and you must remember to change your patches on this same day of the week from now on.
  • If you forget to apply a patch at the start of a new cycle, you will not be protected. If this happens, apply a 'Day 1' patch as soon as you remember and use another method of contraception, such as a condom, during the following seven days. If you have had sex during the time when you were not wearing a patch, speak with your doctor or pharmacist for advice.
  • If you forget to change your patch on Day 8 or Day 15 but you remember when it is less than 48 hours overdue, change to a new patch straightaway and then remember to change it again on your usual change day.
  • If you forget to change a patch on Day 8 or Day 15 and you only remember when it is more than 48 hours overdue, you may not be protected. Remove the old patch and apply a new patch straightaway. You will also need to use another method of contraception such as a condom during the following seven days. The new patch is now your 'Day 1' patch and you must remember to change your patches on this same day of the week from now on.
  • If you forget to remove the patch at the end of a cycle (that is, on Day 22), remove it as soon as you remember and start your next cycle on your usual 'change day'.

If you are using the vaginal ring

  • Before you insert the ring, read the manufacturer's printed information leaflet from inside the pack. It will give you more information about the vaginal ring and how to insert it correctly, and will also provide you with a full list of the side-effects which you may experience from using it.
  • Insert one ring into your vagina on Day 1 of your cycle and then remove it on Day 22. After seven ring-free days, start another cycle. Remember to check the ring regularly to make sure it remains correctly in place.
What to do if your ring comes out
  • If your vaginal ring comes out but it is for less than three hours, rinse it in cool water and re-insert it straightaway. You will not need to use any additional contraception.
  • If your vaginal ring comes out for more than three hours (or if you do not know when it came out), you may not be protected from pregnancy. If this happens during week 1 or 2 of your cycle, rinse the ring with cool water and re-insert it. You will also need to use another method of contraception such as a condom during the following seven days. If this happens during week 3 of your cycle, you can either start a new cycle by inserting a new ring or (providing the ring has been used continuously for at least seven days before this happens) you can allow your period to occur and then insert a new ring within the next seven days.
  • If your ring breaks, remove it and insert a new ring straightaway. Use another method of contraception such as a condom during the following seven days.
  • If you forget to insert a new ring at the start of a new cycle, you will not be protected. If this happens, insert a new ring as soon as you remember and use another method of contraception such as a condom during the following seven days. If you have had sex during the time when you were not using a ring, speak with your doctor or pharmacist for advice.
  • If you forget to remove the ring at the end of a cycle, remove it as soon as you remember and leave seven ring-free days. After the seven ring-free days start another cycle. If you are more than a week late in removing the ring, you may no longer be protected. If this happens, speak with your doctor or pharmacist for advice.
  • The vaginal ring can occasionally be felt by sexual partners, although this is usually not a problem. If you choose to remove the ring before you have sex, make sure that you replace it again within three hours.
  • Try to keep your regular appointments with your doctor or clinic. This is so your doctor can check on your progress. You will need to have your blood pressure checked from time to time.
  • If you suspect at any time that you may be pregnant, stop using the contraception and see your doctor or pharmacist for a pregnancy test straightaway.
  • Important: if you have a bout of being sick (vomiting) or diarrhoea, it can reduce the effectiveness of the pill. If you are sick within two hours of taking a pill, take another pill as soon as possible. If the sickness continues, or if you have severe diarrhoea which lasts for more than 24 hours, you must also use another method of contraception. If this happens, use a condom if you have sex during the illness and for seven days after you recover (or nine days if you are taking Qlaira®). If the sickness and diarrhoea occur during the last week of your tablets, miss out the seven pill-free days and start a new pack of oral contraceptives straightaway. If you are taking an everyday (ED) brand of pill, miss out the seven inactive pills (the pills you take while you are having a period). If you are not sure which these are, or if you are unsure about the advice, speak with your doctor or pharmacist.
  • Your doctor will discuss the risks of contraception with you, and will advise you on the most suitable preparation to use. There is a slight increased risk of a clot in a blood vessel (thromboembolism), although the risk of this is still less than during a pregnancy. Travelling that involves long periods of sitting still (for example, flying for more than three hours) can add to the risk of a blood clot. It's always a good idea to exercise your feet and ankles regularly while travelling, and you may wish to consider wearing flight socks during long flights.
  • Before having any kind of surgery, you must tell your doctor or surgeon that you are using combined hormonal contraception. This is because your doctor may decide that you need to stop the contraception for a period of time to reduce your risk of unwanted blood clots.
  • Combined hormonal contraceptives do not protect you from sexually transmitted diseases or HIV infection. If you are concerned about either of these, ask your pharmacist or doctor for advice on safe sex.
  • If you buy any medicines or herbal remedies, always check with a pharmacist that they are safe to take with your method of contraception. Some remedies which can be bought 'over the counter' can interact with a hormonal contraceptive, making it less effective and increasing the risk of unplanned pregnancy. An example of this is the herbal remedy called St John's wort.
  • Taking combined hormonal contraception can increase the risk of some types of cancer, but it will also protect against other types. Research suggests a small increased risk of breast and cervical cancer, and protection against cancers of the ovary and endometrium. Your doctor will be able to discuss the risks of each of these with you.
Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences them. The table below contains some of the most common ones associated with combined hormonal contraception. You will find a full list in the manufacturer's information leaflet supplied with your medicine. The unwanted effects often improve as your body adjusts to the new medicine, but speak with your doctor or pharmacist if any of the following continue or become troublesome.
Combined hormonal contraception side-effectsWhat can I do if I experience this?
Feeling sick, tummy crampsEat simple meals - avoid rich and spicy food. If you are sick within two hours of taking a pill, take another tablet as soon as possible (see also the information above on vomiting)
HeadacheAsk your pharmacist to recommend a suitable painkiller. If the headache continues or is sudden and severe, contact your doctor for advice
Breast tenderness, increased weight and fluid retention, mood changes, change in sex drive, menstrual changes and breakthrough bleeding, changes in vaginal discharge, leg cramps, visual changesIf any of these become troublesome, speak with your doctor
Increased blood pressure, changes to some blood test resultsYour doctor will monitor for these
Important: combined hormonal contraception can have some serious side-effects, but these are very uncommon. If you experience any of the following symptoms, stop taking/using the contraceptive and contact your doctor for advice straightaway:
  • Any sudden or severe chest pain.
  • Any sudden breathlessness or if you cough up any blood.
  • Any swelling or pain in a leg.
  • Severe stomach pain
  • An unusually painful or severe headache, or any loss of your sight or hearing, or any difficulty swallowing.
  • A bad fainting attack, a fit, or any numbness on one side of your body,
  • Any yellowing of your skin or the whites of your eyes (jaundice).
If you experience any other symptoms which you think may be due to the contraceptive, discuss them with your doctor or pharmacist.
  • Keep all medicines out of the reach and sight of children.
  • Store in a cool, dry place, away from direct heat and light.
Never take more than the prescribed dose. If you suspect that you or someone else might have taken an overdose of this medicine, go to the accident and emergency department of your local hospital. Take the container with you, even if it is empty.
This medicine is for you. Never give it to other people even if their condition appears to be the same as yours.
Do not keep out-of-date or unwanted medicines. Take them to your local pharmacy which will dispose of them for you.
If you have any questions about this medicine ask your pharmacist.
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परिवार नियोजन के इंजेक्शन भी मिलेंगे
परिवार नियोजन के प्रयासों को पूरी तरह कामयाब नहीं होता देख कर केंद्र सरकार ने इस कार्यक्रम को नए सिरे से रफ्तार देने की तैयारी की है।
नई दिल्ली। परिवार नियोजन के प्रयासों को पूरी तरह कामयाब नहीं होता देख कर केंद्र सरकार ने इस कार्यक्रम को नए सिरे से रफ्तार देने की तैयारी की है। इसके तहत अब सरकारी कार्यक्रम में परिवार नियोजन के विभिन्न विकल्प उपलब्ध कराने पर जोर होगा। इसके तहत इंजेक्टेबल कांट्रासेप्टिव भी शामिल होंगे। साथ ही नए सिरे से जागरुकता अभियान भी शुरू किया जाएगा। इसमें सदी के महानायक अमिताभ बच्चन भी दिखाई देंगे।
केंद्रीय स्वास्थ्य मंत्री जेपी नड्डा ने मंगलवार को यहां कहा कि परिवार नियोजन के अभियान को नई रफ्तार देने के लिए खास तौर पर इसके सभी विकल्प उपलब्ध कराने पर जोर दिया जा रहा है। सरकारी कार्यक्रम में पहले से उपलब्ध निरोध को भी नई पैकिंग में लाया जाएगा। साथ ही इस विषय को दोबारा लोगों के ध्यान में लाने के लिए टीवी और रेडियो सहित विभिन्न माध्यमों से जो अभियान चलाया जाना है उसमें अमिताभ बच्चन ब्रांड एंबेस्डर हैं। इस अभियान में परिवार नियोजन के लिए दंपति के अलावा परिवार के अन्य सदस्यों की भूमिका पर भी जोर दिया गया है।
इस मौके पर परिवार नियोजन के लिहाज से अच्छा प्रदर्शन करने वाले राज्यों को सम्मानित भी किया गया। बिहार को महिला नसबंदी के क्षेत्र में, हिमाचल प्रदेश को पुरुष नसबंदी के क्षेत्र में और मध्य प्रदेश को आइयूसीडी के क्षेत्र में बेहतरीन प्रदर्शन के लिए पुरस्कृत किया गया। साथ ही यहां टीकाकरण कवरेज को विस्तार देने के लिए शुरू किए गए अभियान इंद्रधनुष का मोबाइल एप भी लांच किया गया।
- See more at: http://www.jagran.com/news/national-injection-will-be-also-availabele-for-family-planning-13826523.html#sthash.3OLVZHxY.dpuf
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