Depo-Provera and Noristerat are highly effective injectable contraceptives administered every 3 months and 2 months respectively. They work by suppressing ovulation and thickening cervical mucus. Common side effects include changes in menstrual bleeding patterns such as irregular bleeding and amenorrhea. Proper administration and infection prevention practices are required. Women should return on schedule for reinjection to continue contraceptive protection.

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2.  Depo-Provera7 (DMPA): 150 mg of depot-
medroxyprogesterone acetate given every 3
months
 Noristerat7 (NET-EN): 200 mg of norethindrone
enanthate given every 2 months
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FP Training
J.K.Mutua

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Suppress ovulation
Reduce sperm
transport in
fallopian tubes
Change endometrium
Thicken cervical
mucus (prevent
sperm penetration)

4.  Highly effective (0.31
pregnancies per 100 women
during first year of use)
 Rapidly effective (< 24 hours) if started by day 7 of
menstrual cycle
 Intermediate-term method (2 or 3 months
protection per injection)
 Pelvic examination not required to begin use
 Do not interfere with intercourse
4
1
Trussell et al 1998. Note: This efficacy rate refers only to DMPA.

5.  Do not affect breastfeeding
 Few side effects
 No supplies needed by the client
 Can be provided by trained nonmedical staff
 Contain no estrogen
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6.  May increase quantity of breastmilk
 Have no effect on:
◦ Initiation or duration of breastfeeding
◦ Quality of breastmilk
◦ Growth and development of infants
◦ Long-term growth and development of children through
adolescence
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7.  Decrease ectopic pregnancy
 May decrease menstrual cramps
 May decrease menstrual bleeding
 May improve anemia
 Protect against endometrial cancer
 Decrease benign breast disease
 Decrease sickle cell crises
 Protect against some causes of PID
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8.  Changes in menstrual bleeding pattern
◦ Irregular bleeding/spotting initially in most women
 Weight gain ( 2 kg) is common
 Although pregnancy is unlikely, if pregnancy
occurs, it is more likely to be ectopic than in a
nonuser
 Resupply must be available
 Must return for injections every 3 months (DMPA)
or 2 months (NET-EN)
 Return to fertility may be delayed for 7B9 months
(on average) after discontinuation
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9. Women of any reproductive age or parity who:
◦ Want an effective, reversible method
◦ Are postpartum and not breastfeeding
◦ Are breastfeeding (6 weeks or more postpartum)
◦ Are postabortion
◦ Are smokers (any age, any amount)
◦ Do not mind irregular bleeding or amenorrhea
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10. Women of any reproductive age or parity who:
◦ Have moderate to severe menstrual cramping
◦ Take drugs for epilepsy or tuberculosis
◦ Have high blood pressure or blood clotting problems
◦ Prefer not to or should not use estrogen
◦ Cannot remember to take a pill every day
◦ Prefer a method not related to intercourse
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11. Women who cannot tolerate any changes in their
menstrual bleeding pattern, especially amenorrhea.
(Changes in bleeding pattern are main reason women
discontinue PICs.)
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12.  Need for contraception
 Reaction of the partner to menstrual changes
 Interference with sexual or daily activity
 Religious constraints
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13. PICs should not be used if a woman:
◦ Is pregnant (known or suspected)
◦ Has unexplained vaginal bleeding (if serious problem
suspected)
◦ Has breast cancer
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Source: WHO 1996.

14. PICs are not recommended unless other methods
are not available or acceptable if a woman:
◦ Is breastfeeding (< 6 weeks postpartum)
◦ Is jaundiced (symptomatic viral hepatitis or cirrhosis)
◦ Has high blood pressure (≥ 180/110)
◦ Has ischemic heart disease (current or history)
◦ Has had stroke
◦ Has liver tumors (adenoma or hepatoma)
◦ Has diabetes (> 20 years duration)
14
Source: WHO 1996.

15.  Initial injection:
◦ Days 1 to 7 of the menstrual cycle
◦ Anytime during the menstrual cycle when you can be
reasonably sure the client is not pregnant
◦ Postpartum:
 Immediately if not breastfeeding
 After 6 months if using LAM
◦ Postabortion: immediately or within first 7 days
 Reinjection:
◦ DMPA: Up to 4 weeks early or late
◦ NET-EN: Up to 2 weeks early or late
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DMPA NET-EN
Duration 3 months 2 months
Bleeding More amenorrhea More irregular
Needle/pain Smaller/less Larger/more
Reinjection window Up to 4 weeks Up to 2 weeks
Cost Cheaper More expensive
Return to ovulation Later Sooner

17.  Amenorrhea (absence of vaginal
bleeding or spotting)
 Irregular or heavy bleeding
 Headache
 Nausea/dizziness/vomiting
 Weight gain or loss (change in
appetite)
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18.  Give reassurance that this is a common, not
serious side effect
 Evaluate for pregnancy, especially if amenorrhea
occurs after period of regular menstrual cycles
 If no problem found, do not attempt to induce
bleeding with COCs
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19. Prolonged spotting (> 8 days) or moderate bleeding:
 Reassurance
 Check for gynecologic problem (e.g., cervicitis)
 Short-term treatment:
◦ COCs (30-50 µg EE) for 1 cycle1
, or
◦ Ibuprofen (up to 800 mg 3 times daily x 5 days)
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1
Remind client to expect bleeding after completing COCs.

20. Bleeding twice as long or twice as much as normal:
 Carefully review history and check hemoglobin (if
available)
 Check for gynecologic problem
 Short-term treatment:
◦ COCs (30B50 g EE) for 1 cycle1
, or
◦ Ibuprofen (up to 800 mg 3 times daily x 5 days)
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1
Remind client to expect bleeding after completing COCs.

21. If bleeding not reduced in 3B5 days, give:
◦ 2 COC pills per day for the remainder of her cycle
followed by 1 pill per day from a new packet of pills, or
◦ High dose estrogen (50 µg EE COC, or 1.25 mg
conjugated estrogen) for 14B21 days
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22.  Return to health clinic for an injection every 3 months
(DMPA) or every 2 months (NET-EN).
 Changes in menstrual bleeding patterns (amenorrhea)
are common, especially following first 2 or 3 injections.
 If using DMPA, return of fertility is temporarily delayed,
but does not decrease fertility in the long term.
 If using DMPA, 50% of women will stop having any
bleeding by end of first year of use.
 PICs do not provide protection against STDs, (e.g.,
HBV, HIV/AIDS).
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23.  Delayed menstrual period after several months of
regular cycles
 Severe lower abdominal pain
 Heavy bleeding
 Pus or bleeding at injection site
 Migraine (vascular) headaches, repeated very
painful headaches or blurred vision
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24.  Use antiseptic solution to prepare the injection
site (wash area first if poor hygiene).
 Use sterile (or high-level disinfected) needle and
syringe.
 After use, decontaminate needle and syringe and
either:
◦ place in puncture-proof container for disposal, or
◦ clean and final process by sterilization (or high-level
disinfection).
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25.  Adequate training in counseling and provision
 Steady supply (DMPA, NET-EN, antiseptics and
needles and syringes)
 Recommended infection prevention practices
 Correct disposal or processing of syringes (and
needles) for reuse
 System for notifying clients when to return for
injections
 Referral system
 Supervision
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26.  Age restrictions (young and old)
 Parity restrictions (less than two living children)
 Unnecessary medical procedures (lab tests, pelvic
exams)
 Narrow reinjection window
 Inappropriate precautions (diabetes, hypertension,
smokers over age 35, etc.)
 “Rest” period (after 2 or more years)
 Poor management of side effects leading to
discontinuation of method
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