Pre-service Education on FP and AYSRH Session II, Topic 3 Progestin-only Injectable Contraceptives Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 1

Key Points for Providers and Clients An injection every 2 or 3 months, depending on type • Return for injections regularly. Coming back every 3 months (13 weeks) for DMPA or every 2 months for NET-EN is important for greatest effectiveness. Very effective and safe Very 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. Can be used while breastfeeding Safe for breastfeeding women, they do not affect the quality of the breast milk. Starting as soon as 6 weeks after birth Possible side effects Weight gain, headaches, dizziness, and changes in monthly bleeding Adapted from WHO’s Decision-making tool for family planning clients and providers. Introduce this session by telling that: • In the previous sessions, we have learned about hormonal contraceptives in pill form taken orally. • This session discusses another hormonal contraceptive, but it is administered as an injection. Discuss the key points that are important for both clients and providers. • Return for injections regularly. Coming back every 3 months (13 weeks) for DMPA or every 2 months for NET-EN is important for greatest effectiveness. • Projestin- only injectables are very effective and safe, 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. • Possible side effects include weight gain, headaches, dizziness and changes in monthly bleeding. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 2

Key Points for Providers and Clients Often takes longer to get pregnant after stopping After 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 bleeding The 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/AIDS Provide 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. • Return of fertility is often delayed. It takes several months longer on average to become pregnant after stopping progestin-only injectables than after other methods. Changes in monthly bleeding: The 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 • Injection can be as much as 4 weeks late for DMPA or 2 weeks late for NET-EN. Client should come back even if later. • Provides no protection from STIs/HIV. For STI/HIV/AIDS protection, also use condoms. 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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 3

Types of Progestin-Only Injectables DMPA (depot medroxyprogesterone acetate) Injection every 3 months (13 weeks) NET-EN (norethisterone enanthate) Injection every 2 months (8 weeks) Have similar effectiveness, safety, characteristics and eligibility criteria Photo credits: News-Leader, ©2005 Springfield, MO; Museum of Contraception and Abortion, ©2007 Vienna There are two types of progestin-only injectables: DMPA (depot medroxyprogesterone acetate) and NET-EN (has two chemical formulations: norethindrone enanthate and norethisterone enanthate). Each contain a progestin like the natural hormone progesterone in a woman’s body. DMPA and NET-EN are given as intramuscular injections in one of three sites: the muscles of the upper arm, the muscle of the hip, or in the buttock. A woman can decide where she prefers to receive the injection. Ask students to consider how they will talk with their clients about where they prefer to have their injection. Remind students that some clients will be anxious about receiving an injection, so being able to discuss how the procedure will be performed is an important part of making their clients feel comfortable. See Session Plan for additional information on DMPA and NET-EN Source: CCP and WHO, 2010; Kingsley, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 4

Effectiveness of Injectables In this progression of effectiveness, where would you place progestin-only injectables? Implants Male Sterilization Female Sterilization Intrauterine Devices Combined Oral Contraceptives Male Condoms Standard Days Method Female Condoms Spermicides More effective Ask 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. Injectables Less effective Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 5

Progestin-Only Injectables: Mechanism of Action Thicken cervical mucus to block sperm Suppress hormones responsible for ovulation Note: Do not disrupt existing pregnancy Explain 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, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 6

Advantages of Progestin-Only Injectables Safe and very effective Easy to use; requires no daily routine Long-lasting and reversible Can be discontinued without provider’s help Can be provided outside of clinics Can be used by breastfeeding women Use can be private Does not interfere with sex Provide non-contraceptive health benefits Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 7

Progestin-Only Injectables: Health Benefits Help protect against: Risks of pregnancy Endometrial cancer Uterine fibroids May help protect against symptomatic pelvic inflammatory disease (PID) and iron-deficiency anemia Reduce sickle cell crises in women with sickle cell anemia Reduce 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 anemia2 They also reduce the symptoms of endometriosis, including pelvic pain, and irregular bleeding. Source: CCP and WHO, 2011; Manchikanti, 2007. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 8

Disadvantages of Progestin-Only Injectables Have side effects: Menstrual irregularity during the first few months of use or Amenorrhea; some women get anxious if they do not have menses Not possible to discontinue immediately, until DMPA is cleared from the woman’s body. Cause delay in return to fertility Effectiveness depends on user getting injections regularly Provide no protection from STIs/HIV There may be a decrease in bone density for long-term users but study shows that this is reversible. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 9

Progestin-Only Injectables: Side Effects Many women experience no side effects. Possible side effects include: Abdominal bloating and discomfort Amenorrhea (no menses) Headaches and dizziness Illustration credit: Ambrose Hoona-Kab Many 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 use DMPA 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 gain Changes in mood and sex drive Prolonged or heavy bleeding irregular bleeding or spotting Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 10

Progestin-Only Injectables Are Safe For Most Women Almost all women can use progestin-only injectables safely, including women who: Have or have not had children Cannot do or do not want to use other methods Are breastfeeding a baby who is at least 6 weeks old (WHO/MEC) Smoke (regardless of age or number of cigarettes) Have an STI, HIV or AIDS Just had a miscarriage or abortion Are taking medicines, including ARVs to treat AIDS Most health conditions do not affect safe and effective use of injectables Illustration credit: Ambrose Hoona-Kab Most women can use progestin-only injectables safely and effectively, including women who: Have or have not had children Are not married Are of any age, including adolescents and women over 40 years old Smoke cigarettes, regardless of a woman’s age or number of cigarettes smoked Are infected with an STI or HIV, or have AIDS, including those on antiretroviral therapy Are postabortion Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 11 Source: CCP and WHO, 2011

Who Should Not Use Injectables (part 1) Source: WHO, 2010. Had a heart attack or stroke or has blood clots Has breast cancer Has serious liver disease I cannot eat sweets. Has diabetes Has very high blood pressure Hmm… that is high. Who Should Not Use Injectables (part 1) Illustration credit: Ambrose Hoona-Kab Although injectables are safe for the majority of women, a small number of women with certain characteristics or medical conditions should not use DMPA or NET-EN. In addition, women who have two or more conditions that increase their risk of a heart attack or a stroke, such as old age, smoking, obesity, high blood pressure, or diabetes should not be given DMPA or NET-EN. In special circumstances, when other methods are not available or acceptable to her, a qualified provider who can carefully assess the woman’s situation and condition may decide that she can use progestin-only injectables. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 12

Who Should Not Use Injectables (part 2) Source: WHO, 2010. Is pregnant Thinks she may be pregnant My period is late… Is breastfeeding a baby less than six weeks old (WHO/MEC) Has abnormal vaginal bleeding Has systemic lupus Illustration credit: Ambrose Hoona-Kab Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 13

Conditions (selected examples) Category 1 Examples (not inclusive): Who Can Use DMPA or NET-EN WHO Category Conditions (selected examples) Category 1 Age 18-45 years; any parity (including nulliparous); smoking (any amount, any age); breastfeeding after 6 weeks postpartum; postabortion; and acute or chronic hepatitis. NET-ET: Obesity of more than 30 kg/m2 body mass index in women younger than 18 ears of age. DMPA: Women who are using certain types of ARVs (non-nucleoside reverse transcriptase inhibitors or ritonavir-boosted protease inhibitors). DMPA: Women using specific anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone topiramate, or oxcarbazepine). Category 1: For women with these conditions or characteristics, the method presents no risk and can be used without restrictions. Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 14

Conditions (selected examples) Category 2 Examples (not inclusive): Who Can Use DMPA or NET-EN WHO Category Conditions (selected examples) Category 2 Age <18 years or >45; mild hypertension (BP <159/99 mmHg); non-vascular diabetes; prolonged or heavy bleeding patterns; and history of DVT. DMPA: Obesity of more than 30 kg/m2 body mass index in women younger than 18 ears of age. NET-EN: Women who are using certain types of ARVs (non-nucleoside reverse transcriptase inhibitors or ritonavir-boosted protease inhibitors). NET-EN: Women using specific anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone topiramate, or oxcarbazepine). Category 2: For women with these conditions or characteristics, the benefits of using the method generally outweigh the theoretical or proven risks. Other examples of Category 2 conditions that are not listed on this slide <migraines without an aura; migraines with aura/to initiate use; history of deep venous thrombosis (DVT); known hyperlipidemias; cervical cancer; an undiagnosed breast mass; irregular bleeding patterns; cholestasis related to oral contraceptives>. Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 15

Conditions (selected examples) Category 3 and 4 Examples (not inclusive): Who Should Not Use DMPA and NET-EN WHO Category Conditions (selected examples) Category 3 Breastfeeding before 6 weeks postpartum, severe hypertension (≥160/≥100 mmHg), unexplained vaginal bleeding (before evaluation) acute DVT/PE, complicated diabetes, severe liver disease Category 4 Current breast cancer Although progestin-only injectables are safe for most women, there are some exceptions. According to the WHO MEC, progestin-only injectables are not generally recommended for women with category 3 conditions. In these situations, the risks of using this method usually outweigh the advantages. Category 3 conditions include: Acute blood clot in deep veins of legs or lungs, unexplained vaginal bleeding, severe hypertension (≥160/≥100 mmHg),, severe liver disease and most liver tumors, complicated diabetes and breastfeeding before 6 weeks postpartum. Women with category 4 conditions should not use implants. Current breast cancer is the only category 4 condition. Distribute the competency-based checklist for injectables Handout #1. Ask students to spend a few minutes reading through the competency-based checklist. Refer them to the section on client screening (page 4 of the checklist). Explain how to use the screening checklist to screen women who want to use DMPA or NET-EN). Go through each item with students. See Session Plan for Case Studies Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 16

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. Note: If none of these situations apply, you can use a urine pregnancy test or conduct a bimanual pelvic exam to determine if the woman is pregnant. If nothing is available, you can ask the woman to come back during her next menses and provide her with a backup method to use in the meantime. See Session Plan for additional information 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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 17

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) Switching from another method: start immediately Miscarriage or abortion: anytime within 7 days (after day 7 rule out pregnancy). Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 18

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 Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 19

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. Use the slide to discuss how to counsel women about what to expect when getting their injection. Use the second slide to discuss messages the client should remember about when to return for the next injection, side effects and warning signs. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 20

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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 21

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> Using the slide, discuss what to do when a client returns late for her injection. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 22

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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 23

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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 24

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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 25

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. See Session Plan for Roleplays Source: CCP and WHO, 2011. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 26

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 Session Plan for Roleplays 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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 27