7.3.2.2 Parenteral progestogen-only contraceptives

Injection

ChoiceDrugDosage
1st choiceMedroxyprogesterone acetate 150mg/ml (Depo-Provera®)Dose:
By deep intramuscular injection,150mg within the first 5 days of cycle or within the first 5 days after parturition ( delay until after 6 weeks parturition if breastfeeding); for long-term contraception, repeated every 13 weeks[can be administered up to 7 days late (up to 14 weeks* after the last injection) without the need for additional contraceptive precautions]
*FSRH recommendations (outside terms of product licence). For further information refer to FSRH website

Prescribing Notes

  • Depo–Provera® can cause menstrual dysfunction and weight gain. By the end of the first year of use 80% of women will have become amenorrhoeic or have scanty/infrequent periods.
  • When Depo–Provera® is stopped ovarian activity can take up to a year to recover.
  • Depo-Provera® is associated with a small loss of bone mineral density (BMD), which is usually recovered after discontinuation. There has been particular concern about use in women aged <18 years (who have not yet attained their peak bone mass) and among older women who are approaching the menopause when additional BMD loss will naturally occur. There is no available evidence on the effect of Depo-Provera® on long-term fracture risk.
  • Depo–Provera® can be used by adolescents who have yet to achieve their peak bone mass only if other methods are unacceptable or unsuitable.
  • In women with risk factors for osteoporosis a method of contraception other than medroxyprogesterone acetate (Depo-Provera®) should be considered.
  • Depo–Provera® use should be reviewed after 2 years in women of all ages.
  • The effectiveness of Depo–Provera® is unaffected by enzyme-inducing drugs and interval between injections need not be altered.
  • For more information see FSRH guidance.

Caution

See prescribing notes above regarding bone mineral density.

Implant

ChoiceDrugDosage
1st choiceEtonogestrel 68mg (Nexplanon®)Dose:
Consult product literature for insertion and removal instructions

 

Prescribing Notes

  • Nexplanon® insertion and removal requires specialist training
  • Nexplanon® is a low dose long–acting progestogen which suppresses ovulation in all women. Contraceptive effect lasts for 3 years
  • When Nexplanon® is stopped there is no delay in return to fertility
  • No more than 20% of women will experience amenorrhoea, the rest may have unpredictable and sometimes prolonged bleeding. This point should be covered carefully during counselling
  • Women who experience problematic bleeding while using a progestogen-only implant should have a sexual history taken to establish sexually transmitted infection risk and/or be investigated for gynaecological pathology if clinically indicated
  • If bleeding is problematic and gynaecological pathology has been excluded and there are no contra-indications; consider treating with a combined oral contraceptive either cyclically or continuously for up to 3 months (off-label use)
  • Nexplanon® is affected by concomitant use of enzyme-inducing drugs. An alternative contraceptive method should be sought