This study session introduces the types of long-acting hormonal contraceptives which are injectable, or take the form of implants inserted under the skin of the upper arm. Once given to clients, a constant dose of hormonal contraceptives is released slowly into the body, making them very effective over long periods of time. In this study session, you will learn about these methods, their mechanism of action, effectiveness, advantages and disadvantages, and the most common side-effects. You will also learn about the management of side-effects related to these long-acting hormonal contraceptives.
When you have studied this session, you should be able to:
6.1 Define and use correctly all of the key words printed in bold. (SAQs 6.1, 6.2, 6.4 and 6.5)
6.2 Describe the main types of injectable contraceptives, their mechanism of action, effectiveness, advantages and disadvantages, mode of injection, and management of common side-effects. (SAQs 6.2, 6.4 and 6.6)
6.3 Describe the main types of contraceptive implants, their mechanism of action, effectiveness, advantages and disadvantages, insertion procedures, and management of common side effects. (SAQs 6.3 and 6.6)
6.4 Discuss common infection prevention precautions for injections and implant insertion. (SAQ 6.7)
Injectable contraceptives are artificial hormonal preparations administered by a deep intramuscular injection into the muscle of the arm or buttock, to be effective immediately. From the injection site they are slowly absorbed into the bloodstream and the body gets sufficient levels of hormone to provide contraception for one to three months, depending on the type of injectable contraceptive used. Injectable contraceptives can consist of progesterone-only preparations, or combined oestrogen and progesterone preparations (Figure 6.1).
DMPA (Depot Medroxy Progesterone Acetate, or Depo-Provera) is an artificial progestin preparation which resembles the naturally occurring female hormone progesterone. It is usually given in doses of 150 mg, which gives three months’ protection following injection. It is the most widely available and commonly used injectable contraceptive in Ethiopia.
In what situations would you advise a client to choose an injectable contraceptive over an oral contraceptive?
When the client wants to prevent pregnancy for a long period of time, and is having difficulty remembering to take an oral contraceptive pill on a daily basis, then having an injectable contraceptive every month is preferred (Figure 6.2).
In Study Session 5 of this Module, you learnt the mechanism of action of progesterone-only oral contraceptives. Progesterone-only injectable contraceptives have the same mechanism of action as that of the progesterone-only oral contraceptives, except that injectable contraceptives have a longer duration of action.
Can you explain how progesterone-only contraceptives prevent pregnancy?
Progesterone-only contraceptives, including progesterone-only injectables (POIs), prevent pregnancy in the following ways:
DMPA is very effective. In the first year of use only about 0.3 pregnancies per 100 women occur, that is, one pregnancy for every 333 clients who do not get pregnant, providing the injection is given every three months (Figure 6.3).
Why do you think injectable contraceptives are more effective when compared to oral contraceptive pills?
Injectable contraceptives avoid passage through the gastrointestinal tract, and metabolism in the liver.
DMPA is very effective, and has the advantage for the client that it can be used privately without the knowledge of any other person, including their partner. It also has the advantage of being long acting, but reversible if the client later decides to have a child. Moreover, it does not interfere with sexual intercourse. It is also suitable for breastfeeding women (after six weeks post-partum) because it has no oestrogen side-effects.
DMPA has proved to protect against ectopic pregnancy, since ovulation does not occur. However, if ovulation does occur, the chance of ectopic pregnancy is higher than for women not using DMPA. Why does this happen? This is because DMPA reduces fallopian tube peristalsis, which in turn slows the transportation of fertilised eggs from the fallopian tube to the endometrium and, as a result, there is a high chance of implantation in the fallopian tube.
It is important for you to know some of the other contraceptive benefits of DMPA. Scientific research has shown that it helps prevent uterine tumours, may protect against pelvic inflammatory disease by making the cervical mucus thick and impenetrable for microorganisms, and finally it reduces the chance of seizures in women with epilepsy. The advantages and disadvantages of DMPA are summarised in Table 6.1.
In most women, the use of DMPA is associated with disturbance of the menstrual cycle. This can include absence of menstrual periods or monthly bleeding (amenorrhoea) for an unspecified period of time. Also, there can be prolonged menstrual flow, light vaginal bleeding at any time other than during the menstrual period (spotting between periods), or heavy bleeding, which usually occurs during the first two to six months of use. It can increase the appetite of some women, resulting in weight gain. It does not protect couples against sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV).
There can be a delayed return to fertility after stopping DMPA. Most women take an average of four to six months longer than usual to get pregnant, but this may extend to one year in some women. This is because residual levels of DMPA exist for several months in the body after the end of contraceptive protection following the final injection.
Do DMPA injectable contraceptives cause infertility?
No, DMPA does not cause infertility. It is a completely reversible contraceptive, but after stopping DMPA there can be a delayed return to fertility of four to six months.
Disturbance of menstrual cycle.
Delayed return of fertility.
No protection against STIs.
Suitable for breastfeeding women; no oestrogen side-effects.
Increased appetite causing weight gain for some women.
Best choice for those with gastritis or peptic ulcer diseases (ulcer of stomach or duodenum).
Protects against ectopic pregnancy.
Other side-effects include headache and dizziness, breast tenderness, nausea, hair loss, acne and loss of sexual feeling.
If ovulation occurs, the chance of ectopic pregnancy increases.
DMPA cannot be given to all women. In particular, it is not recommended for pregnant women, or those with breast cancer, or where a client has a history of diabetes (increased blood glucose level), advanced heart or liver disease, severe hypertension (increased blood pressure), or frequent severe headaches.
If a woman comes to you with concerns associated with this injection, do not underestimate or ignore her. Reassure her that the side-effects are not dangerous. Remember that counselling after side-effects have occurred is still useful, but not best practice. The best time to counsel a client about side-effects is when they make their contraceptive method choice. This is because many women encountering side-effects may not come to you at all, so it is important that you have given them the information beforehand.
First, you should advise her to wait until the effective days of the injection have passed. Then, if she is concerned about not having her monthly period, for example, she may want to change to another method. With irregular bleeding, reassure her that it is not harmful and usually reduces or stops after the first few months of use. On the other hand, if the bleeding is profuse and continuous, you should refer her for further investigation and management at the health post or hospital, as there may be another cause.
If she is suffering from headaches, suggest she takes Aspirin (500 mg), Ibuprofen (400 mg) or Paracetamol (500 mg), as needed, and provide her with the pain killer of her choice. Be aware that Aspirin and Ibuprofen may not be tolerated by a woman with gastritis or peptic ulcer diseases. In general, if her condition is severe, or if she is unhappy with your advice, refer her to the nearest health centre or hospital.
Box 6.1 summarises the most appropriate times to start DMPA injectable contraceptives.
The injection site should not be massaged or pressurised, as this may accelerate absorption of the drug.
Injectable hormonal contraceptives are different from other injections because they are administered using deep intramuscular injection techniques (Figure 6.4). The vial must be shaken strongly before it is drawn into the syringe, to ensure the active ingredient is in suspension and not in the bottom of the vial. Following the procedure, the injection site should not be massaged or pressurised, because this may accelerate absorption of the drug. Infection prevention procedures are important (see Section 6.3 of this session).
When the client comes to you to have her next or subsequent injection, you should check your records to see when you last gave her an injection. If it is the correct appointment date, give her the injection. If she comes to you up to two weeks before her appointment, or up to one month after her scheduled appointment, you can still give her the injection. But if she is more than one month late, she can get another injection that day only if you can be sure that she is not pregnant.
She is unlikely to be pregnant if:
Noristerat (NET-EN or norethisterone enanthate) is another artificial progestin preparation which resembles the natural female hormone progesterone. It is usually given in doses of 200 mg which gives two months’ protection after injection. It suits clients who want to prevent pregnancy for a relatively shorter period than DMPA users. Although this method is not available in Ethiopia, it is important to understand that all the mechanisms, effectiveness, advantages and disadvantages are similar to DMPA, except that its duration of action is shorter.
Mesigyna is a combination of a short-acting oestrogen and long-acting progesterone that is administered by intramuscular injection to give protection for one month. It is not available in Ethiopia at the moment; however it may come in the future. Note that all of its actions and effectiveness are similar to combined oral contraceptives.
A contraceptive implant is a reversible, long-acting progestin which resembles the natural hormone progesterone in a woman’s body. It consists of flexible tubes or rods, each about the size of a match stick, inserted under the skin of a woman’s upper arm by a trained professional. Implants can give continuous protection for three to seven years, depending on the number of rods inserted. This method of contraception has been used for more than 25 years. There are four types of contraceptive implants used today. These are Norplant, Jadelle, Implanon and Sino-implant, according to their sequence of discovery. In this section, you will learn about their mechanisms of action, effectiveness, advantages and disadvantages, side effects, and how to manage the side effects.
Norplant is a progestin-only contraceptive implant that consists of six rods inserted into the upper arm of the client to five to seven years of protection (see Figure 6.5). Its effectiveness decreases from five years onwards so women are advised to have it removed five years after insertion. It was the first implant to be introduced (25 years ago), and its manufacture was phased out in 2004. Although it is no longer available, it is important for you to know about it, so that you can advise those who have had Norplant implants inserted previously.
Jadelle is a progesterone-only contraceptive implant consisting of two rods implanted (instead of 6 rods in Norplant) to give effective protection for five years. Each rod contains 75 mg Levonorgestrel (150 mg in total). It is a new product, manufactured to replace the Norplant implant. By reducing the number of rods from six to two (Figure 6.6), it has made it easier to insert and remove. This method is in use in Ethiopia, and is provided by many trained health professionals in health centres and hospitals. After appropriate training, you may be able to insert Jadelle.
Sino-implant is another contraceptive implant of two rods prepared from progestin, and is similar to Jadelle. It is effective for five years. It was introduced after Implanon and is available in Ethiopia, but at the time of writing it has not been approved by the Ministry of Health for use in Ethiopia.
Implanon is a single-rod contraceptive implant prepared from another type of progestin, which gives effective protection for three years (Figure 6.7). It looks like a small flexible plastic matchstick. It can be inserted into the arm following a simple procedure, similar to an injection, and you do not need to make an incision as with other implants. Implanon is the best option for women who have had one or more children, or who may want children in the future. It has been introduced for use in Ethiopia, and has been approved by the Ministry of Health to be provided by you at health post level, once you have been given proper training.
Wozero Misgane has two children and works hard on her land. She recently asked you for advice on the most suitable contraceptive method for her. She explained to you that she is worried about the side-effects, that she might want more children again in the future, and that she works hard on her farm, so she needs a contraceptive that does not make her weak.
What would you advise for Wozero Misgane?
You may recommend Implanon for her as it is used by many women like her in Ethiopia and tell her that once it is removed she will be able to become pregnant.
W/ro Misgane decided to have the Implanon rod insertion. Six months later she told other women in her neighbourhood that it was the right contraceptive method for a rural hard-working woman like herself because she has had no side-effects and she has continued working hard without any ill effect.
The mechanism of action of implants is similar to progesterone-only oral contraceptive pills and injectables, regardless of their route and duration of effectiveness.
How do implants prevent pregnancy?
Implants have the following effects:
Implants are more than 99.9% effective when they are inserted correctly (WHO, 2007). This means that less than one woman in 1,000 will get pregnant in the first year of use. There is no reported difference in contraceptive effectiveness or continuation rates among users of the various types of contraceptive implants. However, the effectiveness of contraceptive implants quickly reduces if women weigh more than 70 kg. In this case the implant needs early replacement, as early as one year before the intended year.
Implants are very effective when compared to other contraceptive methods, and are particularly useful for women who know they do not want to get pregnant for a while. Once the implant is in place, the client does not have to think about contraception for the period of the implant. It is also a good choice of method for women who can’t use any contraceptive that contains oestrogen, and for women who find it difficult to regularly take a pill at the same time every day. For these reasons, its continuation rate is high.
Implants require a trained provider (Figure 6.8) to insert and remove the rods. When the implant is first inserted into the upper arm, the woman may feel some bruising, tenderness or swelling at the insertion site. For most women, during the first year of implant, their menstrual cycle may become irregular, lighter, heavier or longer. This usually settles down after the first year. In some clients, periods stop completely (amenorrhoea), but this is not harmful. Your client should be aware of these issues before deciding to have the implant. As with other contraceptives, this method does not protect couples from STIs. In this case, the client is advised to use condoms, as well as having an implant.
In addition to the disadvantages listed above, side effects which are associated with the use of contraceptive implants include weight gain, nervousness, anxiety, nausea, vomiting, dizziness, dermatitis/rashes, abnormal or heavy growth of hair over the body (hirsutism), hair loss, headaches, depression and acne. Sometimes pain, itching, or infection at the site of the implant will occur.
Listen to your client’s worries and complaints and treat her concerns accordingly, referring her for further help if needed. If the client wishes, it is always possible to change to another method. Side-effects are similar to those of progesterone-only injectable contraceptives (see Box 6.2), and can be managed as instructed in the earlier part of this study session.
Implants should not be given to women who have:
Implants can be inserted at any time during the menstrual cycle, preferably within seven days of menstruation or post-abortion. It can also be inserted six weeks after delivery if the mother is fully breastfeeding. Generally, it can be inserted at any time, providing it is possible to confirm that the woman is not pregnant.
Contraceptive implant insertion and removal requires special training and should only be practiced under direct supervision.
Implants can be removed:
The removal of an implant is not a very complicated procedure, but it does require special training and practice under direct supervision. Following removal of any implants, the level of hormonal prevention drops quickly, and the women’s fertility returns within two to six months.
When carrying out any procedure, it is important to prevent the spread of infection by using proper infection prevention procedures. Microorganisms live everywhere in our environment. We normally carry them on our skin and in our bodies. Microorganisms are also found in animals, plants, soil, air and water. Some of these microorganisms can cause infections. Therefore, when you perform any procedure, it is very important to follow the principles of infection prevention precautions detailed in Box 6.3.
When you carry out any invasive procedure, you have to wash your hands thoroughly using water and ordinary soap. You must wear gloves during implant insertion to prevent the transmission of infection. It is mandatory to use an antiseptic, for example Savlon, alcohol or iodine solution, for cleaning wounds or the skin prior to the implant insertion procedure.
In Study Session 6, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
What kind of contraceptive method is good for lactating (breastfeeding) women?
While non-hormonal methods are better, DMPA and other progesterone-only contraceptives would be the next best choice for lactating women. If the mother is not fully breastfeeding, or if menstruation has resumed, DMPA or a progesterone-only pill can be started as early as six weeks after delivery.
Match the correct protective period with each of the hormonal injectables and contraceptive implants.
Using the following two lists, match each numbered item with the correct letter.
How long does it take to become pregnant after the implants are removed? Why?
Women who stop using contraceptive implants can get pregnant as quickly as if they had stopped a non-hormonal contraceptive method. This is because contraceptive implants do not delay the return of fertility once they have been removed.
How do progesterone-only contraceptive injectables and implants prevent the occurrence of pregnancy?
Progesterone-only contraceptives prevent the occurrence of pregnancy because they:
Describe the best times to start DMPA to prevent pregnancy.
The best times to start DMPA to prevent pregnancy are:
W/ro Marta had her Implanon inserted three months ago. She complains that she has been having irregular bleeding since insertion and wants to know what can be done to stop it. Aside from the spotting, she is happy about the method.
Why has she developed this side effect?
How can you help her manage it?
Menstrual irregularity, or inter-menstrual bleeding, or total absence of menstruation (amenorrhoea) are common side effects of Implanon caused by hormonal imbalance, specifically by excess progesterone in the woman’s body. In the absence of infection, reassure W/ro Marta that her bleeding pattern is very common and is normal, particularly during the first three to six months following insertion. If the bleeding is unacceptably high, refer her for further investigation and management to the nearest health centre or hospital.
What are the most important infection prevention precautions you should take when doing any invasive procedure?
These are the most important infection prevention precautions: