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Referral and warning signs
When to refer
Refer if: Contraindications identified. Suspected pregnancy. Unexplained heavy or persistent vaginal bleeding. Severe persistent headaches or other warning signs.
Red flags
- Suspected pregnancy
- Unusually heavy or prolonged vaginal bleeding
- Severe headaches (migraine with aura)
- Severe abdominal pain (rule out ectopic)
- Signs of VTE (rare association, consider if risk factors)
Signs and symptoms
- Common Side Effects: Menstrual changes (irregular bleeding, spotting, heavy bleeding initially, amenorrhoea common after 1 year - esp. DMPA), Weight gain (variable), Headaches, Dizziness, Mood changes, Loss of libido.
- Delayed return to fertility after stopping (average ~10 months from last DMPA injection, faster with NET-EN).
- Potential bone mineral density reduction (DMPA - generally reversible after stopping).
- Warning Signs: Severe headaches, Heavy/prolonged vaginal bleeding, Severe abdominal pain (rule out ectopic pregnancy if amenorrhoeic).
Risk factors
- Contraindications (MEC Category 4): Current Breast Cancer.
- Relative Contraindications (MEC Category 3): Past breast cancer >5yrs ago, Severe liver disease (active/tumour), Multiple risk factors for cardiovascular disease, Unexplained vaginal bleeding (initiation concern), History IHD/Stroke (initiation concern for DMPA), Severe hypertension (≥160/100 - initiation concern for DMPA), Diabetes with nephropathy/retinopathy/neuropathy or >20yrs duration (initiation concern for DMPA), SLE with positive antiphospholipid antibodies.
Diagnosis
Clinical assessment
Eligibility assessment based on medical history and MEC guidelines. Suitable for women desiring medium-term, highly effective, non-daily contraception, including breastfeeding women.
Investigations
- Rule out pregnancy before first injection (or subsequent if >2-4 weeks late).
- BP check (especially for DMPA initiation).
Diagnostic criteria
Client meets medical eligibility criteria for injectable use.
Management
Non-pharmacological management
- Counseling: Explain mechanism, effectiveness, administration schedule (every 2 months for NET-EN, 3 months for DMPA), common side effects (esp. bleeding changes, weight gain, delayed fertility return), lack of STI protection.
- Provide specific return date for next injection.
Pharmacological treatment
- Administration:
- - DMPA-IM: 150mg deep IM injection (gluteal/deltoid) every 12-13 weeks.
- - DMPA-SC: 104mg SC injection (thigh/abdomen) every 12-13 weeks.
- - NET-EN: 200mg deep IM injection every 8 weeks (first 3 injections can be closer).
- - Start within first 7 days of cycle, immediately postpartum (if not breastfeeding), or >6 weeks postpartum (if breastfeeding). If starting later, use backup for 7 days.
- Management of Side Effects:
- - Irregular Bleeding/Spotting/Amenorrhoea: Reassure common, usually not harmful. Rule out pregnancy/pathology if pattern changes or heavy/prolonged. NSAIDs (Ibuprofen 400-800mg TID for 5 days) may help troublesome bleeding. Consider combined ECP or short course COC/estrogen for persistent heavy/prolonged bleeding (specialist advice). If unacceptable, change method.
- - Weight Gain: Counsel on diet/exercise. Reassure effect is variable. Change method if unacceptable.
- - Headache: Analgesia. Rule out severe headache/migraine aura.
- - Delayed Fertility Return: Reassure this is expected, varies individually. Counsel on timing if planning pregnancy.
- Drug Interactions: Reduced effectiveness with Rifampicin, some anticonvulsants (check MEC). Efavirenz/Nevirapine generally okay per WHO MEC.
Monitoring
Ensure timely return for repeat injections. Assess side effects and satisfaction at each visit. Check weight/BP periodically.
Complications
- Menstrual disturbances (often lead to discontinuation).
- Weight gain.
- Delayed return to fertility.
- Potential short-term reduction in bone mineral density (DMPA).
- Injection site reactions (rare).
Prevention
- Adherence to correct injection schedule.
- Appropriate screening using MEC.
Patient education
- Method effectiveness and schedule.
- Common side effects (bleeding changes expected, weight gain possible, delayed fertility return).
- Does not protect against STIs/HIV.
- Importance of returning on time for next injection.
- Warning signs to report.
- Option to discontinue anytime, but effect wears off gradually.
Uganda-specific notes
DMPA (Depo-Provera) is a very popular and widely available method. Counseling on bleeding changes and delayed fertility return is crucial for continuation. DMPA-SC allows potential for self-injection programs.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15, Section 15.2.5