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Pre-service Education on FP and AYSRH

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. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 2.

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Pre-service Education on FP and AYSRH

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

  2. Key Points for Providers and Clients Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 2

  3. Key Points for Providers and Clients Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 3

  4. 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 Source: CCP and WHO, 2010; Kingsley, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 4

  5. Effectiveness of Injectables Injectables In this progression of effectiveness, where would you place progestin-only injectables? More effective Less effective Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 5

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

  7. 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

  8. 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) Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 8 Source: CCP and WHO, 2011; Manchikanti, 2007.

  9. 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

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

  11. 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 Progestin-Only Injectables Are Safe For Most Women Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 11 Source: CCP and WHO, 2011

  12. I cannot eat sweets. Hmm… that is high. Who Should Not Use Injectables (part 1) Has diabetes Has breast cancer Has serious liver disease Has very high blood pressure Had a heart attack or stroke or has blood clots Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 12

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

  14. Category 1 Examples (not inclusive): Who Can UseDMPA or NET-EN Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 14

  15. Category 2 Examples (not inclusive): Who Can UseDMPA or NET-EN Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 15

  16. Category 3 and 4 Examples (not inclusive):Who Should Not UseDMPA and NET-EN Source: WHO, 2010. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 16

  17. 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. 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

  18. When Can A Woman Start Injectables (part 2) Postpartum and not breastfeeding: anytime within 4 weeks after delivery (after 4 weeks, rule out pregnancy) Postpartum and breastfeeding: wait 6 weeks (follow checklist instructions). (WHO/MEC) Miscarriage or abortion: anytime within 7 days (after day 7 rule out pregnancy). Switching from another method: start immediately Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 18

  19. 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 Very common: Weight gain Less common: Some others Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 19

  20. Counseling about Progestin-Only Injectables:Getting Your Injection • 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 Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 20

  21. Counseling about Progestin-Only Injectables:Post-Injection Messages See a nurse or doctor if: What to remember: • Unusually heavy or long bleeding • Name of your injectable: • When to come for next injection: • A bright spot in your vision before bad headaches • Yellow skin or eyes • Bleeding changes and weight gain are common. Come back if they bother you. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 21

  22. 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 Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 22

  23. Management of Side Effects:Bleeding Changes Counseling and reassurance are key Source: CCP and WHO, 2011. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 23

  24. Management of Side Effects:Bleeding Changes, continued Source: CCP and WHO, 2011. Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 24

  25. Management of Side Effects:Other Side Effects Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 25 Source: CCP and WHO, 2011.

  26. Problems That May Require Switching from Injectables to Another Method Progestin-Only Injectable Contraceptives, Session II Topic 3 Slide 26 Source: CCP and WHO, 2011.

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

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