Contraceptive injection: snapshot of providers

Shannon is a 15-year-old patient who is sexually active. She has previously used oral contraceptives, but Shannon experienced an unplanned pregnancy when she missed several days of pills in her pill pack and failed to come in for emergency contraception. What birth control methods can you offer?

The contraceptive injection (depot medroxyprogesterone acetate, DMPA, Depo-Provera, Pfizer, New York City; Medroxyprogesterone Acetate Injectable Suspension, USP, Teva Pharmaceuticals USA, North Wales, PA) continues as a top choice for birth control, particularly for adolescents, say respondents to the 2009 Contraceptive Technology Update Contraception Survey. About 99% of survey respondents say they would prescribe the injectable for young teens, up from 2008's 91% statistic.

Quick Start is gaining ground as an initiation option; 72% say they are beginning injections in this manner. Why use Quick Start? It eliminates the gap between decision and implementation, results in higher initiation rates, yields higher continuation rates (short term), results in lower pregnancy rates, and offers higher method satisfaction, said Anne Burke, MD, MPH, assistant professor in the Department of Gynecology and Obstetrics at the Johns Hopkins University School of Medicine at the 2009 Contraceptive Technology Quest for Excellence Conference.1

When considering use of Quick Start (initiation of method at time of initial visit), three questions must be answered:

  • Is the patient pregnant now?
  • Has she had unprotected intercourse in the last five days?
  • What will she use as a backup method until the hormonal method takes effect?2
According to the2007-2009 Managing Contraception for Your Pocket, the first DMPA injection may be given at any time in a woman's menstrual cycle if a clinician is reasonably certain a woman is not pregnant.3If the day of the first shot is not within five days of the start of a woman's period, clinicians should recommend that patient use a backup contraceptive for seven days, provide emergency contraception (EC), and repeat pregnancy test in two to three weeks if there has been recent unprotected intercourse, it advises.3

While the risk of current pregnancy generally can be assessed from taking a patient's history, a urine test should be administered in all cases as indicated by coital history. Emergency contraception is very important, says Susan Wysocki, WHNP-BC, FAANP, president and CEO of the Washington, DC-based National Association of Nurse Practitioners in Women's Health. "The best clinical pearl for Quick Start, regardless of method, is to provide EC as appropriate to sexual history, and provide it on site," says Wysocki.

Women who receive Quick Start DMPA injections should be counseled to use a backup method such as abstinence or condoms for seven days following the injection to allow the cervical mucus to sufficiently thicken to block sperm entry into the upper genital tract. Women who begin the method whose last menstrual period started less than five days ago do not require backup contraception.3

In November 2004, the Food and Drug Administration (FDA) added a "black box" warning to DMPA labeling to highlight that prolonged use might result in loss in bone mineral density (BMD). The warning advised that bone loss in women who use Depo-Provera is greater with increased duration of use and might not be completely reversible. The injectable contraceptive should be used as a long-term birth control method (longer than two years) only if other birth control methods are inadequate, the updated label advised.

DMPA has been associated with losses of BMD at the hip and spine of 0.5% to 3.5% after one year of use, and 5.7% to 7.5% after two years.4-7 DMPA's greatest effect on BMD occurs during the first few years of use.7,8 However, BMD has been demonstrated to return to levels at or near baseline at two years after the discontinuation of DMPA.8,9

Concerns about the effects of DMPA on BMD should not prevent clinicians from prescribing the method, nor should its use be limited to two years, stated a 2008 committee opinion released by the American College of Obstetricians and Gynecologists.10 A 2009 review of data regarding the impact of hormonal contraception on skeletal health in adolescents observes, "Although more data on skeletal health outcomes following the use of oral and injectable contraceptives would be welcomed, theoretic concerns regarding the impact of depot medroxyprogesterone acetate and combination oral contraceptive use on adolescent and young women should not restrict the initiation or continuation of these important contraceptive methods."11

Remember to advise on the importance of daily exercise and age-appropriate calcium and vitamin D intake to DMPA users, especially in teens, who often do not get enough calcium. The Institute of Medicine recommended average daily intake of calcium for teens ages 14-18 is 1,300 mg; for women ages 19-50, it is 1,000 mg.12

References

  1. Burke AE. Extended regimens and Quick Start: Why prescribe it? Presented at the 2009 Contraceptive Technology Quest for Excellence conference. Atlanta; October 2009.
  2. Nelson AL. Quick-Start/ Same-Day-Start contraception: Breaking down barriers for women. Female Patient 2008. Accessed at www.femalepatient.com.
  3. Zieman M, Hatcher RA, Cwiak C, et al. 2007-2009 Managing Contraception for Your Pocket. Tiger, GA: Bridging the Gap; 2007.
  4. Berenson AB, Radecki CM, Grady JJ, et al. A prospective, controlled study of the effects of hormonal contraception on bone mineral density. Obstet Gynecol 2001; 98:576-582.
  5. Ulrich CM, Georgiou CG, Snow-Harter CM, et al. Bone mineral density in mother-daughter pairs: Relations to lifetime exercise, lifetime milk consumption, and calcium supplements. Am J Clin Nutr 1996; 63:72-79.
  6. Santelli JS, Abma J, Ventura S, et al. Can changes in sexual behaviors among high school students explain the decline in teen pregnancy rates in the 1990s? J Adolesc Health 2004; 35:80-90.
  7. Clark MK, Sowers MR, Nichols S, et al. Bone mineral density changes over two years in first-time users of depot medroxyprogesterone acetate. Fertil Steril 2004; 82:1,580-1,586.
  8. Scholes D, LaCroix AZ, Ichikawa LE, et al. Injectable hormone contraception and bone density: Results from a prospective study. Epidemiology 2002; 13:581-587.
  9. Kaunitz AM, Miller PD, Rice VM, et al. Bone mineral density in women aged 25-35 years receiving depot medroxy-progesterone acetate: Recovery following discontinuation. Contraception 2006; 74:90-99.
  10. ACOG Committee Opinion No. 415: Depot Medroxy-progesterone Acetate and Bone Effects. Obstet Gynecol 2008; 112:727-730.
  11. Tolaymat LL, Kaunitz AM. Use of hormonal contraception in adolescents: Skeletal health issues. Curr Opin Obstet Gynecol 2009; 21:396-401.
  12. National Institutes of Health. Dietary Supplement Fact Sheet: Calcium. Fact sheet. Accessed at ods.od.nih.gov/factsheets/calcium.asp.