Answers to EC protocol, DMPA impact on lipids

Puzzled about protocols for dispensing emergency contraception (EC) to male partners? Wondering about the impact of depot medroxy-progesterone acetate (DMPA, Depo-Provera, Pharmacia Corp, Peapack, NJ) on lipid levels?

The following members of Contraceptive Technology Update’s Editorial Advisory Board address these issues: Linda Dominguez, RNC, NP, assistant medical director of the Albuquerque-based Planned Parenthood of New Mexico; Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/ Jacksonville; Michael Rosenberg, MD, MPH, clinical professor of obstetrics and gynecology and adjunct professor of epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm specializing in reproductive health; and Felicia Stewart, MD, adjunct professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California San Francisco and co-director of the Center for Reproductive Health Research & Policy.

Question: I’m a public health nurse working in a family planning clinic. Within our county, we have three outlying clinics within 30-60 minutes of the metropolitan center. Those clinics are staffed only one to three days per week. On several occasions, we have had young men present in the clinics requesting EC for their girlfriends who are unwilling to come in for fear of being seen by an acquaintance in the small community. We are attempting to gather information about the possibility of dispensing EC to male partners for immediate use. Can you provide any precedence or protocols that would address this?

Dominguez: The one informal protocol that comes to mind that is similar is the provision of prescription or dispensing extra medication for treatment of sexually transmitted diseases (STDs) for recent contact partners. This has been a sanctioned practice documented in the CDC Guidelines for the Treatment of Sexually Transmitted Diseases.

Another solution would be a telephone intake by staff with the woman and then provision of prescription to local pharmacy. Your public health clinic would need to work up a procedure/protocol. Paperwork would have to be generated to establish a relationship with the patient to satisfy the need for a provider/patient interaction for prescribing regulations. Also the public health department would want to capture this patient contact for their numbers.

Rosenberg: I don’t know of any protocols, but the basic message around EC use is that it is remarkably safe and needs to be used on a timely basis. Partner treatment is an accepted component of STD treatment, and I believe that EC use should similarly be encouraged.

Stewart: Maybe the clinic could speak to the woman by telephone, and then the partner could pick it up? That way, the prescription is for the woman, and the clinician has a chance to gather confidential info directly from her, but the convenience issue is dealt with.

Question: What effect does Depo Provera have on cholesterol? Has it been found to create any problems because of the lowered estrogen effects in women who take Depo Provera for years?

Kaunitz: Use of DMPA contraception lowers HDL levels and raises LDL levels. In contrast to use of oral contraceptives, triglycerides do not rise with use of DMPA. The clinical implications, if any, of these findings are unknown. Regarding lower estrogen production by the ovaries during use of DMPA: Bone mineral density declines during use of DMPA, then rises back toward baseline after use of inject-able contraception. This phenomenon appears similar to what happens with bone density during lactation (another state associated with lower estrogen levels). Long-term implications, including osteoporosis or fractures, have not been demonstrated to result from use of DMPA birth control.