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Contraception - Management
What advice should I give on what to do when the repeat progestogen-only injectable is late?
- Up to 14 days late (i.e. up to 98 days since the last injection):
- Repeat the injection.
- No additional contraception is needed.
- More than 14 days late (i.e. more than 98 days since the last injection):
- Exclude pregnancy before repeating the injection:
- Use an additional contraceptive method for 7 days after giving the injection.
- If pregnancy cannot be excluded immediately:
- Consider if emergency contraception is indicated (see the CKS topic on Contraception - emergency).
- Advise alternative methods, and delay repeating the injection until there is a negative pregnancy test at least 3 weeks after the last unprotected sex.
- After the injection, continue with alternative contraception for 7 more days.
Clarification / Additional information
- Table 1 shows the differences between the licensed and unlicensed uses of progestogen-only injectables.
Table 1. Licensed and unlicensed use of progestogen-only injectables — repeated and late injections.
Use | Licensed use, as in the Summary of Product Characteristics (SPC) | Evidence-based use outside the terms of the product licence |
|---|
Repeated and late injections | Depot medroxyprogesterone acetate: The injection should be given every 12 weeks. As long as injections are given no later than 5 days after the due date, no additional method is required. If the interval from the last injection is > 89 days (12 week + 5 days), pregnancy should be excluded before the next injection is given and an additional method used for 14 days. For norethisterone enantate: The injection may be repeated once, after 8 weeks. No information is given regarding late injection. | Depot medroxyprogesterone acetate: Injections should be repeated every 12 weeks. Depot medroxyprogesterone acetate can be given up to 2 weeks early (10 weeks) or 2 weeks late (14 weeks) after the last injection without the need for an additional method. For norethisterone enantate: Injections should be repeasted every 8 weeks. Norethisterone enantate can be given up to 2 weeks early (6 weeks) or up to 2 weeks late (10 weeks) without the need for an additional method. If depot medroxyprogesterone acetate or norethisterone enantate is more than 2 weeks late: Contraceptive protection may be lost and protocols should be developed locally to guide women and clinicians in deciding on the need for emergency contraception and the timing of the next injection. |
|
Basis for recommendation
- These recommendations follow guidelines issued by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FFPRHC, 2002; FFPRHC, 2005a], which are developed from guidance issued by a World Health Organization (WHO) expert working group [WHO, 2004a].
- The basis of the WHO recommendations are [WHO, 2004a]:
- The expert working group considered the risk of ovulation to be minimal within 2 weeks after the time for a repeated injection (3 months for depot medroxyprogesterone acetate and 2 months for norethisterone enantate).
- The mechanisms of action, the medical eligibility criteria, and the adverse-effects of depot medroxyprogesterone acetate and norethisterone enantate are similar. Therefore it is safe to stop using one and start using the other.
- Whereas an estimated 48 hours of progestogen-only pill use was deemed necessary to achieve contraceptive effect on cervical mucus, the time required for progestogen-only injectables to exert such an effect was uncertain.
- Where recommendations are sometimes inconsistent, CKS has followed the FFPRHC guidelines. For example:
- The Summary of Product Characteristics for depot medroxyprogesterone acetate regards a delay of more than 5 days in repeating the injection as compromising the reliability of contraception [ABPI Medicines Compendium, 2004c]. However, the FFPRHC would regard a delay of up to 2 weeks as not affecting reliability of contraception [FFPRHC, 2005a].
- The Summary of Product Characteristics for depot medroxyprogesterone acetate recommends 14 days of additional contraceptive protection when the repeated injection is more than 5 days late [ABPI Medicines Compendium, 2004c]. However, the FFPRHC recommend 7 days [FFPRHC, 2005a].
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