• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy.
• Assess risk for osteoporosis.
• Assess risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling.
• Check the woman's blood pressure.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for a progestogen-only injectable.
• Breast and cervical examinations, routine blood tests, and thrombophilia screening are not required to assess eligibility for a progestogen-only injectable.

In depth

• If long-acting contraception is required for a few months, use depot medroxyprogesterone acetate (Depo-Provera^®) or norethisterone enantate (Noristerat^®).
• If long-acting contraception is required for an extended period (i.e. > 16 weeks), depot medroxyprogesterone acetate (Depo-Provera^®) is recommended.

In depth

• Having menstrual cycles and not postpartum, or post-abortion or post-miscarriage:
• Give the injection during days 1–5 of the menstrual period. Additional contraception is not needed.
• You can also give the first injection after day 5 (unlicensed use) if reasonably certain the woman is not pregnant. Advise additional contraception for 7 days.
• Amenorrhoeic and reasonably certain not pregnant:
• Give the first injection at any time (unlicensed use). Advise additional contraception for 7 days.
• Postpartum and not breastfeeding:
• Give the first injection on day 21 — additional contraception is not needed. If the injection is given after day 21, advise additional contraception for 7 days.
• Injectable progestogens can be started before 21 days if there is good reason to do so. Noristerat^® can be used immediately after birth. Depot medroxyprogesterone acetate can be started within 5 days of birth (prolonged heavy bleeding can occur).
• Breastfeeding:
• < 6 weeks postpartum: Noristerat^® can be used immediately after birth. Delay using DepoProvera^® until at least 6 weeks after birth. If because of the risk of pregnancy, it must be used before this, delay until at least day 21 days postpartum (unlicensed use).
• Between 6 weeks and 6 months postpartum, and amenorrhoeic: give the first injection at any time. Advise additional contraceptive for 7 days unless fully breastfeeding.
• > 6 weeks postpartum, and menstrual periods have returned: give the first injection as advised for other women having menstrual cycles.
• Women who are post-abortion or post-miscarriage:
• Give injections immediately after miscarriage (unlicensed use), or abortion (unlicensed use for depot medroxyprogesterone acetate). If started > 7 days after abortion (unlicensed use), advise additional contraception for 5 days.

In depth

• Norethisterone enantate, arrange for the second injection to be given in 8 weeks.
• Depot medroxyprogesterone acetate, arrange repeat injections at 12-week intervals:
• There is a two-week 'window of safety' if the repeat injection is late.
• At the follow-up visit check the woman's knowledge of what to do if her injection is late, review eligibility for progestogen injectables, and address any problems.
• If problems arise, change to another method (if this is what she wants or needs), or repeat the injection, or change to the other type of injectable.

In depth

• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy.
• Assess risk for osteoporosis.
• Assess risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling.
• Check the woman's blood pressure.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for a progestogen-only injectable.
• Breast and cervical examinations, routine blood tests, and thrombophilia screening are not required to assess eligibility for a progestogen-only injectable.

In depth

• If long-acting contraception is required for a few months, use depot medroxyprogesterone acetate (Depo-Provera^®) or norethisterone enantate (Noristerat^®).
• If long-acting contraception is required for an extended period (i.e. > 16 weeks), depot medroxyprogesterone acetate (Depo-Provera^®) is recommended.

In depth

• Currently using a hormonal method — excluding the levonorgestrel-releasing intrauterine system (IUS):
• Can have the first injection immediately. If the previous method was another injectable, the woman should have the new progestogen-only injectable when the repeated injection would have been given for the current contraceptive (unlicensed use).
• Currently using a non-hormonal method other than a copper intrauterine device (IUD):
• Can have the first injection immediately. If it has been > 5 days since menstrual bleeding started (unlicensed use), advise additional contraception for 7 days.
• Currently using a copper IUD or levonorgestrel-releasing IUS:
• Can have the first injection within 5 days after the start of menstrual bleeding. The IUD or IUS can be removed at that time.
• Can also start at any other time (unlicensed use), but to provide uninterrupted contraceptive protection, the IUD or IUS should be removed at least 7 days after the injection.
• If amenorrhoeic or bleeding is irregular, the injection can be given as advised for other amenorrhoeic women — see Start injectable: not using contraception.

In depth

• Norethisterone enantate, arrange for the second injection to be given in 8 weeks.
• Depot medroxyprogesterone acetate, arrange repeat injections at 12-week intervals:
• There is a two-week 'window of safety' if the repeat injection is late.
• At the follow-up visit check the woman's knowledge of what to do if her injection is late, review eligibility for progestogen injectables, and address any problems.
• If problems arise, change to another method (if this is what she wants or needs), or repeat the injection, or change to the other type of injectable.

In depth

• 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 additional contraception for 7 days.
• If pregnancy cannot be excluded:
• Consider if emergency contraception is indicated. For more information, 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.

In depth

• Advise that many women experience irregularities in menstruation while using a progestogen-only injectable:
• A few women have very heavy or prolonged bleeding. This can be managed by:
• Treating with a combined oral contraceptive (either cyclically or continuously) for up to 3 months.
• Treating with mefenamic acid 500 mg twice or three times a day for 5 days.
• Changing to another contraceptive method.
• Some women experience prolonged amenorrhoea; this is most likely in older women and, with forewarning, is usually accepted.
• Exclude or manage other situations which could result in unscheduled bleeding, such as:
• Sexually transmitted infections.
• Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
• Pregnancy.
• Gynaecological conditions such as cervical cancer. Provided there is consistent and correct use of contraception, speculum examination is warranted:
• For persistent bleeding beyond the first 3 months of use.
• For new symptoms or a change in bleeding after at least 3 months of use.
• If the woman has not participated in a National Cervical Screening programme.
• If requested by the woman.
• After a failed trial of modification of treatment.
• If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)

In depth

• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy.
• Assess risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling.
• Check the woman's blood pressure.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for a progestogen-only implant.

In depth

• Provided that it is reasonably certain that the woman is not pregnant, the progestogen-only implant can be inserted at any time, but the need for additional contraception varies.
• First implant, or switching from a hormonal method of contraception:
• Ideally insert within days 1–5 of the menstrual period.
• If inserted outside this time, or if the woman is amenorrhoeic, additional contraception is needed for 7 days.
• If switching from a progestogen-only injectable, the implant should be inserted no later than the time when the next injection is due.
• Switching from a copper intrauterine device (IUD) or a levonorgestrel-releasing intrauterine system (LNG-IUS):
• Insert the implant and remove the IUD or LNG-IUS at least 7 days later.
• Postpartum:
• Ideally insert on day 21 for immediate contraceptive protection.
• If started after day 21, additional contraception is needed for 7 days, unless she is fully breastfeeding.
• Post-abortion or post-miscarriage:
• If inserted on the same day (for abortion, whether induced or spontaneous, at < 24 weeks' gestation) no additional contraceptive method is required.
• If started more than 5 days days after abortion or miscarriage, an additional contraceptive method is required for 7 days.

In depth

• No routine follow up is needed.
• Review when the implant needs to be removed or if the woman requests early removal.

In depth

• A woman who experiences heavy or prolonged bleeding may be treated by:
• Treating with a combined oral contraceptive (either cyclically or continuously) for up to 3 months
• Changing another contraceptive method.
• Amenorrhoea is a common adverse effect of the implant, and is not harmful.
• Exclude or manage other situations which could result in unscheduled bleeding, such as:
• Sexually transmitted infections.
• Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
• Pregnancy.
• Gynaecological conditions such as cervical cancer. Speculum examination is warranted:
• For persistent bleeding beyond the first 3–6 months of use.
• For new symptoms or a change in bleeding after at least 3 months of use.
• If the woman has not participated in a National Cervical Screening programme.
• If requested by the woman.
• After a failed trial of modification of treatment.
• If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)

In depth