If given within the first 7 days of the menstrual cycle, it becomes effective immediately. However, if CICs are started after the first 7 days of a cycle or the woman is not menstruating, a back-up method is recommended to be used for 7 days. Some providers recommend a back-up method be used for 7 days if Cyclofem or Mesigyna are begun after the fifth day of the cycle.

Hypothetically, all CICs are effective when begun within the first 7 days of the menstrual cycle.

Rationale: Deladroxate is effective immediately when given within the first 7 days of the menstrual cycle and possibly later. Most clinical trials of Cyclofem and Mesigyna (two newer, lower-dose formulations of CICs) have used the first 5 days of the cycle as the period for initiation. However, a recent study has demonstrated high contraceptive efficacy for a CIC similar to Cyclofem and Mesigyna when initiated between days 7 and 10 of the menstrual cycle.

Some experts believe that the lower-dose CICs are effective at least as promptly as COCs. These CICs have slightly less estrogen effect and more progestin effect than COCs, and it is presumed that their effect on cervical mucus is at least as prompt as the effect of COCs (46, 152).

Rationale: There are no data on the effects of combined injectables used during lactation. The following rationale is based on what is known about combined oral contraceptives.

Even low-dose (30 micrograms) COCs decrease breastmilk production; it may be that estrogen-containing injectables, although they have a lower estrogen dose than COCs, will have a similar effect, but this has not been studied (310, 311).

Rationale: Blood coagulation and fibrinolysis are essentially normalized by 3 weeks postpartum (and are close to normal at 2 weeks postpartum). CICs have minor effects on blood coagulation (51, 98).

Rationale: CICs may be initiated any time after a first- or second-trimester abortion or postseptic abortion (310).

The grace period of combined injectable contraceptives is officially 3 days. If a client comes in after the grace period (27 to 33 days after the previous injection), advise her that delays in obtaining injections increase the risk of pregnancy. Offering re-injection for women who come in after the grace period is reasonable for women who state that, once beyond the grace period, they have been abstaining or consistently using a back-up method and/or the provider can be reasonably sure that the woman is not pregnant.

Rationale: Clinical trials have studied the efficacy of CICs given 27 to 33 days after the previous injection and found the efficacy to be very high. Some studies have found that the risk of ovulation is low up to 60 days after the previous Cyclofem or Mesigyna injection (1, 18, 235).

Recommendation: There is a risk of in utero exposure to the injectable if she is pregnant when she receives the next injection. However, there is no evidence that fetal exposure to CICs will be harmful.

Rationale: Although the estrogens and progestins in CICs have no known teratogenic effects, avoiding the risk of fetal exposure is preferable on general principles (28, 251).

Recommendation: It is acceptable to give the injection if you can be reasonably sure she is not pregnant (see How to Be Reasonably Sure the Woman Is Not Pregnant). Some programs will advise women to use a back-up method for the rest of the cycle.

Rationale: Approximately 20% of CIC users experience frequent or prolonged menstrual bleeding within the first 3 months. However, these variations from normal bleeding patterns tend to decrease with time (300).

Recommendation: If bleeding has stopped and the woman wants to continue using CICs, reassure her first. The woman should be reassured by informing her that these effects usually pose no threat to health and tend to improve over time.

Rationale: Compared with women not using any contraceptive method, CIC users experience a significantly increased incidence of frequent, irregular, and prolonged bleeding (300).

Recommendation: If a woman is experiencing more days of bleeding than she was prior to starting CICs, the first approach should be counseling to provide information and reassurance.

If the bleeding is intolerable to the woman but she wishes to continue CICs, then administration of supplementary short-term estrogen (or COCs) or prostaglandin inhibitors may be tried.

Rationale: Little research has been done on the management of heavy bleeding in CIC users. Prolonged or heavy bleeding in users of COCs or progestin-only injectables may be managed by stabilizing the endometrium with increased doses of estrogen or by ibuprofen (or related nonsteriodal anti-inflammatory drugs), which blocks prostaglandin synthesis and thus decreases uterine bleeding (261, 303).

Recommendation: Some women may not be able to tolerate heavy or prolonged bleeding and will discontinue CICs and need another method. Evaluate and address anemia if appropriate.

Do not perform uterine evacuation unless another medical condition is suspected. (Vacuum aspiration is always the preferred method of uterine evacuation.)

Rationale: Nurses, midwives, and other community health workers can be appropriately trained to initiate and resupply injectables (303).

Recommendation: Under certain circumstances, clients may be provided with the supplies for self-administration or administration by another individual, provided that appropriate storage and infection-prevention procedures can be assured and that the woman knows where she can receive supportive services, should she have any problems.

However, some women may prefer the more reliable menstrual periods produced by the CIC with 10 mg of estradiol enanthate and 150 mg of dihydroxyprogesterone acetophenide (this "menstrual signal" can serve as a reminder for reinjection) or may otherwise have a personal preference. The older CIC may be made available since it may be an appropriate choice for some women.

Rationale: Both the older and newer CICs have very high efficacy. However, there is a theoretical concern of using 10 mg of estrogen monthly, because of the possible negative effects on blood coagulation. Newer CICs, such as Cyclofem and Mesigyna, have half the estrogen dosage of the older CICs. The lower-dose CICs have, at least theoretically, less risk.