Effective.
One of the most effective family planning methods: less than 1 pregnancy per 100 users per year. DMPA works chiefly by preventing ovulation.

Most widely used of several injectables.
An estimated 30 million women have used DMPA. Other injectables include NET EN (norethindrone enanthate, or Noristerat®), effective for 2 months, and Cyclofem™ and Mesigyna®, both effective for 1 month. DMPA and NET EN are progestin-only injectables, while 1-month injectables contain both progestin and estrogen.

Widely approved.
Drug regulatory agencies in over 100 countries have approved DMPA. The United States Food and Drug Administration approved DMPA for contraception in October 1992.

A good choice for women who—

• Want a very convenient contraceptive and prefer injections to voluntary sterilization, an IUD, or implants
• Are troubled by estrogen side effects of oral contraceptives
• Do not want to take a pill each day or to use a contraceptive just before sexual relations
• Can accept changes in menstrual bleeding patterns
• Want their use of a contraceptive to be a private matter that no one else needs to know about.

Many can provide DMPA.
Many health care providers, including many pharmacists, know how to give injections. They need to counsel clients about side effects, especially menstrual changes. To eliminate any risk of transmitting infections, including HIV/AIDS, providers must use sterile or disinfected needles and syringes.

Menstrual changes common.
Most women have irregular menstrual cycles in the first year of use and then stop menstruating for three months or more at a time. Others have irregular bleeding, spotting, or changes in the duration and amount of bleeding. Weight gain (average 1-2 kg/yr) also is common.

Cancer studies yield new information.
A World Health Organization (WHO) study found that DMPA did not increase women's overall risk of breast cancer, invasive cervical cancer, liver cancer, or ovarian cancer, and it decreased risk of endometrial cancer. DMPA may speed up the growth of existing breast cancer, however; women face a slightly increased risk of breast cancer in the first five years after they start DMPA, according to combined data from WHO and New Zealand studies. WHO's 9-year case-control study involved more than 15,000 women in Kenya, Mexico, and Thailand.

Cardiovascular effects minimal.
Because DMPA does not contain estrogen, users are thought to face less risk of cardiovascular disease than users of combined oral contraceptives.

Fertility not impaired although return is delayed.
When a woman stops DMPA, fertility returns on average 6 months after the next injection would have been given. There is no permanent impairment of fertility.

Can be used by breastfeeding women.
Although hormonal methods are not the first choice for breast- feeding women, in most studies DMPA has had no effect on breast-milk production or has increased the volume of breast milk.

Other issues studied.
Although exposure of a fetus to any hormones should be minimized, studies have been reassuring that fetal exposure to DMPA does not cause congenital malformations. One study indicates possible decreased bone density in long-term users, but more research is needed.

Women especially at risk of STDs need condoms.
DMPA does not protect against STDs, including HIV/AIDS. Women who have multiple sexual partners or use intravenous drugs—or whose sexual partners have other partners or use intravenous drugs—should use condoms even if they rely on DMPA for family planning.

For policy-makers:

• If not already done, register injectable contraceptives.
• Ensure that injectables are offered in family planning programs.
• Avoid restrictions based on age and parity. There are no medical reasons to require users of injectables to have reached a certain age or to have had children or a certain number of children.
• Allow women who have epilepsy, tuberculosis, varicose veins, or deep venous thrombosis (blood clots in veins) to use DMPA or NET EN.
• Consider nonclinical distribution and make sure that good quality is maintained. Community-based programs and social marketing programs can make injectables more accessible.

• Conduct seminars for policy-makers and providers when introducing or expanding services. Conduct pilot studies to assess clients' responses to injectables.
• Conduct audience research to identify views, concerns, and misperceptions about injectables. Such information helps when designing communication programs and training providers.
• Provide accurate information for providers, clients, and the public. Use the mass media whenever possible.
• Train providers to counsel with sensitivity and to prevent infection. Use a variety of interactive training methods and offer periodic refresher training. Where programs have not offered injectables, providers may know less about them than about other contraceptives.
• Ensure that women using injectables have access to treatment for very heavy or prolonged bleeding.
• Consider offering only one type of progestin-only injectable and, if there is demand, one monthly progestin-estrogen injectable. Offering more injectables increases choice but may strain logistics systems.
• Ensure a reliable supply of injectables. Order six months to a year in advance and take the time to make accurate forecasts of demand.
• Shorten the travel time for injectables and other contraceptives from manufacturer to clinic. For example, remove a level in the distribution chain from port to clinic.
• Allow flexibility in the injection schedule. Women may receive their first injection whenever the provider is reasonably sure that they are not pregnant, not just in the first seven days of their menstrual cycle. DMPA users can be at least two weeks late for their injections; NET EN users can be at least one week late.
• Order disposable needles and syringes packed with injectables to avoid any import duties on the equipment and to prevent shortages that lead to unsafe reuse. Order extra needles and syringes if possible.
• Set up procedures to ensure that disposable needles and syringes are not reused. Plan disposal of needles and syringes as part of overall logistics planning.

• Learn about injectables. Well-informed providers can give clients balanced information and avoid biases for or against injectables.
• Take the time to counsel. Women who have been counseled about the side effects of injectables, particularly changes in menstrual bleeding, tend to be more satisfied with the method and use it longer than women who have not been counseled.
• Prevent infection by using a new disposable needle and syringe for each injection and disposing of it carefully. If reusable needles and syringes must be used, sterilize or high-level disinfect before each use.
• Help prevent sexually transmitted diseases (STDs). Injectables do not protect against STDs, including HIV/AIDS. For women who choose injectables and are at risk for STDs, recommend condoms in addition.