PROGESTIN-ONLYCONTRACEPTIVEMETHODS: IDENTIFICATION OF CANDIDATEFOR INITIAL START, RESTART OR CONTINUATION

DEFINITION

Progestin-onlymethodsareavailableaspills,injections,implantsand IUDs.The three LNG-IUDsare describedin IdentificationofIntrauterineDevice(IUD)Candidateprotocol.Manywomenpreferthe convenienceandefficacyofimplantableandinjectableprogestin-onlymethods.Awomanwho experiencesunacceptableestrogen-relatedsideeffectsorhascontraindicationstoestrogen- containingcontraceptivemethodsmaybeabletouseprogestin-onlybirthcontrolmethods successfully.Progestin-onlymethodsmaybepreferredtocombinationhormonalmethodsforwomen withchloasma,hypertension,VTE,severeheadaches,chronicasymptomatichepaticdisease, breastfeeding,tobaccouseand age≥ 35, or witha BMIgreaterthan30.

Thetypicalusefirst yearfailure rateforprogestin-onlypills (POPs)isthesameasforconventionalpills(9%)butfailureratesmaybelower inbreastfeedingwomen. Peak serum levels are reached approximately 2 hours after administration, followed by rapid destruction and elimination. By 24 hours after administration, serum levels are at baseline; therefore taking POPs at the same time daily is very important.

Progestin-onlyimplantshavefirst yearfailureratesthatareatleastaslow assterilizationandwithcorrectandconsistentusemaybeaslowas0.1%andarenotaffectedby obesity.Progestin-onlyimplantsareoftenmorepopularamongadolescentwomen.

Theprogestin-onlyinjection(depomedroxyprogesteroneacetate [DMPA]orDepoProvera)has afirst year failureratewithtypicaluseof6.4%,butwithcorrectandconsistentuse,thefailurerateisonly0.3%. DMPAisavailablein2 formulations:DMPA150mgIManddepo-subQprovera104 mg. DMPAoffers manynoncontraceptivehealthbenefits,includingreducingfrequencyofacutesicklecellcrises, reducingtheintensityofdysmenorrhea,treatingsevereanemiainwomenwithexcessivemenstrual bloodloss,and reducingthepainofendometriosis.Itislikelythatallprogestin-onlymethodsreduce theriskofendometrialcancer,especiallyinanovulatorywomen.Severalstudieshavereportedthat structuredcounseling,especiallyaboutlongeractingmethodsmaybeveryusefulinhelpingwomen choosemoreeffectivemethodsandmaximizecontinuationrates.

SUBJECTIVE

Mustinclude:

  1. LNMPandmenstrual history.
  2. Medical,sexualandcontraceptivehistory(initialorupdate), review of systems (QFP, pg.8).
  3. Evaluationforallergiestoanycomponentofthemethodortoantisepticorlocalanesthesia,if consideringimplant.
  4. Historyofanyrecentunprotectedintercourse.

Mustexclude:

AllCDC category 4 conditions–(Unacceptable risk for method use).

Use caution with CDC category 3 conditions- (Risks outweigh advantages for method use) individualized management must be based on protocols approved by the Medical Director or clinic physician.

  1. Breast Cancer (CDC 4 current, CDC 3 for > 5 years past)
  2. Cirrhosis (severe – decompensated)(CDC 3)
  3. Liver tumors (adenoma, or hepatoma) (CDC 3)
  4. Positive (or unknown) antiphospholipid antibodies (CDC 3). People with Systemic Lupus Erythematous are at increased risk of ischemic heart disease, stroke and venous thrombosis.
  5. Bariatric surgery (history of) - malabsorptive procedure i.e., Roux-en-Y gastric bypass, biliopancreatic diversion) (CDC 3 POPs only). Banding is OK.
  6. Cardiovascular Disease, multiple risk factors (CDC 3 DMPA); Stroke (CDC 3)
  7. Unexplained vaginal bleeding (CDC 3 before evaluation/DMPA and implant)
  8. Rheumatoid arthritis-Immunosuppressive therapy (CDC 3 continuation/DMPA)
  9. Diabetes with nephropathy/retinopathy/neuropathy (CDC 3/DMPA)
  10. With other vascular disease or diabetes of >20 years duration (CDC 3/DMPA)
  11. Anticonvulsants –phenytion, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine (CDC 3 for POP)

NOTE:Breastfeedingwomencaninitiateanysystemicprogestin-onlymethodimmediately postpartum,despitelabelingrecommendations,aslongasthewomencantoleratea slightincrease inlochialbloodloss.Thereisnoincreaseinpostpartumdepressionduetoprogestin-only methods.

OBJECTIVE

Mayinclude:

  1. BP.ObtainMDconsultifBPs≥ 160orBPD≥100mmHg.(forimplantandinjection).
  2. Weight,BMI(obesityisnota contraindicationtoanyprogestin-onlymethod.Theefficacyof implantsandinjectionsisnotaffectedbypatientweight.)

NOTE:Progestin-onlymethodsmaybeinitiatedorrestartedwithoutpelvicexaminationin asymptomaticwomenwhohavenothadrecentexams.RoutineSTDtestingmaybeperformed usingurinespecimens,ifindicated.

LABORATORY

Mustinclude:

  1. Routinepregnancytestingisunwarranted.
  2. Negativesensitiveurinepregnancytest(UCG)onlyifpatienthasunexplainedirregular ordelayedmensesorsymptomsofpregnancy. Theremay bemoreneedtodocumentthatpregnancyhasbeenruledoutforimplantcandidatesseeking placementatunconventionaltimes.

ASSESSMENT

Candidate for systemic progestin-only hormonal method initiation, restart or continuation

PLAN

  1. ObtainMDconsultifanyUSMECcategory3 conditionsfordesiredmethod.
  2. Ifprogestin-onlybirthcontrolpillsareselected,patientmaystartinoneof2 ways:

a.ImmediatelywithQuickStart(preferredapproach):

1)IfLMP≤5daysearlier,starttodaywithnobackupmethodneeded.

2)IfLMP5 daysearlier,managementdependsuponhistoryof recentunprotected intercourse(seeAttachment1).

a)IfnounprotectedintercoursesinceLMP:

  1. Havepatientstartprogestin-onlypillimmediately.Advisehertouseabstinence oruseback-upmethodfor2 days.

a)Provide12monthsupplyofpills

  1. A prescription may be extended beyond 12 months in order for client to schedule annual visit.
  2. ProvidehormonalECinadvanceofneed ifpossible.SeeEmergencyContraception(EC) protocol.

b) Ifunprotectedintercourseinlast5 days:

  1. ProvideECtodayaccordingtoEmergencyContraception[EC]protocol.The patientcanstartherpillsaccording to the EC protocol.

a)Havepatientuseabstinenceorback-upmethodfor2 daysafterstarting progestin-onlypills.Hernextmensesmaybedelayed.

  1. HavepatientgetUCGin3 weeksifshedoesnothaveanormal mensesbythen.
  2. Provide12monthsupplyofpills
  3. ProvideECinadvanceofneed.SeeEmergencyContraception[EC]protocol.

3) Ifanyunprotectedintercourse>5daysearlier,useoneofthefollowingoptions:

a) Considerpregnancytest,asindicated.Advisepatientthatpregnancytestmaynotbe 100%accurate.

  1. Ifpregnancytestisnegative,havepatientstartprogestin-onlypillstodayanduse abstinenceorback-upmethodfor2 days.
  2. Ifnopregnancytestisindicated,havepatientstartprogestin-onlypillstodayand useabstinenceorback-upmethodfor2 days.
  3. HavepatientgetUCGin3weeksifshedoesnothaveanormalmenses.
  4. Provide12monthsupplyofpills,ifpossible.Returnappointmentsmaybe scheduledearlier,as needed.

a)A prescription may be extended beyond 12 months in order for client to schedule annual visit.

  1. ProvideECinadvanceofneed.SeeEmergencyContraception[EC]protocol.

OR

b) Firstdayofnextmenses(lesspreferredapproach).

  1. Provideintervalmethod.Havepatientstartherfirstpillonthefirstdayofhernextmenses.Noback-up methodneeded.
  1. Provide12monthsupplyofpills

a)A prescription may be extended beyond 12 months in order for client to schedule annual visit.

4)ProvideECinadvanceofneed.SeeEmergencyContraception(EC)protocol.

PLAN

3. IfDMPAisselected,administrationdependsondateofLMPandcurrentmethodused.

a.IfLMP≤ 7 daysagoorifswitchingfromaneffectivemethodsuchasIUD,implant, combinedhormonalmethod,lastDMPAinjectiongiven15weeks (up to 2 weeks late from last injection “13 wks + 2 wks. Ref. SPR pg. 21)andnosymptomsof pregnancy,giveDMPAwitheitheroneofthefollowing:

1) DMPA150mgdeepIMinjectionindeltoidareaofthearmor ventral gluteal area of buttocks usinga21-23gaugeneedle.Donotmassageareaafterinjection.Noback-up methodneeded.

Note: In obese women, deltoid injection preferred. Longer needle may be needed to reach muscle in gluteus of women with BMI over 30

OR

2) depo-sub Q provera104subcutaneouslyover5-7secondsinanteriorthighorabdomen (exceptnearumbilicus).Noback-upmethodneeded.

  1. IfLMP> 7 daysagoandifnotswitchingfromeffectivemethodsasnotedabove,twooptions areavailable:

1) QuickStart(sameday)injection(preferredapproach).

a) IfnounprotectedintercoursesinceLMP(orsincelastcontraceptiveeffective), provideDMPAasoutlinedaboveandadvisetheuseof abstinenceorbackup method for7 days.

b) IfanyunprotectedintercoursesinceLMPordatesincelastcontraceptiveeffective, determineneedforUCG.IfnotindicatedorifUCGnegative:

  1. Ifunprotectedintercourseinprior5 days,offerEC(See Emergency

Contraception (EC) Protocol).

(a) IfpatientacceptsEC,patientmayalsobegivenDMPAatthisvisit. Instruct hertouseabstinenceorback-upmethodfor7days.Ifshehashadany unprotectedintercoursesinceLMP,recommendrepeatUCGin2-3weeksif nomenses,orifshehasanysignsorsymptomsofpregnancy.

(b)IfpatientdeclinesEC,recommendabstinenceorprovidebarriermethodfor14days.Havepatientreturnin14daysforrepeaturinepregnancytest.Ifthat testisnegative,administerwithDMPAandhavepatientuse abstinenceor back-upmethodfor7 days.Ifmensesreturnsbefore14days,patientmay returnforinjectionon mensesandavoidneedforback-upmethod.

  1. Iflastintercourse5 daysago,offerurinepregnancytest.IfUCGnegative, advisepatientthattestmaybetooearlytodetectpregnancy,butthatDMPAhas noknownadverseeffectsonfetus.

(a) OfferDMPAandrecommendabstinenceorback-upmethodfor7 days.SuggestrepeatUCGin2-3weeksifnomenses,orifanysignsorsymptoms ofpregnancy.

(b)IfUCGnegative,butpatientdesirestowaitforinjection,recommend abstinenceorprovidebarriermethodfor14days.Havepatientreturnin14 daysforrepeaturinepregnancytest.Ifthattestisnegative,injectwith DMPAandhavepatientuseabstinenceorback-upmethodfor7 days.If mensesreturnsbefore14days,

PLAN

patientmayreturnforinjectionon menses andavoidneedforback-upmethodandUCG.

  1. DMPAmaybegivenimmediatelyafterpregnancylossortermination,andtopostpartum womenbeforetheyaredischargedhomeafterdeliverywhetherornottheyarebreastfeeding unlessthewomanhassevereanemiaorheavybleeding.Thereisnoincreaseintheriskof postpartumdepressionwithimmediatepostpartumuseofDMPA.DMPAhasnotbeenshown toreducebreastmilkproductionordurationofbreastfeeding.
  2. Calculatedateofnextinjectionandschedulenext visit.

1)DMPA150mgIM:11-13weeks

2)Depo-sub Q provera104:12-14weeks

  1. Forwomenwhohavehadpreviousproblemsorconcernswithunscheduledbleedingwith DMPAandnocategory3 or4conditionsforCOCs,considerpre-treatingwithCOCsfor2 monthspriortofirstDMPAinjection.
  2. A prescription may be extended beyond 12 months in order for client to schedule annual visit.
  3. OfferECinadvanceofneed(SeeEmergencyContraception[EC]protocol)

4. Ifimplantselected,placeonlyifconfidentpatientisnotpregnant:

  1. Nobackupmethodisneededifimplantplacedatanyofthefollowingtimes:

1)Duringfirst5 daysofmenses.

2)Atanytimeifswitchingfromcombinedhormonalcontraception,includinghormonefree intervalsofCOCs,patchorvaginalring.

3) Atanytimeifswitchingimmediatelyfromprogestin-onlymethod,includingprogestin-onlypills,DMPAinjection,LNG-IUDorimplant.

4)Ifexclusivelybreastfeeding,andamenorrheicinthefirst6 monthsfollowingdelivery, may place immediately if no recent unprotected intercourse

5)Within5 daysoffirsttrimesterpregnancyloss.

6)Within28daysaftersecondorthirdtrimesterpregnancylossordelivery.

  1. Ifplacingatanyothertime,confirmpregnancytestnegative,provideEC,ifneeded,and adviseabstinenceorprovidebarriermethodfor7 daysafterimplantplacement.
  2. Ifplacingthisvisit:

1)Explainrisksandbenefitsofimplants.Counselaboutbleedingchangesthatmaybe expected.

2)Obtaininformedconsentusingmanufacturer’sinformedconsentformoralocalformthat includesalltheinformationfoundinFDA-approvedform.

3)Placeimplantaccordingtomanufacturer’sinstructions, in the non-dominant upper arm, subdermally just under the skin, avoiding the sulcus (groove) between the biceps and triceps muscles, and the large blood vessels and nerves that lie there in the neurovascular bundle deeper in the subcutaneous tissues.

4)Verifyplacementofimplant.

5)Providepost-placementinstructionsandprecautions.Adviseabstinenceorback-up contraceptionfor7 days,ifneeded.

6)Documentaplacementprocedurenote.

  1. HavepatientreturnforannualexaminationandPRNproblems.

PATIENT EDUCATION

  1. Remindthepatientthatanyofthesemethodsofcontraceptionissaferforherhealththan pregnancywouldbe.
  2. Advisewomenthatprogestin-onlymethodsdonotprotectagainstSTIs,includingHIV and Zika Virus. RecommendsafersexpracticesifpatientisatriskforSTIs, HIV, or Zika Virus.
  3. Progestin-onlypills:

a.Reviewprogestin-onlypillinstructions:

1)ReinforceneedforshorttermuseofbarriermethodifusingQuickStart(seeAttachment1)

2)Advisepatienttotakeonepillatthesametimeeachday.Donotstop useduringmenses.

3)Tellpatientthatprogestin-onlypillsdonotregulatemenstrualcycle;shewillbleed accordingtoherownbody’scycle.Infrequentmensesdoesnotposeariskfor endometrialcancerforwomenusingprogestin-onlypills. Intheabsenceofothersignsor symptomsofpregnancy,notestingisneeded.

4)Missedpillinstructions:

a) If≤3hourslateintakingherpill,advisehertotakemissedpillassoonaspossible anduseabstinenceorotherback-upmethodfor2 days.

b) If3 hourslateintakingherpilland shehashad otherwiseunprotectedintercourse inlast3 days,advisehertouseEC. (SeeEmergencyContraception[EC]protocol). Havepatientrestartpilltomorrowanduseabstinenceoraback-upmethodfor7-14 days.SuggestUCGifnomensesin3 weeksorifsymptomsofpregnancydevelop.

c) If3hourslateintakingherpillbuthasnothadanyintercourseinlast5days,have patienttaketoday’spillnow,continuewithdailypillsanduse abstinenceorbackup for7 days.SuggestUCGifnextmensesdelayedbymorethan1 weekorifsymptoms ofpregnancydevelop.

b. Instructpatientaboutpossiblemenstrualchangeswithprogestin-onlypills:

1) Mostwomenwillexperiencemenstrualchanges.Mostwomenexperienceareductionin totalbloodloss,butthetimingofthebleedingdependsuponthewoman’sownbody cycle.Itisnotpossibletopredictwhichofthefollowingpatternsanyindividualwoman mayhave:

a) Regular, predictablecycles.

b) Irregularbleeding cycles.

c) Spotting,unscheduledbleeding.

d) Prolongedbutgenerallylightercycles.

e) Amenorrhea(leastfrequentpattern).

2) Advisepatienttotakeprogestin-onlypillduringmensesand evenwhenshehasspotting orbleedingbetweenregularbleedingepisodes.

3) Usemenstrualcalendarifpatienthasmenstrualirregularities.

4) RecommendRTCforpregnancytestif symptomsofpregnancyoccur.

c.Warnpatientsaboutrareserioussideeffects.Thesesideeffectsarenotgenerallyduetothe pill,buttheydowarrantimmediateevaluation.Advisepatientthatif shehasheavybleedingor ifshehasunusuallystrongcramping,abdominalpainorfever,sheshouldreturnforexamor gotoER.Thesesymptomsmayrepresentectopicpregnancy,anovariancystoramiscarriage.

PATIENT EDUCATION

d. Advisebreastfeedingpatienttoreturnwhenplanningtodiscontinuebreastfeedingorplanning toaddsupplementalfeedingstoinfant,ifshedesirestouseacombinedhormonalmethod.

4. DMPA:

  1. AdvisepatientthatifsheneededECanddoesnotmenstruateinthe3 weeksfollowingher injection,sheshouldgetrepeatpregnancytest.
  2. Advisepatienttoreturnforrepeatinjectionin11-13weeksifDMPA150mgIMgivenorin 12-14weeksifDepo-subQprovera104given.Stresstheimportanceoftimelyreinjectionsto enjoythefullcontraceptivepotentialofthismethod.
  3. AdvisepatientaboutpossiblemenstrualchangeswithDMPAincludingirregularmenstrual bleeding,spottingorunscheduledbleeding,prolongedbleeding,diminishedand/orno bleeding.Overtime,mostwomenstopallbleedingandspotting.Counselwomenthatthe absenceofbleedinginDMPAisa significanthealthbenefitanddoesnotindicatethatthey aremenopausalorhavelongterminfertility.Amenorrheacanbeespeciallybeneficialfor activewomen,thosewithphysicaldisabilitiesandthosewhosufferpainorheavybloodloss withmenses.
  4. Advisepatientofpossibleweightchangesandotherpotentialsideeffectsincludingheadache, moodswings,hairchanges,andotherproblemslistedonpackageinsert.Remindherthat theseproblemsareoftennotduetoDMPA,butsheshouldreturntobeevaluatedifthey botherher.Inparticular,studiesshowthatsomeweightgainattributabletoDMPAmaybe seenin obese teens,butnotinadultwomen.Rarelywomenhaveananaphylacticreaction immediatelyfollowinginjection.
  5. Instructpatienttochangehermethod6-18monthspriortoattemptingpregnancy.Advise patientthatfertility(ovulation)maynotreturnforupto2 years,butthathalfthewomenwill ovulatewithin10monthsoftheirlastinjection.
  6. Remindpatientthatallwomenneedadequatecalciumintake.Recommendcalcium supplementationifpatient’sdailydietprovideslessthanadequateamounts(1000mgadult women;1300mgadolescentwomen).
  7. Counselpatientsabouttheinjectionadministration.Answerconcernsrelatedtoneedle apprehension.
  8. AdvisepatientusingDMPAthattemporarybutreversiblebonelosscanoccur.Some subgroupsmayexperiencehigherfractures.

1) IfadolescentDMPAusershaveanyofthefollowingriskfactorsforfracture, advisethat DMPAmayhaveamoreprofoundimpactontheirbonehealth:

a) BMI≤16isthegreatestriskforosteoporosis,butDMPAgiventoestrogen-deficient post-menopausalwomenhelpedbone.Theimpactonteensisnotasclear.

b) Otherrisksincludephysicalimmobility,renaldisease,cysticfibrosis,anorexia nervosa,previousestrogendeficiency,hyperthyroidism,malabsorption,chronic corticosteroiduseanduseofotherimmunosuppressiveagents,strongfamilyhistory ofosteoporoticfractures.Hereevenmoreindividualcounsellingaboutrelative benefitsandrisksisneeded.

  1. Advisepatienttoreturn to clinicif sheexperiencesheavyvaginalbleeding,symptomsofpregnancyor otherseriousproblems.

5. Implant:

  1. Informpatientthatsheshould:

PATIENT EDUCATION

1)Keepthepressuredressingonfor24hours.

2)TheSteri-stripscanbetakenoffin3-5days,althoughit isbettertowaituntiltheyfallof bythemselves.Steri-stripsshouldnotberemovedbypatientuntilscabovertheplacement sitehasfallenoff.

3)Ifherarmissore,shemayalsotakeTylenolorIbuprofenforthediscomfortorplaceice packs(20minutesanhour)asneeded.

  1. Advisepatienttoexpectslightbruisingandsorenessaroundimplantsite forafewdaysafter placement,andthattheimplantmaybeslightlyvisibleafterhealing.
  2. Advisepatienttowatchfortheserarewarningsignsandseekmedicalcarepromptlyifanyof thefollowingappears:

1)Bleedingfromtheplacementsite.

2)Increasingtenderness,redness,warmthorpusaroundtheimplant.

3)Fever,chills.

4)Anysignthattheimplantisbeingexpelled.

  1. Advisepatientthatprotectionfrompregnancybeginsimmediatelyifplacementistimed accordingto manufacturer’srecommendation.Otherwisesheshouldnotrelyontheimplant alonefor7 daysafterplacement.
  2. Advisepatientthatbleedingmaybelesspredictablewithimplantuse.Overtime,she will usuallyhavelessbleeding.

1)Counselherthatifherbleedingis acceptableinthefirst3 months,shecanexpectthat followingcycleswillbeacceptable.

2)Ifherfirst3 cyclesareabnormal,tellherthatshehasa50%chancethatherbleedingwill improveinsubsequentmonths.Thetimebetweenperiodsmayvaryandshemayhave spottingin betweenperiods.

3)Suggestshekeepamenstrualcalendarandcarryalightdaypantylinerwithher.

  1. RemindhertousebackupmethodsifshestartsusinganySt.John’sWortorprescription drugsthatcanreducetheeffectivenessofherimplant.
  2. Counselpatientthatthereisnoharmtoherhealthifshemissesherperiods,butinstructherto returnforpregnancytestingifshehasanysymptomsofpregnancyorisconcernedaboutthe possibilityofpregnancy.
  3. Advisepatientofpossibleweightchangesandotherpotentialsideeffectsincludingheadache, moodswings,hairchanges,prolongedovariancystsandothereffectslistedonpackageinsert.

1)Remindherthatmostofthose“sideeffects”arenotduetotheimplant.Forexample,ina trialcomparingtheimplantwithanon-hormonalIUD,bothgroupsofwomengainedthe sameamountofweight.

  1. Advisehertoalwaysmentionherimplantwheneversheisseenbymedicalpersonnel/clinician.
  2. Remindherthattheimplantiseffectivefor3 years.Tellhershewillbegivenausercardthat willremindherofthisdate.Remindherthatsheistokeepthecardina secureplace.Advise patientthatanewimplantmaybeplacedin3 yearsifdesired.
  3. Counselherthatfertilityreturnspromptlyafterremovalofherimplant.
  4. Advisepatientthatshemayrequesttohaveherimplantremovedatanytimeforanyreason.
  5. Encouragepatienttoreturnforroutinewellwomanexams.
  6. Zika virus education and prevention strategies

1)Avoid traveling to impacted areas

2)Avoiding mosquito bites if traveling to impacted areas

3)Using condoms to prevent transmission of virus

4)Avoiding pregnancy if infected or partner infected

a)Risk to unborn fetus

REFER TO MD/ED

  1. PatientwithUSMECcategory 3 and 4 conditionsforthemethodshestronglydesires.
  1. Patientwhodeclinespelvicexaminationbuthassymptomsorsignsindicatingneedforevaluation.
  2. Patientwithadifficultimplantremoval.
  3. PatientwithanaphylacticshockwithDMPAorotherprocedures.

REFERENCES

  1. Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations 2016 available at
  2. CentersforDiseaseControlandPrevention(CDC).U.S.MedicalEligibilityCriteriafor ContraceptiveUse,2016.Availableat
  3. Centers for Disease Control and Prevention (CDC). Zika Virus Homepage -
  4. HatcherRAetal(editor)ContraceptiveTechnology-20thEditionArdentMedia,Inc.NewYork, NY2011:193-203;209-229;237-245.
  5. CentersforDiseaseControlandPrevention(CDC).Providing Quality Family Planning Services, 2014.MMWR; 59(RR-4):1-86.Availableat

Reviewed/Revised 2018

ATTACHMENT1

SUMMARYOF RECOMMENDATIONSFORMETHODINITIATIONAND FORMANAGEMENTOFINCONSISTENTUSEOFSYSTEMIC PROGESTIN-ONLYBIRTHCONTROLMETHODS(exceptLNGIUD)

InitiatingMethodUse / NumberofDays Back-upMethod orabstinence Needed / ECrecommended If AnyUnprotected CoitusIn last 5 days
Last5 days*
Progestin-OnlyPills
Startingcycleday1-5ofcycle / 0 / No
Startingcycleday6 orlater / 2 / Yesss
DMPA
Startingcycleday1-7 / 0 / No
Startingcycleday8 orlater / 7 / Yes
Implant
Startingcycleday1-5 / 0 / No
DuringhormonefreeintervalofOCs,patchorvaginalring
Atanytimewithprogestin-onlypills / 0 / No
AttimenextDMPAinjectionisdue(upto15weeksfromlast
injection) / 0 / No
AttimeofimplantorIUDremoval / 0 / No
Within5 daysoffirsttrimesterpregnancyloss / 0 / No
Within28daysafter2ndtrimesterpregnancyloss / 7 / Yes
Within28daysafter3rdtrimesterdelivery / 7 / Yess
Exclusivelybreastfeedinginthefirstsixmonthsandamenorrheicwith
nounprotectedintercourse / 0 / No
Placementatanyothertime / 7 / Yes
InterruptionofUse
Progestin-OnlyPills
1pilllatebylessthan3 hours / 2 / Yes
1ormorepillslatebymorethan3 hours / 2 / Yes
DMPA
Lastinjectionupto15weeksagoifnopregnancysymptoms / 0 / No
Lastinjection15 weeksago / 7 / Yes

* Ifunprotectedintercourseinlast5 days,considerrepeatpregnancytestin3 weeksifnomenses.

Reviewed/Revised 2018

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