3 MONTHLY INJECTABLE CONTRACEPTION VS. IMPLANTS

It’s been exactly 30 months since I last blogged. I joined school for my specialization and this being my first time in a public Kenyan university, I wasn’t certain how the idea of blogging would be perceived; my original plan was to remain unnoticed and to keep a low-profile as much as possible. I guess I had so many myths running through my mind about treatment of students in Kenyan Universities; that you are there to be seen and not heard - I later learned that all that was not true; no teacher would punish their student for wanting to disseminate knowledge and for exploring their talents. I also had a total change in setting from rural Meru where I experienced firsthand unique situations in a rural setting which was more or less a Primary Health Care set-up where I was the first contact with a diverse pool of patients. In the 30 months I underwent self-discovery, a lot of growing up, understanding my new group of friends and acquaintances; had a slight brush with depression at some point and generally life happened. I decided to wait for the writing bug to attack me naturally and spontaneously. I tried writing at some point last year but the write-up turned out so plastic and therefore I kept a draft unpublished copy.

One week back, a relative approached me and wanted a quick prescription for her usual ‘Depo’contraception injection which she could easily get from a local Chemist without having to queue at a hospital or clinic. I got into doctor-mode and asked her if she was aware that there were better more reliable methods of contraception. She unleashed all these myths about the methods I was advising her about and even pulled a ‘IUCD is Haram in Islam’ statement. What worried me more was that she had used injectable progestin for more than 24 months straight and was already exhibiting some of the side-effects associated with its prolonged use.

DISCLAIMER : For purpose of this blog post, we will not use Depo or  Depo-Provera brand name , we will use the chemical name of 3monthly injectable progestin -  Depot Medroxyprogesterone Acetate (DMPA). This post is not about a brand but the chemical components of the mentioned drugs.

DMPA is among many progestin only contraceptives. This group of contraception contains an analogue of the hormone progesterone; this is in comparison to combined contraceptive methods that contain derivative of both progesterone and estrogen in combination (will write about combined contraceptive methods in subsequent blog posts). Other progestin only contraceptive methods include the mini-pill that is taken daily especially in breastfeeding women, implants such as Implanon and Jadelle (implants are more reliable methods) and the progestin-containing intra-uterine devices - Mirena (very reliable!!!).

DMPA is an injectable method that is given every 3 months . It is a very popular method in Kenya with a use of 15%. It is administered as an intramuscular injection every 90 days; we have other formulations that are given once every 2 months. Its actual mode of action is by thickening cervical mucus making it non-penetrable to sperm and by making the lining of the uterus unsuitable for implantation. It may have an effect in suppressing ovulation (ovum release).

Most notable advantages of DMPA include;

• ·        It is suitable for patients who may forget the daily pill
• ·        It is suitable for breastfeeding women (after 4 weeks of delivery) because it doesn’t suppress milk production
• ·        Is suitable for patients who may have contraindications to combined hormonal contraceptives use such as smokers, patients with hypertension, patients with risk of developing deep venous clots, patients with history or risk of (uterine)cancers.
• ·        It is reliable with a failure rate of only 7 % in typical use (perfect use has a failure rate of 0.3%)
• ·        Less likelihood of anemia especially in women who get decreased or total lack of menses
• ·        Confidentiality – there is no evidence that anyone can use to figure out that you are on dmpa. It is an injection; no rods that can be felt e.t.c. This is particularly important in clients whose spouses are opposed to contraceptives, or unmarried women wanting to avoid stigma
• ·        No complicated process during uptake ; no unnecessary vaginal examination
• ·        Has been shown to reduce the symptoms of endometriosis
• 
  
• ·        It’s cheaper - although when you calculate the number of 3 monthly injections you will have in 3-5 years , implants are definitely cheaper in the long-run

Disadvantages include,

·        May cause irregular menstrual bleeding – some women report heavy irregular bleeding, some women may have light irregular spotting, while some women have a total lack of menses especially after extended use

·        Prolonged ovulation suppression may cause difficulty in return to fertility. Some cases may take up to 18 months to 2 years to conceive after cessation of use of DMPA

·        Prolonged use for more than 2 years continuously causes loss of bone mineral density (due to lowered estrogen levels). This is particularly of concern in adolescents who should be undergoing a growth spurt and in women approaching menopause (these women will soon be in menopause which is associated with a further accelerated bone loss). The return of normal bone density has been postulated to take around 5 years after stoppage of use

·        Depression and mood swings has been noted in women on prolonged DMPA use

·        Weight gain due to fluid overload. Women who gain weight in the first 6 months of DMPA use are more likely to have increased weight gain in the long-term

·        Headaches and migraines

·        Doesn’t protect against STI or HIV (condom-up!!!!!)

·        Others – e.g bloating, breast tenderness

Contraindications include,

·        Pregnancy (obviously!!!!)

·        Uterine bleeding of unexplained cause

·        Breast cancer or abnormal breast masses

·        Active or history of thromboembolic disease e.g deep venous clots, strokes etc

·        Cerebrovascular disease

·        Significant liver disease or liver masses

·        Not advisable in the first 4 weeks of breastfeeding (highly controversial issue)

The main point I wanted to drive home with this post is about the side-effects of DMPA on prolonged use. Of main concern is the issue of decreased bone mineral density and prolonged return to fertility with DMPA. There are definitely better progestin methods such as Implanon (three year implant) and Jadelle (5 year implant).

Implants have the same mode of action as DMPA because they have they have the same componenet ; progesterone although in different formulations. 

Advantages of Implants over injectable progestins include;

·        Long term method hence reliable (you only have to remember after the years have lapsed!!!)

·        Highly efficient family planning method (failure rate less than 1%)

·        These are not associated with decreased bone mineral density,

·        The return to fertility is quicker, rapid. This is of importance in women who have not started their families yet and in women who have not achieved their ideal family size

·        Although they may be associated with decreased menstruation or total lack of menses, they are mostly not associated with heavy bleeding

·        Have decreased prevalence of weight gain, headaches, mood swings, acne

·        Can be inserted immediately after delivery and doesn’t affect breastfeeding at any point

NB: Some of the effects of DMPA like headache, breast tenderness etc may be felt with implants but to a lesser intensity

I hope this read was helpful in clearing things up. I tried to make it as layman’s as possible and avoided jargon use. Feel free to email or comment below for any queries, criticism, corrections or more information.

Next blog will be on IUCDs and there will be a special segment on its use in Islam ; demystifying any myths.

Have a blessed weekend!

Dr. K