Combination injectable contraceptives for contraception
In trials of combined injectable contraceptives versus progestogen-only contraceptives, the former had lower rates of early discontinuation due to amenorrhea or other bleeding disturbances, but had higher rates of discontinuation due to other reasons. Overall, combined injectable contraceptives appear to be more acceptable than progestogen-only injectables.
RHL Commentary by Affandi B
1. EVIDENCE SUMMARY
This review aimed to assess the contraceptive efficacy, bleeding patterns, discontinuation, user preferences, and side-effects of combination injectable contraceptives. The included trials had compared combination injectables with either progestogen-only methods or the intrauterine device (IUD).
The 25 mg depot-medroxyprogesterone acetate (DMPA) + 5 mg estradiol cypionate (E2C) and 50 mg norethisterone enantate (NET-EN) + 5 mg estradiol valerate (E2V) combinations had higher rates of cyclical (regular) bleeding, less amenorrhoea and fewer infrequent bleeding pattern than only150 mg DMPA and 200 mg NET-EN, respectively. Women using 150 mg DMPA were more likely to discontinue for amenorrhoea or bleeding problems. In contrast, women using 25 mg DMPA + 5 mg E2C were more likely discontinue early for 'other medical' reasons. Women using the 50 mg NET-EN + 5 mg E2V combination had higher rates of cyclical (regular) bleeding and lower rates of infrequent bleeding patterns compared with progestogen-only contraceptive, 200 mg NET-EN.
Life-table analysis found no difference in the overall discontinuation rates between the combination injectables 25 mg DMPA + 5 mg E2C and 50 mg NET-EN + 5 mg E2V.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
It has been estimated that 122.7 million women have an unmet need for family planning (1). The main reasons why people do not use modern contraceptive methods are, fear of side-effects, not knowing about different available options or simply not wanting to use them. The former two barriers can be overcome to a large extent by providing people with more information about family planning methods. The combined injectable methods may be acceptable to those who discontinue progestogen-only methods due to bleeding disturbances.
Progestogen-only injectable contraceptive methods (DMPA and NET-EN) were highly accepted in Indonesia when they were first introduced in the country in 1976
3). The main reported reasons for their discontinuation were amenorrhoea, irregular bleeding, and spotting. When a combined injectable contraceptive was introduced in Indonesia in 1990s, its acceptance rate was even better that of DMPA and NET-EN. The Indonesian women prefer the combined injectable contraceptive because it produces a more regular (cyclical) bleeding than does DMPA. It is estimated that more than 60% of injectable contraceptive users in Indonesia are using the combined injectable contraceptive 25 mg DMPA + 5 mg E2C.
2.2. Applicability of the results
The trials of the safety and acceptability of combined injectables included in the Cochrane review were conducted in a variety of settings, involving both developed and developing countries. Hence, the findings of the review would be applicable to all settings. Our own experience in Indonesia suggests that combined injectable contraceptives have greater acceptability than progestogen-only injectables. However, the levels of discontinuation and their reasons may differ across cultural settings.
2.3. Implementation of the intervention
There are few implications—mainly related to informing the health care staff about the advantages and potential side-effects of the method—of adding combined injectables to the existing contraceptive method mix if the mix already includes progestogen-only methods. Even where injectable contraceptives (progestogen-only or combined) are not currently offered, it would be relatively simple to include combined injectables to the method mix. This will require training of health care staff in giving injections (where health care workers are not already trained to do this) and in being able to counsel women eligible (4) to use steroid hormonal methods regarding the advantages and side-effects of combined injectables.
In developing country settings there is a need to conduct operations and socio-behavioral research to improve further the delivery and acceptability of combined injectables.
- Ross JA and Winfrey WL. Unmet need for contraception in the developing world and the former Soviet Union: an updated estimate. International Family Planning Perspectives 2002;28:138–143.
- Affandi B. Long-acting hormonal contraception. In: Kempers RD, Cohen J, Haney AF, and Younger JB, eds. Fertility and reproductive management 1998;295–308.
- Alexander NJ. Contraception: present and future. Medical Journal of Indonesia 1999;8:7–11.
- World Health Organization, Geneva. Selected practice recommendations for contraceptive use, 2004. ;.
This document should be cited as: Affandi B. Combination injectable contraceptives for contraception: RHL commentary (last revised: 20 February 2006). The WHO Reproductive Health Library; Geneva: World Health Organization.