Monthly Injectables

Monthly Injectables

key Points for Providers and Clients

• Bleeding changes are common but not harmful. Typically, lighter monthly bleeding, fewer days of bleeding, or irregular or infrequent bleeding.

• Return on time. Coming back every 4 weeks is important for greatest effectiveness.

• Injection can be as much as 7 days early or late. Client should come back even if later.

What Are Monthly Injectables?

• Monthly injectables contain 2 hormones—a progestin and an estrogen— like the natural hormones progesterone and estrogen in a woman’s body. (Combined oral contraceptives also contain these 2 types of hormones.)

• Also called combined injectable contraceptives, CICs, the injection.

• Information in this chapter applies to medroxyprogesterone acetate (MPA)/estradiol cypionate and to norethisterone enanthate (NET-EN)/estradiol valerate. The information may also apply to older formulations, about which less is known.

• MPA/estradiol cypionate is marketed under the trade names Ciclofem, Ciclofemina, Cyclofem. Cydo-Provera, Feminena, Lunella. Lunelle. NoyafenLaod others. NET-EN/estradiol valerate is marketed under the trade names Mesigyna and Norigynon.

• Work primarily by preventing the release of eggs from the ovaries (ovulation).

How Effective?

Effectiveness depends on returning on time: Risk of pregnancy is greatest when a woman is late for an injection or misses an injection.

• As commonly used, about 3 pregnancies per 100 women using monthly injectables over the first year. This means that 97 of every 100 women using injectables will not become pregnant.

• When women have injections on time, less than 1 pregnancy per 100 women using monthly injectables over the first year (5 per 10,000 women).

Return of fertility after injections are stopped: An average of about one month longer than with most other methods.

Protection against sexually transmitted infections (STIs): None

Monthly InjectablesWhy Some Women Say They Like Monthly Injectables

• Do not require daily action
• Are private: No one else can tell that a woman is using contraception
• Injections can be stopped at any time
• Are good for spacing births

Side Effects, Health Benefits, and Health Risks

Side Effects

Some users report the following:

• Changes in bleeding patterns including:
– Lighter bleeding and fewer days of bleeding m Irregular bleeding
– Infrequent bleeding
– Prolonged bleeding
– No monthly bleeding
• Weight gain
• Headaches
• Dizziness
• Breast tenderness

Known Health Benefits and Health Risks

Long-term studies of monthly injectables are limited, but researchers expect that their health benefits and health risks are similar to those of combined oral contraceptives (see Combined Oral Contraceptives, Health Benefits and Health Risks, p. 3). There may be some differences in the effects on the liver, however.

Correcting Misunderstandings

Monthly injectables:

• Can stop monthly bleeding, but this is not harmful. It is similar to not having monthly bleeding during pregnancy. Blood is not building up inside the woman.

• Are not in experimental phases of study. Government agencies have approved them.

• Do not make women infertile.

• Do not cause early menopause.

• Do not cause birth defects or multiple births.

• Do not cause itching.

• Do not change women’s sexual behavior.

Who Can and Cannot Use Monthly Injectables

Safe and Suitable for Nearly All Women

Nearly all women can use monthly injectables safely and effectively, including women who:

• Have or have not had children
• Are not married
• Are of any age, including adolescents and women over 40 years old
• Have just had an abortion or miscarriage
• Smoke any number of cigarettes daily and are under 35 years old
• Smoke fewer than 15 cigarettes daily and are over 35 years old
• Have anemia now or had anemia in the past
• Have varicose veins
• Are infected with HIV, whether or not on antiretroviral therapy

Women can begin using monthly injectables:

• Without a pelvic examination
• Without any blood tests or other routine laboratory tests
• Without cervical cancer screening
• Without a breast examination
• Even when a woman is not having monthly bleeding at the time, if it is reasonably certain she is not pregnant

Medical Eligibility Criteria for

Monthly Injectables

Ask the client the questions below about known medical conditions. Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can start monthly injectables if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still start monthly injectables.

1. Are you breastfeeding a baby less than 6 months old?

• NO  • YES
• If fully or nearly fully breastfeeding: She can start 6 months after giving birth or when breast milk is no longer the baby’s main food—whichever comes first.

• If partially breastfeeding: She can start monthly injeetables as soon as 6 weeks after giving birth.

2. Have you had a baby in the last 3 weeks that you are not breastfeeding?

• NO  • YES She can start monthly injectables as soon as 3 weeks after childbirth.

3. Do you smoke 15 or more cigarettes a day?

• NO  • YES If she is 35 years of age or older and smokes more than 15 cigarettes a day, do not provide monthly injectables. Urge her to stop smoking and help her choose another method.

4. Do you have severe cirrhosis of the liver, a liver infection, or liver tumor? (Are her eyes or skin unusually yellow? [signs of jaundice])

• NO  • YES If she reports serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver tumor), do not provide monthly injectables. Help her choose a method without hormones. (It she has mild cirrhosis or gall bladder disease, she can use monthly injectables.)

5. Do you have high blood pressure?

• NO  • YES If you cannot check blood pressure and she reports a history of high blood pressure, or if she is being treated for high blood pressure, do not provide monthly injectables. Refer her for a blood pressure check if possible or help her choose another method without estrogen.

Check her blood pressure if possible:

• If blood pressure is below 140/90 mm Hg. provide monthly injectables.

• If systolic blood pressure is 140 mm Hg or higher or diastolic blood pressure is 90 or higher, do not provide monthly Injectables. Help her choose a method without estrogen, but not progestin-only injectables if systolic blood pressure is 160 or higher or diastolic pressure is 100 or higher.

(One blood pressure reading in the range of 140-159/90-99 mm Hg is not enough to diagnose high blood pressure. Provide a backup method’ to use until she can return for another blood pressure check, or help her choose another method now if she prefers. If blood pressure at next check is below 140/90, she can use monthly injectables.)

6. Have you had diabetes for more than 20 years or damage to your arteries, vision, kidneys, or nervous system caused by diabetes?

• NO  •YES Do not provide monthly injectables. Help her choose a method without estrogen but not progestin-only injectables.

7. Have you ever had a stroke, blood clot in your legs or lungs, heart attack, or other serious heart problems?

• NO  • YES If she reports heart attack, heart disease due to blocked or narrowed arteries, or stroke, do not provide monthly injectables. Help her choose a method without estrogen but not progestin-only injectables. If she reports a current blood clot in the deep veins of the leg or in the lung (not superficial clots), help her choose a method without hormones.

8. Do you have or have you ever had breast cancer?

• NO  • YES Do not provide monthly injectables. Help her choose a method without hormones.

9. Do you sometimes see a bright area of lost vision in the eye before a very bad headache (migraine aura)? Do you get throbbing, severe head pain, often on one side of the head, that can last from a few hours to several days and can cause nausea or vomiting (migraine headaches)? Such headaches are often made worse by light, noise, or moving about.

• NO  • YES If she has migraine aura at any age, do not provide monthly injectables. If she has migraine headaches without aura and is age 35 or older, do not provide monthly injectables. Help these women choose a method without estrogen. If she is under 35 and has migraine headaches without aura, she can use monthly injectables.

10. Are you planning major surgery that will keep you from walking for one week or more?

• NO  • YES If so, she can start monthly injectables 2 weeks after the surgery. Until she can start monthly injectables, she should use a backup method.

11. Do you have several conditions that could increase your chances of heart disease (coronary artery disease) or stroke, such as older age, smoking, high blood pressure, or diabetes?

• NO  • YES Do not provide monthly injectables. Help her choose a method without estrogen, but not progestin-only injectables.

For complete classifications, see Medical Eligibility Criteria for Contraceptive Use. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.

Using Clinical Judgment in Special Cases

Usually, a woman with any of the conditions listed below should not use monthly injectabies. In special circumstances, however, when other, more , appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use monthly injectabies. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.

• Not breastfeeding and less than 3 weeks since giving birth

• Primarily breastfeeding between 6 weeks and 6 months since giving birth

• Age 35 or older and smokes more than 15 cigarettes a day

• High blood pressure (systolic blood pressure between 140 and 159 mm Hg or diastolic blood pressure between 90 and 99 mm Hg)

• Controlled high blood pressure, where continuing evaluation is possible

• History of high blood pressure, where blood pressure cannot be taken (including pregnancy-related high blood pressure)

• Severe liver disease, infection, or tumor

• Age 35 or older and has migraine headaches without aura

• Younger than age 35 and has migraine headaches that have developed or have gotten worse while using monthly injectables

• Had breast cancer more than 5 years ago, and it has not returned

• Diabetes for more than 20 years or damage to arteries, vision, kidneys, or nervous system caused by diabetes

• Multiple risk factors for arterial cardiovascular disease, such as older age, smoking, diabetes, and high blood pressure

Monthly Injectables for Women With HIV

• Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can safely use monthly injectables.

• Urge these women to use condoms along with monthly injectables. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.

Providing Monthly Injectables

When to Start

IMPORTANT: A woman can start injectables any time she wants if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy Checklist.

 
Woman’s situation  When to start
Having menstrual cycles or switching from a nonhormonal method Any time of the month

• If she is starting within 7 days after the start of her monthly bleeding, no need for a backup method.

• If it is more than 7 days after the start of her monthly bleeding, she can start injectables any time it is reasonable certain she is not pregnant. She will need a backup mathod for the first 7 days after the injection.

• If she is switching from an IUD, she can start injectables immediately.

Switching from a hormonal method • Immediately, if she has been using the hormonal method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding. No need for a backup method.

• If she is switching from another injectable, she can have the new injectable when the repeat injection would have been given. No need for a backup method.

Fully or nearly fully breastfeeding

Less than 6 months after giving  birth

• Delay her first injection until 6 months after givingbirth or when breast milk is no longer the baby’s main food—whichever comes first.
Fully or nearly fully breastfeeding

More than 6 months after giving birth

• If her monthly bleeding has not returned, she can start injectables any time-it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.
Partially breastfeeding

Less than 6 weeks after giving birth

• Delay her first injection until at least 6 weeks after giving birth.
Partially breastfeeding

More than 6 weeks after giving birth

• If her monthly bleeding has not returned, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.

• If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles.

Not breastfeeding

Less than 4 weeks after giving birth

• She can start injectables at any time on days 21-28 after giving birth. No need for a backup method.
Not breastfeeding

More than 4 weeks after giving birth

• If her monthly bleeding has not returned, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.

• If her monthly bleeding has returned, she can start injectables as advised for women having menstrual cycles.

No monthly bleeding (not related to childbirth or breastfeeding) • She can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.
After miscarriage or abortion • Immediately. If she is starting within 7 days after first- or second-trimester miscarriage or abortion, no need for a backup method.

• If it is more than 7 days after first- or second- trimester miscarriage or abortion, she can start injectables any time it is reasonably certain she is not pregnant. She will need a backup method for the first 7 days after the injection.

After taking emergency contraceptive pills (ECPs) • She can start injectables on the same day as the ECPs. There is no need to wait for her next monthly bleeding to have the injection. She will need a backup method for the first 7 days after the injection.

Giving Advice on Side Effects

IMPORTANT: Thorough counseling about bleeding changes and other side effects must come before giving the injection. Counseling about bleeding changes may be the most important help a woman needs to keep using the method.

Describe the most common side effects

• Lighter bleeding and fewer days of bleeding, irregular bleeding, and infrequent bleeding.
• Weight gain, headaches, dizziness, breast tenderness, and possibly other side effects.

Explain about these side effects

• Side effects are not signs of illness.
• Usually become less or stop within the first few months after starting injections.
• Common, but some women do not have them.
• The client can come back for help if side effects bother her.

Giving the Injection

1. Obtain one dose of injectable, needle and syringe

• 25 mg MPA/estradiol cypionate or 50 mg NET-EN/estradiol valerate, intramuscular injection needle, and 2 ml or 5 ml syringe. (NET-EN/estradiol valerate is sometimes available in prefilled syringes.)

• For each injection use a disposable auto-disable syringe and needle from a new sealed package (within expiration date and not damaged), if available.

2. Wash

• Wash hands with soap and water, if possible.
• If injection site is dirty, wash it with soap and water.
• No need to wipe site with antiseptic.

3. Prepare vial

• MPA/estradiol cypionate: Gently shake the vial.
• NET-EN/estradiol valerate: Shaking the vial is not necessary.
• No need to wipe top of vial with antiseptic.
• If vial is cold, warm to skin temperature before giving the injection.

4. Fill syringe

• Pierce top of vial with sterile needle and fill syringe with proper dose. (Omit this step if syringe is preloaded with injectable formulation.)

5. Inject formula

• Insert sterile needle deep into the hip (ventrogluteal muscle), the upper arm (deltoid muscle), the buttocks (gluteal muscle, upper outer portion), or outer (anterior) thigh, whichever the woman prefers. Inject the contents of the syringe.

• Do not massage injection site.

6. Dispose of disposable syringes and needles safely

• Do not recap, bend, or break needles before

• Place in a puncture-proof sharps container,

• Do not reuse disposable syringes and needles. They are meant to be destroyed after a single use. Because of their shape, they are very difficult to disinfect. Therefore, reuse might transmit diseases such as HIV and hepatitis.

• If reusable syringe and needle are used, they must be sterilized again after each use.

Supporting the User

Give specific instructions

• Tell her not to massage the injection site.

• Tell the client the name of the injection and agree on a date for her next injection in about 4 weeks.

“Come Back Any Time”: Reasons to Return Before the Next Injection

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; she has a major change in health status; or she thinks she might be pregnant.

General health advice: Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the nurse or doctor what method she is using.

Planning the Next Injection

1. Agree on a date for her next injection in 4 weeks.

2. Ask her to try to come on time. She may come up to 7 days early or 7 days late and still get an injection.

3. She should come back no matter how late she is for her next injection. If more than 7 days late, she should abstain from sex or use condoms, spermicides, or withdrawal until she can get an injection. She can also consider emergency contraceptive pills if she is more than 7 days late and she has had unprotected sex in the past 5 days.

Helping Continuing Users

Repeat Injection Visits

1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.

2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs.

3. Give her the injection. Injection can be given up to 7 days early or late.

4. Plan for her next injection. Agree on a date for her next injection (in 4 weeks). Remind her that she should try to come on time, but she should come back no matter how late she is.

5. Every year or so, check her blood pressure if possible.

6. Ask a long-term client if she has had any new health problems. Address problems as appropriate. For new health problems that methods.

7. Ask a long-term client about major life changes that may affect her needs—’particularly plans for having children and STI/HIV risk. Follow up as needed.

Managing Late Injections

• If the client is less than 7 days late for a repeat injection, she can receive her next injection. No need for tests, evaluation, or a backup method.

• A client who is more than 7 days late can receive her next injection if:

– She has not had sex since 7 days after she should have had her last injection, or
– She has used a backup method or has taken emergency contraceptive pills (ECPs) after any unprotected sex since 7 days after she should have had her last injection.

She will need a backup method for the first 7 days after the injection.

• If the client is more than 7 days late and does not meet these criteria, additional steps can be taken to be reasonably certain she is not pregnant.

• Discuss why the client was late and solutions. If coming back on time is often a problem, discuss using a backup method when she is late for her next injection, taking ECPs, or choosing another method.

Managing Any Problems

Problems Reported as Side Effects

May or may not be due to the method.

Problems with side effects affect women’s satisfaction and use of injectables. They deserve the provider’s attention. If the client reports side effects, listen to her concerns, give her advice, and, if appropriate, treat.

Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Irregular bleeding (bleeding at unexpected times that bothers the client)

• Reassure her that many women using monthly injectables experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.

• For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin- only injectables, and IUDs,and they may also help for monthly injectables.

• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use.

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)

• Reassure her that many women using monthly injectables experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.

• For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other NSAID, beginning when heavy bleeding starts. NSAIDs provide some relief of heavy bleeding for implants, progestin- only injectables, and IUDs,and they may also help for monthly injectables.

• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).

• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use.

No monthly bleeding

• Reassure her that some women using monthly injectables stop having monthly bleeding, and this not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Weight gain

• Review diet and counsel as needed.

Ordinary headaches (noumigrainous)

• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325—1000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during use of injectables should be evaluated.

Breast tenderness

• Recommend that she wear a supportive bra (including during strenuous activity and sleep).

• try hot or cold compresses.

• Suggest aspirin (325-650 mg), ibuprofen (200-400 mg), paracetamol (325-1000 mg), or other pain reliever.

• Consider locally available remedies.

Dizziness

• Consider locally available remedies.

New Problems That May Require Switching Methods

May or may not be due to the method.

Unexplained vaginal bleeding (that suggests a medical condition not related to the method)

• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
• She can continue using monthly injectables while her condition is being evaluated.
• If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using monthly injectables during treatment.

Migraine headaches

• Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using monthly injectables, should stop using injectables.

• Help her choose a method without estrogen.

Circumstances that will keep her from walking for one week or more

• If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:

– Tell her doctors that she is using monthly injectables.
– Stop injections one month before scheduled surgery, if possible, and use a backup method during this period.
– Restart monthly injectables 2 weeks after she can move about again.

Certain serious health conditions (suspected heart or liver disease, high blood pressure, blood clots in deep veins of legs or lungs, stroke, breast cancer, or damage to arteries, vision, kidneys, or nervous system caused by diabetes).

• Do not give the next injection.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care.

Suspected pregnancy

• Assess for pregnancy.
• Stop injections if pregnancy is confirmed.
• There are no known risks to a fetus conceived while a woman is using injectables.

Questions and Answers About Monthly Injectables

1. How are monthly injectables different from DMPA or NET-EN?

The major difference between monthly injectables and DMPA or NET-EN is that a monthly injectable contains an estrogen as well as a progestin, making it a combined method. In contrast, DMPA and NET-EN contain progestin only. Also, monthly injectables contain less progestin. These differences result in more regular bleeding and fewer bleeding disturbances than with DMPA or NET-EN. Monthly injectables require a monthly injection, whereas NET-EN is injected every 2 months and DMPA, every 3 months.

2. Do monthly injectables function like combined oral contraceptives?

Largely, yes. Monthly injectables (also called combined injectable contraceptives) are similar to combined oral contraceptives (COCs).

There are few long-term studies done on monthly injectables, but researchers assume that most of the findings about COCs also apply to monthly injectables. Monthly injectables, however, do not pass through the liver first because they are not taken by mouth like COCs. Short- term studies have shown that monthly injectables have less effect than COCs on blood pressure, blood clotting, the breakdown of fatty substances (lipid metabolism), and liver function. Long-term studies of the health risks and benefits of monthly injectables are underway.

3. Do monthly injectables cause birth defects? Will the fetus be harmed if a woman accidentally uses monthly injectables while she is pregnant?

No. Good evidence from studies on other hormonal methods shows that hormonal contraception will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using monthly injectables or accidentally starts injectables when she is already pregnant.

4. Do monthly injectables cause abortion?

No. Research on combined contraceptives finds that they do not disrupt an existing pregnancy. They should not be used to try to cause an abortion. They will not do so.

5. Should the dates for a woman’s repeat injections be based on when monthly bleeding starts?

No. Some providers think that the next injection should only be given when the next monthly bleeding begins. Bleeding episodes should not guide the injection schedule, however. A woman should receive the injection every 4 weeks. The timing of injections should not be based on her monthly bleeding.

6. Can monthly injectables be used to bring on monthly bleeding?

No. A woman may experience some vaginal bleeding (a “withdrawal bleed”) as a result of an injection, but there is no evidence that giving a woman who has irregular bleeding a single injection of a monthly injectable will cause her monthly bleeding to begin properly about one month later. Also, giving.a pregnant woman an injection will not cause an abortion.

7. Can women who smoke use monthly injectables safely?

Women younger than age 35 who smoke any number of cigarettes and women 35 and older who smoke fewer than 15 cigarettes a day can safely use monthly injectables. (In contrast, women 35 and older who smoke any number of cigarettes should not use combined oral contraceptives.) Women 35 and older who smoke more than 15 cigarettes a day should choose a method without estrogen such as progestin-only injectables, if available. All women who smoke should be urged to stop smoking.

8. Do monthly injectables change women’s mood or sex drive?

Generally, no. Some women using monthly injectables report these complaints. The great majority of injectabies users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to monthly injectables or to other reasons. There is no evidence that monthly injectables affect women’s sexual behavior.

9. Can women with varicose veins use monthly injectables?

Yes. Monthly injectables are safe for women with varicose veins.

Varicose veins are enlarged blood vessels close to the surface of the skin. They are not dangerous. They are not blood clots, nor are these veins the deep veins in the legs where a blood clot can be dangerous (deep vein thrombosis). A woman who has or has had deep vein thrombosis should not use monthly injectables.

10. Do monthly injectables make a woman infertile?

No. There may be a delay in regaining fertility after stopping monthly injectabies, but in time the woman will be able to become pregnant as before, although fertility decreases as women get older. The bleeding pattern a woman had before she used monthly injectables generally returns a few months after the last injection. Some women may have to wait a few months before their usual bleeding pattern returns.

11. How long does it take to become pregnant after stopping monthly injectables?

Women who stop using monthly injectabies wait about one month longer on average to become pregnant than women who have used other methods. This means they become pregnant on average 5 months after their last injection. These are averages. A woman should not be worried it she has not become pregnant even as much as 12 months after stopping use. After stopping monthly injectabies, a woman may ovulate before her monthly bleeding returns—and thus can become pregnant. If she wants to continue avoiding pregnancy, she should start another method before monthly bleeding returns.

12. What if a woman returns for her next injection late?

Current WHO guidance recommends giving a woman her next monthly injection if she is up to 7 days late, without the need for further evidence that she is not pregnant. Some women return even later for their repeat injection, however. Providers can use Further Options to Assess for Pregnancy if an injectables user is more than 7 days late for her repeat injection.