This Guidelines summary gives clinical guidance, evidence-based recommendations, and good practice points for health professionals on the use of progestogen-only injectables.
The guidance is intended for any health professional or service providing contraception or contraceptive advice in the UK.
The summary outlines key recommendations, side effects, length of usage, and when in the menstrual cycle to start the contraception, plus other considerations.
The document updates and replaces previous Faculty of Sexual and Reproductive Healthcare (FSRH) guidance on progestogen-only injectable contraception.
Reflecting on Your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
Long-acting reversible contraceptives (LARCs) are those that are administered less frequently than once a month. Both depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) are long-acting progestogens; the combined contraceptive injectable is not available in the UK.
DMPA is formulated for deep intramuscular (IM) injection as Depo-Provera (150 mg medroxyprogesterone acetate in 1 ml) and subcutaneous (SC) injection as Sayana Press (104 mg MPA in 0.65 ml). NET-EN is less commonly used in the UK. It is available as Noristera (200 mg in 1 ml), administered by IM injection. NET-EN is licensed for short-term use by women whose partners have undergone vasectomy until successful vasectomy is confirmed, and after rubella immunisation.
- When administered at the recommended dosing interval the failure rate of progestogen-only injectable contraception is approximately 0.2% in the first year of use. With typical use the failure rate is approximately 6%
- Health professionals should be familiar with the most up-to-date UK Medical Eligibility Criteria for progestogen-only injectable contraception
- Amenorrhoea or reduced bleeding is common in progestogen-only injectable users and may benefit women with menstrual problems
- DMPA use may reduce pain associated with endometriosis
- Women should be advised about changes in bleeding patterns
- Use of DMPA is not associated with an increased risk of ovarian or endometrial cancer and may offer some protection
- DMPA is a contraceptive option for women with sickle cell disease and may reduce the severity of sickle crisis pain.
Bone Mineral Density
- Progestogen-only injectable use is associated with a small loss of bone mineral density, which is usually recovered after discontinuation
- In women aged under 18 years, progestogen-only injectable contraception can be used after consideration of alternative methods
- Women using DMPA who wish to continue use should be reviewed every 2 years to assess individual situations, and to discuss the benefits and potential risks
- Women are generally advised to switch to another method at age 50 years. If a woman does not wish to stop using DMPA, consideration may be given to continuation, providing the benefits and risks have been assessed and the woman informed of the potential risks.
- There is possibly a weak association between current use of DMPA and breast cancer. Any increased risk is likely to be small and reduce with time after stopping.
- A causal association between DMPA and venous thrombosis has not been demonstrated in the small number of studies that have investigated this relationship
- From the limited evidence available it is not possible to confirm or exclude an association between progestogen-only injectable use and myocardial infarction or stroke.
- There is a weak association between cervical cancer and use of DMPA for 5 years or longer. Any increased risk appears to reduce with time after stopping and could be due to confounding factors
- Health professionals should check that women requesting DMPA are up to date with cervical cytology screening and, if relevant, have completed the human papillomavirus (HPV) vaccination programme
- Women should be informed about the link between HPV and cervical cancer and advised about strategies that reduce the risk such as condom use, smoking cessation, regular cervical screening, and, where appropriate, vaccination against HPV.
- Use of DMPA appears to be associated with weight gain, particularly in women under 18 years of age with a body mass index (BMI) 30 kg/m2 or greater
- Women who gain more than 5% of their baseline body weight in the first 6 months of DMPA use are likely to experience continued weight gain
- Injection site reactions appear to be more common with use of SC DMPA than with use of IM DMPA
- Whilst there is little evidence available to demonstrate causation, a number of possible side effects such as acne, decreased libido, mood swings, headache, hot flushes, and vaginitis have been reported with use of DMPA.
Length of Usage
- There is no upper limit for duration of use of the progestogen-only injectable
- Progestogen-only injectable users should be advised to return on the date their next injection is due, or sooner if they experience any adverse reactions or intolerable side effects
- In line with other contraceptive methods, an annual prescription can be given. At each visit the health professional administering the injectable should assess the time since last injection, bleeding pattern, changes in sexual health, and check that women still fulfil the medical eligibility criteria
- Long-term users should be reviewed at least every 2 years by a prescriber.
- The gluteal muscle in the buttock is the preferred site for IM DMPA administration but it can be administered into the deltoid muscle of the upper arm. In women with deep adipose tissue in the gluteal area, standard-length needles may not reach the muscle layer and SC DMPA or deltoid administration of IM DMPA should be considered
- SC DMPA should be injected into the abdomen or anterior thigh.
When in the Menstrual Cycle to Start Progestogen-Only Injectable Contraceptives
- If quick starting beyond day 5, a woman may start progestogen-only injectable contraceptives at any time if it is reasonably certain that she is not pregnant.
Criteria for Excluding Pregnancy
- Health professionals can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
- she has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease
- she has been correctly and consistently using a reliable method of contraception (for the purposes of being reasonably certain that a woman is not currently pregnant, barrier methods of contraception can be considered reliable providing that they have been used consistently and correctly for every episode of intercourse)
- she is within the first 5 days of the onset of a normal (natural) menstrual period
- she is less than 21 days’ postpartum (non-breastfeeding women)
- she is fully breastfeeding, amenorrhoeic, AND less than 6 months’ postpartum.
- she is within the first 5 days after abortion, miscarriage, ectopic pregnancy, or uterine evacuation for gestational trophoblastic disease
- she has not had intercourse for more than 21 days AND has a negative high-sensitivity urine pregnancy test (able to detect human chorionic gonadotropin levels around 20 mIU/ml).
Table 1: Advice on Starting Progestogen-Only Injectable Contraception
|Circumstances||Starting Day||Additional Contraceptive Protection Required?||Any Additional Information|
|Women having menstrual cycles||Day 1–5 of cycle||No||It is advisable to check that the menstrual period is typical of the woman’s usual bleeding pattern in terms of duration, heaviness, and timing|
|After day 5 of cycle||Yes (7 days)||If there has been a risk of pregnancy, consider EC and quick starting (see below)[C]|
|Women who are amenorrhoeic||Any time if it is reasonably certain she is not pregnant||Yes (7 days)||If there has been a risk of pregnancy, consider EC and quick starting (see below)[C]|
|Postpartum[A]||21 days or fewer postpartum||No|
|Fewer than 21 days if menstrual cycles have returned||Start as for other women having menstrual cycles||If there has been a risk of pregnancy, consider EC and quick starting (see below)[C]|
|Fewer than 21 days’ postpartum if menstrual cycles have not returned||Yes (7 days)||If there has been a risk of pregnancy, consider EC and quick starting (see below)[C]|
|Post-first- or second-trimester abortion||Up to and including day 5[B]||No||The injectable can be initiated after the first part of a medical abortion (see FSRH guideline on Contraception after pregnancy)|
|At any other time if it is reasonably certain she is not pregnant||Yes (7 days)|
|Quick starting after oral EC OR in other situations in which pregnancy cannot be excluded[C]||If pregnancy cannot be excluded, ideally use a bridging method until negative PT at 3 weeks. If bridging method inappropriate or unacceptable, consider quick-starting injectable with advice to use additional precaution for 7 days after injection and pregnancy test, no sooner than 3 weeks after most recent UPSI. Note that after UPA–EC, quick start should be delayed for 5 days.|
|[A] Prior to 6 weeks’ postpartum use of DMPA in breastfeeding women is UKMEC 2[B] The FSRH advises that women ideally start on the day or day after a first- or second-trimester abortion|
[C] See FSRH guidance on Quick starting contraception
Abbreviations: DMPA=depot-medroxyprogesterone acetate; EC=emergency contraception; LNG=levonorgestrel; PT=pregnancy test; UKMEC=UK medical eligibility criteria; UPA=ulipristal acetate; UPSI=unprotected sexual intercourse.
Table 2: Switching From Another Contraceptive to Progestogen-Only Injectable Contraception
|Situation||Starting||Additional Contraceptive Protection Required?||Additional Information|
|Switching from CHC (if taken correctly)||Day 1–2 of the HFI||No|
|Day 3–7 of HFI OR week one following the HFI||Yes (7 days). If UPSI has occurred after day 3 of the HFI, advise continuing the CHC method for at least 7 days||When switching after a 7-day HFI, there are no data to confirm that suppression of ovulation is maintained|
|Week 2–3 of pill/ring/patch||No, providing the CHC method has been used consistently and correctly for 7 consecutive days before switching||There is evidence to suggest that taking hormonally active pills for 7 consecutive days prevents ovulation. Therefore, as long as there have been 7 days of CHC use, 7 hormone-free days can occur without any effect on contraceptive efficacy|
|Switching from traditional POP (if taken correctly) OR LNG-IUS||Any time||Yes (7 days)|
If UPSI in last 7 days, retain LNG IUS for 7 days after starting injectable
|The continuing method provides contraceptive cover while the effects of the injectable are established|
|Switching from desogestrel POP (if taken correctly) OR progestogen-only implant (≤3 years since implant insertion)||Any time||No|
|>3 years since implant insertion||Any time||Yes (7 days)||If there has been a risk of pregnancy, consider the need for EC and a PT no sooner than 3 weeks after the most recent incidence of UPSI|
|Switching from Cu-IUD|
Day 1–5 of menstrual cycle
Any other time
Yes (7 days). If UPSI in last 7 days, retain Cu-IUD for 7 days
|Abbreviations: CHC=combined hormonal contraception; Cu-IUD=copper intrauterine device; EC=emergency contraception; HFI=hormone free interval; POP=progestogen-only pill; PT=pregnancy test; UPSI=unprotected sexual intercourse|
Administering Repeat Injections
- Women should be advised to return every 13 weeks for a repeat injection of IM or SC DMPA (outside the product licence for IM DMPA)
- An injection of DMPA can be administered up to 7 days late (up to 14 weeks after the last injection) without the need for additional contraceptive precautions (outside the product licence for IM DMPA)
- If necessary, an early repeat injection of DMPA can be administered from 10 weeks and from 6 weeks for NET-EN (outside product licence).
- Women who discontinue their progestogen-only injectable and who do not wish to conceive should be advised to start another contraceptive method before or at the time of their next scheduled injection, even if amenorrhoeic
- Women should be informed that there can be a delay of up to 1 year in the return of fertility after discontinuation of IM or SC DMPA
- The consistent and correct use of condoms (male or female) can reduce the risk of sexually transmitted infection (STI) transmission and should therefore be recommended as a risk-reduction strategy
- A causal relationship between progestogen-only injectable contraception and HIV transmission/acquisition has not been established but cannot be completely excluded
- Women who experience unscheduled bleeding during use of a progestogen-only injectable and who are medically eligible can be offered a combined oral contraceptive (COC) for 3 months. This can be taken in the usual cyclic manner or continuously without a hormone-free interval (outside product licence). Longer-term use of the injectable and COC has not been studied and is a matter of clinical judgement
- Women with unscheduled bleeding during use of a progestogen-only injectable contraceptive can be offered 500 mg mefenamic acid up to three times daily for 5 days
- The efficacy of DMPA contraception is not reduced with concurrent use of enzyme inducing drugs
- No increased risk of pregnancy has been demonstrated in progestogen-only injectable users with higher body weight, although data are limited in women with a BMI 40 kg/m2 or greater.