starting progestogen-only injectable contraception

Last edited 08/2019 and last reviewed 03/2021

• SPC advises that depot medroxyprogesterone acetate (DMPA) can be started up to Day 5 without additional contraceptive precautions
  
  
• 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 (1)
  • 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 >21 days AND has a negative high-sensitivity urine pregnancy test (able to detect hCG levels around 20 mIU/ml)

Key:

(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

EC, emergency contraception; LNG, levonorgestrel; UPA, ulipristal acetate; UPSI, unprotected sexual intercourse.

Note that NICE suggest (2):

• provided that it is reasonably certain that the woman is not pregnant, the use of injectable contraceptives may be started:
  • up to and including the fifth day of the menstrual cycle without the need for additional contraceptive protection
  • at any other time in the menstrual cycle, but additional barrier contraception should be used for the first 7 days after the injection
  • immediately after first- or second-trimester abortion, or at any time thereafter
  • at any time post-partum - the FSRH guidance here is more detailed see above
• additional information about starting postpartum
  • women who are breast feeding should wait until 6 weeks post partum before starting Depo Provera because medroxyprogesterone acetate and its metabolites are excreted in breast milk. At 6 weeks of age the infant's enzyme system should be more mature (3,4)
• depo-Provera can be started within 5 days of childbirth or abortion. However if Depo-Provera is started so soon after childbirth then this may cause heavy bleeding and so waiting until 6 weeks post partum is thought to be better (3,4)

Reference:

• FSRH (April 2019). Progestogen-only Injectable Contraception
• NICE (September 2014). Long-acting reversible contraception (update)
• Prescriber 2001; 12 (5):83-95.
• Drug and Therapeutics Bulletin 1996;34 (12): 93-5.