Can you provide references for the QuickStart approach to initiating Depo-Provera injections?

Q:        I attended the Contraceptive Technology conference in October 2009.  It was reported that the WHO now states you may initiate Depo-Provera even after day 7 of menstrual cycle and may give injections up to 4 weeks after the normal injection timing.

I have tried to find the WHO reference to initiate policy changes in our clinic and can not find it on line.  What is the reference that lists these changes?

Thanks for any help my may provide.

A:  Great question.  Thank you!  It gave me the opportunity to prepare a more complete reference to this practice.  Here are the places the QuickStart method is described:

1.    Family Planning: A Global Handbook for Providers published by USAID, the Johns Hopkins Bloomberg School of Public Health and the World Health Organization, 2007 Page  68. 2.    Selected Practice Recommendations for Contraceptive Use, Second edition. A WHO Family Planning Cornerstone.  Recommendation #5 3. Zieman, M et al Managing Contraception 2007-2009;   See algorithm 27.1, on page 128. 4. Chapter 9 of the 19th edition of Contraceptive Technology Injectable Contraceptives[dk1]  By Alisa B. Goldberg, MD, MPH and David A. Grimes, MD Providing DMPA (from Contraceptive Technology) DMPA is provided in either 1 cc vials or prefilled syringes containing 150 mg. The label states a 2-year shelf-life. Using a sterile needle and syringe, inject the DMPA deeply into the deltoid or the gluteus maximus muscle. Injections into the deltoid are less embarrassing but may be slightly more painful. The 21- to 23-gauge needle should be 2.5 to 4 cm long. Immediately after injection do not massage the area over the injection, because it could lower the effectiveness of DMPA. DMPA-SC is available in prefilled, single-use syringes. Subcutaneous DMPA injections can be given in the anterior thigh or abdominal wall.   If a DMPA injection is given within 5 to 7 days of a normal last menstrual period, no backup contraception is needed. The WHO states that DMPA can be given at any time in a menstrual cycle if the woman can be reasonably certain that she is not pregnant. If DMPA is given later than the seventh day in the menstrual cycle, it is important that women use backup contraception for 7 days and receive a follow-up pregnancy test several weeks later to diagnose pregnancy in a timely fashion. A recent study of immediate initiation of DMPA among 149 women who presented on cycle day 8 or later, found that 47% of women continued to a second dose of DMPA, 92% returned for their follow up pregnancy test (half required many reminders) and 3 women were pregnant (2%).

Email from RAH on 1-14: Did you get my reply?  What are you doing with regard to initiating Depo injections?

Her reply on 1-14: “Yes, thank you it was helpful.  I work at the University of South Carolina student health center.  We usually will start Depo within the first 7 days of the cycle.  We are discussing our current policy and deciding if changes need to be made.  I was more interested in how late an injection may be given.  I had found in the Selected Practice Recommendations for Contraceptive Use, 2^nd edition of WHO recommendation #6 that you may give Depo Provera up to 2 weeks late (after the 13 week injection time frame) and do not need additional contraception.  I thought I had heard at the conference from two different lectures that you could give it up to 4 weeks late.  I didn’t know if the WHO had updated the 2004 Selected Practice Recommendations.” 

“Thanks for your input.”

Julie Cuy Castellanos, WHNP
Women’s Health Nurse Practitioner

Key words:  Contraceptive Technology conference, Depo-Provera injections, timing, menstrual cycle, WHO (World Health Organization), reference, change policy, QuickStart, Family Planning: A Global Handbook for Providers, Selected Practice Recommendations for Contraceptive Use, Managing Contraception, Injectable contraceptives, Dr. Alisa B. Goldberg, Dr. David A. Grimes

References:

Goldberg AB, Grimes DA. Injectable contraceptives IN Hatcher RA, Trussell J, Nelson AL. et al Contraceptive Technology 19^th edition, pages 168 and 169: Ardent Media Inc. 2008

Zieman N. In Hatcher RA, Cwiak C, Darney P, Creinin MD, Stosur HR. et al Managing Contraception, page 128: 2007-2009

1. Burke AE. Extended regimens and Quick Start: why prescribe it? Presented at the 2009 Contraceptive Technology Quest for Excellence conference. Atlanta; October 2009.

2. Nelson AL. Quick-Start/ Same-Day-Start contraception: breaking down barriers for women. Female Patient 2008; accessed at: http://www.femalepatient.com/html/arc/sig/prac/articles/033_03_025.asp

3. Zieman M, Hatcher RA, Cwiak C, et al. 2007-2009 Managing Contraception for Your Pocket. Tiger, GA: Bridging the Gap; 2007.

4. Berenson AB, Radecki CM, Grady JJ, et al. A prospective, controlled study of the effects of hormonal contraception on bone mineral density. Obstet Gynecol 2001; 98:576-582.

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