Depo-Provera: comparison with some other ... - epgonline.org

Depo-Provera: comparison with some other
contraceptive methods
Depo-Provera (medroxyprogesterone)
The Intrauterine (IUS) system (levonorgestrel)
IM injection 1 Intimate procedure 2
No need to check for threads or be concerned about expulsion
If the woman wishes to become pregnant injections need to be
stopped 1
Women should be advised how to check the threads of their
IUS 2
The IUS should be removed from the uterus if the woman
wishes to become pregnant 2
Delay in return to fertility 1 No delay in return to fertility 3
64.9% of nulliparous women reported mild to moderate pain on
insertion of the IUS 4
Depo-Provera
Sub-dermal implant (etonogestrel)
Standard deep IM injection technique 1 Insertion should be carried out by somebody specially trained 5
No need for removal Insertion requires aseptic technique using a local anaesthetic 5
Nothing to get lost or migrate
Non-palpable implants should always be located by ultrasound
(USS) or MRI, and subsequently removed using USS 5
Amenorrhoea reported in 55% of women at 1 year 1 Amenorrhoea reported in 20% of women 5,7
Evidence-base called into question by NICE due to protocol
violations 7
Depo-Provera
More than 99% effective in pregnancy prevention 8,9,10
No need to remember daily tablets 1
Amenorrhoea common in long-term use 6
All currently available LARC methods (intrauterine devices
[IUDs], the intrauterine system [IUS], injectable contraceptives
and implants) are more cost effective than the combined oral
contraceptive Pill even at 1 year of use 8
Oral contraception (combined and progesterone only)
“Missed Pill” is the most frequent cause of pregnancy in
women using oral contraception 11
With the Pill, tablets must be taken as prescribed to ensure
maximum efficacy 13
Withdrawal-bleed in standard usage of the combined oral
contraceptive Pill 12
Injectable contraceptives are more cost-effective than the
combined oral contraceptive Pill even at 1 year of use 8
References:
1. Depo-Provera SPC, available at http://emc.medicines.org.uk/.
2. Mirena SMPC, available at http://emc.medicines.org.uk/.
3. NICE guidance. Effective and appropriate use of long-acting reversible contraception. Available at http://www.nice.org.uk/nicemedia/pdf/LARC_2ndcons_algorithm.pdf. Last accessed January 2008.
4. Suhonen S, Haukkkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception 2004;
69: 407-412.
5. Implanon SPC, available at http://emc.medicines.org.uk/.
6. Mainwaring R, Hales HA, Stevenson K et al. Metabolic parameter, bleeding, and weight changes in US women using progestin only contraceptives. Contraception 1995; 51: 149-153.
7. National Institute for Health and Clinical Excellence (2005). Long-acting reversible contraception. The effective and appropriate use of long-acting reversible contraception. Published by the RCOG Press, London.
Available from www.nice.org.
8. National Institute for Health and Clinical Excellence (2005). Quick reference guide. Long-acting reversible contraception. NICE clinical guideline no. 30. London: National Institute for Health and Clinical Excellence.
Available from www.nice.org.
9. Trussell J, Kowal D. The essentials of contraception: efficacy, safety and personal considerations. In: Hatcher RA, Trussell J, Stewart F et al. Contraceptive Technology 17 th rev ed. New York, NY Ardent Media; 1998: 211-
247.
10. Kaunitz AM. Current concepts regarding use of DMPA. J Rep Med 2002: 47 (Suppl 9); 785-789.
11. Barjot P, Graesslin O, Cohen D et al. Pregnancies occurring under contraception: lessons from the GRECO study. Gyne Obstet & Fert 2006: 34; 120-126.
12. Nussey S and Whitehead S. The Gonad in Endocrinology: An Integrated Approach. BIOS Scientific Publishers Ltd, 2001. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=endocrin&partid=29#A1245. Accessed January
2008.
13. British National Formulary 54. Available at http://www.bnf.org/bnf/bnf/current/4573.htm. Last accessed January 2008.
Depo-Provera prescribing information can be found overleaf. Please refer to the Summary of
Product Characteristics before prescribing any of these products.

Prescribing information:
Depo-Provera 150 mg/ml (medroxyprogesterone acetate)
ABBREVIATED PRESCRIBING INFORMATION (UK)
(ALL CLAIMS)
Please refer to the SmPC before prescribing Depo-Provera 150 mg/ml.
Presentation: 1 ml Disposable syringe, containing 150 mg medroxyprogesterone acetate in a Sterile suspension for injection.
Indication: Long-term contraceptive agent, in women who have been counselled concerning the likelihood of menstrual disturbance,
potential delay in return to full fertility and risks of bone mineral density losses. Short-term contraception for the following (i) For
partners of men undergoing vasectomy, until the vasectomy becomes effective, (ii) In women who are being immunised against rubella
(iii) In women awaiting sterilisation. Dosage: First injection: 150mg intramuscular injection during the first 5 days of a normal
menstrual cycle. Post Partum: Within 5 days post partum (if not breast-feeding). Women in puerperium can experience prolonged and
heavy bleeding, therefore caution is required, and women should be advised accordingly. If the puerperal woman will breast-feed, the
initial injection should be no sooner than 6 weeks post partum. Further doses: These should be given at 12 week intervals, however as
long as the injection is given no later than 5 days after the 12 week interval, no additional contraception measures are required. For
partners of men undergoing vasectomy, a second injection 12 weeks after the first may be necessary in a small proportion of patients
where the partner's sperm count has not fallen to zero. If the dose repeat interval is greater than 89 days (12 weeks and 5 days) for any
reason, then pregnancy should be excluded before the next injection is given and the patient should use additional contraceptive
measures (e.g. barrier) for fourteen days after this subsequent injection. Elderly: Not appropriate. Children: Depo-Provera is not
indicated before menarche (Refer to the Summary of Product Characteristics section 4.2 Posology and method of administration) Data
in adolescent females (12-18 years) is available (see section 4.4 Special Warnings and Special Precautions for Use). Other than
concerns about loss of BMD, the safety and effectiveness of Depo-Provera is expected to be the same for adolescents after menarche
and adult females. Administration: By deep intramuscular injection. The sterile aqueous suspension should be vigorously shaken just
before use to ensure the dose being given represents a uniform suspension. Contraindications: Known sensitivity to
medroxyprogesterone acetate or any of its ingredients. Pregnancy, either for diagnosis or therapy. Known or suspected hormonedependent
malignancy of breast or genital organs. Patients with abnormal uterine bleeding, whether administered alone or in
combination with oestrogen until a definite diagnosis has been established and the possibility of genital tract malignancy eliminated.
Special Warnings and Precautions: Loss of bone mineral density, increasing with length of use. A risk: benefit assessment should be
performed, especially in young or adolescent women and if use is anticipated to be long term (ie 2 years or longer). In adolescents and
women with significant lifestyle and/or medical risk factors for osteoporosis, other methods of contraception should be considered
before using Depo-Provera. Women should be counselled that there is a potential for delay in return to full fertility following use of
the method, regardless of the duration of use. Disruption of normal menstrual cycle. Small increase in the risk of being diagnosed with
breast cancer, compared with non-users. Considered among the risk factors for osteoporosis. Weight Gain. Very few reports of
anaphylactoid reactions. Pulmonary embolism, cerebrovascular disease or retinal thrombosis. Rare cases of thrombo-embolism have
been reported. History of endogenous depression, including premenstrual-type depression, should be carefully monitored. Migraine or
unusually severe headaches, acute visual disturbances of any kind, pathological changes in liver function and hormone levels. Patients
with thromboembolic or coronary vascular disease should be carefully evaluated before treatment. Decreased glucose tolerance.
Diabetic patients should be carefully monitored while receiving therapy. Increased and decreased in total cholesterol, triglycerides and
low-density lipoprotein (LDL) cholesterol. Associated with a 15-20% reduction in serum high density lipoprotein (HDL) cholesterol
levels. Potential for an increased risk of coronary disease should be considered prior to use. Patients with recent trophoblastic disease,
exhibiting abnormal chorionic gonadotrophin levels. Pathologists should be informed of the patient's use of Depo-Provera if
endometrial or endocervical tissue is submitted for examination. Results of certain laboratory tests may be affected. Refer to the
Summary of Product Characteristics for more detailed information on Special Warnings and Precautions. Drug interactions:
Aminoglutethimide administered concurrently may significantly depress bioavailability. The possibility of interaction (including oral
anticoagulants) should be borne in mind in patients receiving concurrent treatment with other drugs. Pregnancy and Lactation:
Check for pregnancy before initial injection, and also if administration of subsequent injection is delayed beyond 89 days (12 weeks
and 5 days). Side-effects: Common: Menstrual irregularities (bleeding and/or amenorrhoea), weight changes, headache, nervousness,
abdominal pain or discomfort, dizziness, asthenia (weakness or fatigue), decreased libido or anorgasmia, backache, leg cramps,
depression, nausea, insomnia, leucorrhoea, acne, vaginitis, pelvic pain, breast pain, no hair growth or alopecia, bloating, rash, oedema,
hot flushes. Uncommon: (fewer than 1 % of subjects) galactorrhoea, melasma, chloasma, convulsions, changes in appetite,
gastrointestinal disturbances, jaundice, genitourinary infections, vaginal cysts, dyspareunia, paraesthesia, chest pain, pulmonary
embolus, allergic reactions, anaemia, syncope, dyspnoea, thirst, hoarseness, somnolence, decreased glucose tolerance, hirsutism,
pruritus, arthralgia, pyrexia, pain at injection site, injection site abscess, blood dyscrasia, rectal bleeding, changes in breast size, breast
lumps or nipple bleeding, axillary swelling, prevention of lactation, sensation of pregnancy, lack of return to fertility, paralysis, facial
palsy, scleroderma, osteoporosis, uterine hyperplasia, varicose veins, dysmenorrhoea, thrombophlebitis, deep vein thrombosis. In postmarketing
surveillance rare cases of osteoporosis including osteoporotic fractures have been reported in patients taking Depo-Provera.
Package Quantities and Basic NHS Cost: Single 1ml Syringe pack: £6.01. Legal Category: POM. Marketing Authorisation
Number and Holder: PL 00032/0082, Pharmacia Limited, Ramsgate Road, Sandwich, CT13 9NJ, UK. Last Revised: August 2007.
Further information is available on request from: Medical Information at Pfizer Limited, Walton Oaks, Dorking Road, Tadworth,
Surrey, KT20 7NS, UK. Tel: +44 (0) 1304 616161
Adverse events should be reported to Pfizer Medical Information on 01304 616161
Information about adverse event reporting can also be found at www.yellowcard.gov.uk
Ref: DP 4_0
Date of preparation January 2008
DPR-056-08