World Health Organization

Selected woman’s characteristics
Breastfeeding Status:
Time Selected: Between 0 hours and 12 months
Method Selected: Progestogen-Only Injection
Note: Some methods are unavailable for specific time ranges
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Description

POIs: Injected into the muscle or under skin every 2 or 3 months, depending on product

How it works

Thickens cervical mucous to block sperm and egg from meeting and prevents ovulation

Effectiveness to prevent pregnancy

99% with correct and consistent use

97% as commonly used

Comments

Injectables: Delayed return to fertility (about 1-4 months on the average) after use; irregular vaginal bleeding common, but not harmful.

Progestogen-Only Injection

POIs include depot medroxyprogesterone acetate (DMPA)

norethisterone enanthate (NET-EN). There are three formulations considered here:

  1. DMPA-IM = 150  mg of DMPA given intramuscularly
  2. DMPA-SC = 104  mg of DMPA given subcutaneously
  3. NET-EN = 200  mg of NET-EN given intramuscularly

Evidence available for DMPA-IM applies to DMPA-SC and, therefore, DMPA-SC should have the same categories as DMPA-IM.

MEC categories for contraceptive eligibility

Category 1 A condition for which there is no restriction for the use of the contraceptive method
Category 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method
Category 4 A condition which represents an unacceptable health risk if the contraceptive method is used
For further information, please refer to: Medical eligibility criteria for contraceptive use, fifth edition.

Explanation of A, C, D and S categories

A = accept There is no medical reason to deny sterilization to a person with this condition.
C = caution The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D = delay The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.
S = special The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anaesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or there is otherwise any delay.
For further information, please refer to: Medical eligibility criteria for contraceptive use, fifth edition.

Explanation of I and C

I = initiation
C = continuation
For further information, please refer to: Medical eligibility criteria for contraceptive use, fifth edition.

Conditions / Subconditions

Breastfeeding Status:

No breastfeeding status was selected using the "Women’s characteristics" filters.

Breastfeeding Category Clarifications/Special considerations
a) < 6 weeks postpartum 3

Clarification:
There is theoretical concern about the potential exposure of the neonate to DMPA/NET-EN during the first 6 weeks postpartum.

In many settings, however, pregnancy-related morbidity and mortality risks are high, and access to services is limited. In such settings, DMPA/NET-EN may be among the few methods widely available and accessible to breastfeeding women immediately postpartum.
b) ≥ 6 weeks to < 6 months postpartum (primarily breastfeeding) 1
c) ≥ 6 months postpartum 1
Non-breastfeeding Category Clarifications/Special considerations
a) < 21 days 1
b) ≥ 21 days 1

Medical Condition:

No medical conditions were selected using the "Women’s characteristics" filters.

Cardiovascular disease Category Clarifications/Special considerations
Current and history of ischaemic heart disease 3
Stroke 3
Diabetes Category Clarifications/Special
considerations
a) History of gestational disease 1
b) Non-vascular disease
   i) non-insulin dependent 2
   ii) insulin dependent 2
c) Nephropathy / retinopathy / neuropathy 3
d) Other vascular disease or diabetes of > 20 years’ duration 3
Headaches Category Clarifications/Special
considerations
I C
a) Non-migrainous (mild or severe) 1 1 Clarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not.
Read More
b) Migraine
i) without aura
    age < 35 years 2 2
    age > 35 years 2 2
ii) with aura, at any age 2 3

Headaches / Migraine

    Clarification: Classification depends on accurate diagnosis of those severe headaches that are migrainous and those that are not. Any new headaches or marked changes in headaches should be evaluated. Classification is for women without any other risk factors for stroke. Risk of stroke increases with age, hypertension and smoking.
HIV WHO Stage 3 or 4 Category Clarifications/Special considerations
Severe or advanced HIV clinical disease (WHO stage 3 or 4) 1 Clarification: Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to Drug Interactions.
Read More

HIV WHO Stage 3 or 4

    Clarification: Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to Drug Interactions.
    Available studies on the association between progestogen-only injectable contraception and HIV acquisition have important methodological limitations hindering their interpretation. Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition; other studies have not found this association. The public health impact of any such association would depend upon the local context, including rates of injectable contraceptive use, maternal mortality, and HIV prevalence. This must be considered when adapting guidelines to local contexts. WHO expert groups continue to actively monitor any emerging evidence. At the meeting in 2014, as at the 2012 technical consultation, it was agreed that the epidemiological data did not warrant a change to the MEC. Given the importance of this issue, women at high risk of HIV infection should be informed that progestogen-only injectables may or may not increase their risk of HIV acquisition. Women and couples at high risk of HIV acquisition considering progestogen-only injectables should also be informed about and have access to HIV preventive measures, including male and female condoms.
Hypertension Category Clarifications/Special considerations
a) History of hypertension, where blood pressure CANNOT be evaluated (including hypertension in pregnancy) 2 Clarification: It is desirable to have blood pressure measurements taken before initiation of POC, use.
Read More
b) Adequately controlled hypertension, where blood pressure CAN be evaluated 2
c) Elevated blood pressure levels (properly taken measurements)
i) systolic 140-159 or diastolic 90-99 mm Hg 2
ii) systolic ≥ 160 or diastolic ≥ 100 mm Hg 3
d) Vascular disease

Hypertension

  • Clarification: It is desirable to have blood pressure measurements taken before initiation of POC use. However, in some settings blood pressure measurements are unavailable. In many of these settings, pregnancy-related morbidity and mortality risks are high, and POCs are among the few types of methods widely available. In such settings, women should not be denied the use of POCs simply because their blood pressure cannot be measured.
  • Clarification: Women adequately treated for hypertension are at reduced risk of acute myocardial infarction (MI) and stroke as compared with untreated women. Although there are no data, POC users with adequately controlled and monitored hypertension should be at reduced risk of acute MI and stroke compared with untreated hypertensive POC users.
Obesity Category Clarifications/Special considerations
a) > 30 kg/m2 BMI
b) Menarche to < 18 years and ≥30 kg/m2 BMI
Pelvic infection Category Clarifications/Special considerations
Current purulent cervicitis or chlamydial infection or gonorrhoea/Pelvic inflammatory disease/Sepsis 1
Tuberculosis Category Clarifications/Special considerations
a) Non-pelvic 1 Clarification: If a woman is taking rifampicin, refer to the last section of this table, on Drug Interaction
b) Pelvic 1
Venous thromboembolism Category Clarifications/Special considerations
a) History of DVT/PE 2
b) Acute DVT/PE 3
c) DVT/PE and established on anticoagulant therapy 2
d) Family history (first-degree relatives) 1

Drug Interactions:

No drug interactions were selected using the "Women’s characteristics" filters.

Anticonvulsants Category Clarifications/Special considerations
a) Certain anticonvulsants,(phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) DMPA=1
NET-EN=2		 Clarification: Although the interaction of certain anticonvulsants NET-EN is not harmful to women, it is likely to reduce the effectiveness of NET-EN.
Read More
b) Lamotrigine 1

Anticonvulsants

    Clarification: Although the interaction of certain anticonvulsants NET-EN is not harmful to women, it is likely to reduce the effectiveness of NET-EN. Use of other contraceptives should be encouraged for women who are long-term users of any of these drugs. Use of DMPA is Category 1 because its effectiveness is not decreased by the use of certain anticonvulsants.
Antimicrobial Therapy Category Clarifications/Special considerations
a) Broad-spectrum antibiotics 1
b) Antifungals 1
c) Antiparasitics 1
Rifampin/rifabutin DMPA=1
NET-EN=2
Antiretroviral Therapy Category Clarifications/Special considerations
a) Nucleoside reverse transcriptase inhibitors (NRTIs) Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives.
Read More
Abacavir (ABC) 1
Tenofovir (TDF) 1
Zidovudine (AZT) 1
Lamivudine (3TC) 1
Didanosine (DDI) 1
Emtricitabine (FTC) 1
Stavudine (D4T) 1
b) Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Efavirenz (EFV)
Etravirine (ETR) DMPA=1
NET-EN=2
Nevirapine (NVP) 1
Rilpivirine (RPV) DMPA=1
NET-EN=2
c) Protease inhibitors (PIs)
Ritonavir-boosted atazanavir (ATV/r)
Ritonavir-boosted lopinavir (LPV/r) DMPA=1
NET-EN=2
Ritonavir-boosted darunavir (DRV/r) DMPA=1
NET-EN=2
Ritonavir (RTV) DMPA=1
NET-EN=2
d) Integrase inhibitors
Raltegravir (RAL) DMPA=1
NET-EN=2

Antiretroviral therapy

    Clarification: Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted PIs) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. Available studies on the association between progestogen-only injectable contraception and HIV acquisition have important methodological limitations hindering their interpretation. Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition; other studies have not found this association. The public health impact of any such association would depend upon the local context, including rates of injectable contraceptive use, maternal mortality, and HIV prevalence. This must be considered when adapting guidelines to local contexts. WHO expert groups continue to actively monitor any emerging evidence. At the meeting in 2014, as at the 2012 technical consultation, it was agreed that the epidemiological data did not warrant a change to the MEC. Given the importance of this issue, women at high risk of HIV infection should be informed that progestogen-only injectables may or may not increase their risk of HIV acquisition. Women and couples at high risk of HIV acquisition considering progestogen-only injectables should also be informed about and have access to HIV preventive measures, including male and female condoms.

Other:

No other conditions were selected using the "Women’s characteristics" filters.

Adolescents Category Clarifications/Special considerations
Adolescents 2 Special consideration: Adolescents, In general, adolescents are eligible to use any method of contraception and must have access to a variety of contraceptive choices.
Read More

Adolescents

    Special consideration: Adolescents, In general, adolescents are eligible to use any method of contraception and must have access to a variety of contraceptive choices. Age alone does not constitute a medical reason for denying any method to adolescents. While some concerns have been expressed regarding the use of certain contraceptive methods in adolescents (e.g. the use of progestogen-only injectables by those below 18 years), these concerns must be balanced against the advantages of avoiding pregnancy. It is clear that many of the same eligibility criteria that apply to older clients apply to young people. However, some conditions (e.g. cardiovascular disorders) that may limit use of some methods in older women do not generally affect young people since these conditions are rare in this age group. Social and behavioural issues should be important considerations in the choice of contraceptive methods by adolescents. For example, in some settings, adolescents are also at increased risk for STIs, including HIV. While adolescents may choose to use any one of the contraceptive methods available in their communities, in some cases, using methods that do not require a daily regimen may be more appropriate. Adolescents, married or unmarried, have also been shown to be less tolerant of side-effects and therefore have high discontinuation rates. Method choice may also be influenced by factors such as sporadic patterns of intercourse and the need to conceal sexual activity and contraceptive use. For instance, sexually active adolescents who are unmarried have very different needs from those who are married and want to postpone, space or limit pregnancy. Expanding the number of method choices offered can lead to improved satisfaction, increased acceptance and increased prevalence of contraceptive use. Proper education and counselling both before and at the time of method selection can help adolescents address their specific problems and make informed and voluntary decisions. Every effort should be made to prevent service and method cost from limiting the options available.
Adolescents Category     Clarifications / Special Considerations
Adolescents 2
Smoking Category Clarifications/Special considerations
a) Age < 35 years 1
b) Age > 35 years
i) < 15 cigarettes/day 1
ii) > 15 cigarettes/day 1
Note: Some methods are unavailable for specific time ranges
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