Problems Reported as Side Effects

These problems may or may not be due to the progestin-only injectables but they affect women’s satisfaction and use of this method and therefore deserve the provider’s attention. The following information advises how to address any reported side effects and specific conditions.

Any reported side effects

• Listen to the client’s concerns, give her advice and support, and, if appropriate, treat the condition. Make sure she understands the advice and agrees.
• Offer to help her choose another method—now, if she wishes, or if problems cannot be overcome.

No monthly bleeding

• Reassure the client that most women using progestin-only injectables stop having monthly bleeding over time, and this is not harmful. There is no need to lose blood every month; blood is not building up inside her. It is similar to not having monthly bleeding during pregnancy. It does not mean she has become infertile. Some women are happy to be free from monthly bleeding, when they understand that it is not harmful.
• If not having monthly bleeding bothers the woman, she may want to switch to monthly (combined) injectables, if available (see Chapter 5).

Irregular bleeding (bleeding at unexpected times)

• Reassure her that many women using progestin-only injectables experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
• For modest short-term relief, she can take 500 mg mefenamic acid twice daily after meals for 5 days, or 40 mg of valdecoxib once daily for 5 days, beginning when irregular bleeding starts. 
• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

Weight gain

• Review the client’s diet with her and counsel as needed.

Abdominal bloating and discomfort     

• Consider locally available remedies.

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)

• Reassure the client that some women using progestin-only injectables experience heavy or prolonged bleeding. It is not harmful and usually becomes less or stops after a few months.
• For modest short-term relief she can try (one at a time), beginning when heavy bleeding starts:     
  • 500 mg mefenamic acid twice daily after meals for 5 days
  • 40 mg of valdecoxib daily for 5 days
  • 50 µg ethinyl estradiol daily for 21 days y     
• If bleeding becomes a health threat or if the woman wants, help her choose a different method. In the meantime, she can use one of the treatments listed above to help reduce bleeding.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding).

Ordinary headaches (nonmigrainous)

• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1,000 mg), or other pain reliever.
• Any headaches that get worse or occur more often during use of injectables should be evaluated.

Mood changes or changes in sex drive  

• Ask the client about changes in her life that could affect her mood or sex drive, including changes in her relationship with her partner. Give support as appropriate.
• Clients who have serious mood changes such as major depression should be referred for care.
• Consider locally available remedies.

Dizziness

• Consider locally available remedies.

New Problems That May Require Switching Methods

These problems also may or may not be due to the use of progestin-only injectables.

Migraine headaches (see the job aid on Identifying Migraine Headaches and Auras)

• If the client has migraine headaches without aura, she can continue to use the method if she wishes.
• If she has a migraine aura, do not give the injection. Help her choose a method without hormones. 

Unexplained vaginal bleeding (that suggests a medical condition not related to the method)

• Refer or evaluate the client by history and pelvic examination. Diagnose and treat as appropriate.
• If no cause of bleeding can be found, consider stopping progestin-only injectables to make diagnosis easier. Provide another method of her choice (but not an implant or copper-bearing or hormonal IUD) to use until the condition is evaluated and treated.
• If bleeding is caused by an STI or pelvic inflammatory disease, she can continue using progestin-only injectables during treatment.

Certain serious health conditions (suspected blocked or narrowed arteries, serious liver disease, severe high blood pressure, blood clots in deep veins or legs or lungs, stroke, breast cancer, or damage to arteries, vision, kidneys, or nervous system caused by diabetes). See Appendix B – Signs and Symptoms of Serious Health Conditions.

• Do not give next injection.
• Give her a backup method to use until the condition is evaluated.
• Refer the client for diagnosis and care if she is not already under care.

Suspected pregnancy

• Assess the client for pregnancy.
• Stop injections if pregnancy is confirmed.
• There are no known risks to a fetus conceived while a woman is using injectables (see Question 12) or to a woman who receives an injection while pregnant.