Problems Reported as Side Effects

May or may not be due to the method.

• Problems with side effects affect women’s satisfaction and use of injectables. They deserve the provider’s attention. If the client reports side effects, listen to her concerns, give her advice and support, and, if appropriate, treat. Make sure she understands the advice and agrees.
• Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

Irregular bleeding (bleeding at unexpected times that bothers the client)

• Reassure her that many women using monthly 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 try 800 mg ibuprofen 3 times daily after meals for 5 days, or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help for monthly injectables.
• 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”).

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

• Reassure her that many women using monthly injectables experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.
• For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days, or other NSAID, beginning when heavy bleeding starts. NSAIDs provide some relief of heavy bleeding for implants, progestin-only injectables, and IUDs, and they may also help for monthly injectables.
• 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”).

No monthly bleeding

• Reassure her that some women using monthly injectables stop having monthly bleeding, and this is not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not pregnant or infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.)

Weight gain

• Review diet and counsel as needed.

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.

Breast tenderness

• Recommend that she wear a supportive bra (including during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1,000 mg), or other pain reliever.
• Consider locally available remedies.

Dizziness

• Consider locally available remedies.

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New Problems That May Require Switching Methods

May or may not be due to the method.

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

• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
• She can continue using monthly injectables while her condition is being evaluated.
• If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using monthly injectables during treatment.

Migraine headaches (see Identifying Migraine Headaches and Auras)

• Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using monthly injectables, should stop using injectables.
• Help her choose a method without estrogen.

Circumstances that will keep her from walking for 1 week or more

• If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:
  • Tell her doctors that she is using monthly injectables.
  • Stop injections one month before scheduled surgery, if possible, and use a backup method during this period.
  • Restart monthly injectables 2 weeks after she can move about again.

Certain serious health conditions (suspected heart or liver disease, high blood pressure (systolic pressure of 140 mm Hg or higher or diastolic pressure of 90 mm Hg or higher), blood clots in deep veins of 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 the next injection.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care.

Suspected pregnancy

• Assess 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 3, next page).

Starting treatment with lamotrigine

• Combined hormonal methods, including monthly injectables, can make lamotrigine less effective. Unless she can use a different medication for seizures than lamotrigine, help her choose a method without estrogen.