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Questions and Answers About Monthly Injectables

1.   How are monthly injectables different from DMPA or NET-EN?

The major difference between monthly injectables and DMPA or NET-EN is that a monthly injectable contains an estrogen as well as a progestin, making it a combined method. In contrast, DMPA and NET-EN contain progestin only. Also, monthly injectables contain less progestin. These differences result in more regular bleeding and fewer bleeding disturbances than with DMPA or NET-EN. Monthly injectables require a monthly injection, whereas NET-EN is injected every 2 months and DMPA, every 3 months.

2.   Do monthly injectables function like combined oral contraceptives?

Largely, yes. Monthly injectables (also called combined injectable contraceptives) are similar to combined oral contraceptives (COCs). There are few long-term studies done on monthly injectables, but researchers assume that most of the findings about COCs also apply to monthly injectables. Monthly injectables, however, do not pass through the liver first because they are not taken by mouth like COCs. Short-term studies have shown that monthly injectables have less effect than COCs on blood pressure, blood clotting, the breakdown of fatty substances (lipid metabolism), and liver function. Long-term studies of the health risks and benefits of monthly injectables are underway.

3.   Do monthly injectables cause birth defects? Will the fetus be harmed if a woman accidentally uses monthly injectables while she is pregnant?

No. Good evidence from studies on other hormonal methods shows that hormonal contraception will not cause birth defects and will not otherwise harm the fetus if a woman becomes pregnant while using monthly injectables or accidentally starts injectables when she is already pregnant.

4.   Do monthly injectables cause abortion?

No. Research on combined contraceptives finds that they do not disrupt an existing pregnancy. They should not be used to try to cause an abortion. They will not do so.

5.   Should the dates for a woman’s repeat injections be based on when monthly bleeding starts?

No. Some providers think that the next injection should only be given when the next monthly bleeding begins. Bleeding episodes should not guide the injection schedule, however. A woman should receive the injection every 4 weeks. The timing of injections should not be based on her monthly bleeding.

6.   Can monthly injectables be used to bring on monthly bleeding?

No. A woman may experience some vaginal bleeding (a “withdrawal bleed”) as a result of an injection, but there is no evidence that giving a woman who has irregular bleeding a single injection of a monthly injectable will cause her monthly bleeding to begin properly about one month later. Also, giving a pregnant woman an injection will not cause an abortion.

7.   Can women who smoke use monthly injectables safely?

Women younger than age 35 who smoke any number of cigarettes and women 35 and older who smoke fewer than 15 cigarettes a day can safely use monthly injectables. (In contrast, women 35 and older who smoke any number of cigarettes should not use combined oral contraceptives.) Women 35 and older who smoke more than 15 cigarettes a day should choose a method without estrogen such as progestin-only injectables, if available. All women who smoke should be urged to stop smoking.

8.   Do monthly injectables change women’s mood or sex drive?

Generally, no. Some women using monthly injectables report these complaints. The great majority of injectables users do not report any such changes, however, and some report that both mood and sex drive improve. It is difficult to tell whether such changes are due to monthly injectables or to other reasons. There is no evidence that monthly injectables affect women’s sexual behavior.

9.   Can women with varicose veins use monthly injectables?

Yes. Monthly injectables are safe for women with varicose veins. Varicose veins are enlarged blood vessels close to the surface of the skin. They are not dangerous. They are not blood clots, nor are these veins the deep veins in the legs where a blood clot can be dangerous (deep vein thrombosis). A woman who has or has had deep vein thrombosis should not use monthly injectables.

10.  Do monthly injectables make a woman infertile?

No. There may be a delay in regaining fertility after stopping monthly injectables, but in time the woman will be able to become pregnant as before, although fertility decreases as women get older. The bleeding pattern a woman had before she used monthly injectables generally returns a few months after the last injection. Some women may have to wait a few months before their usual bleeding pattern returns.

11.  How long does it take to become pregnant after stopping monthly injectables?

Women who stop using monthly injectables wait about one month longer on average to become pregnant than women who have used other methods. This means they become pregnant on average 5 months after their last injection. These are averages. A woman should not be worried if she has not become pregnant even as much as 12 months after stopping use. After stopping monthly injectables, a woman may ovulate before her monthly bleeding returns—and thus can become pregnant. If she wants to continue avoiding pregnancy, she should start another method before monthly bleeding returns.

12.  What if a woman returns for her next injection late?

Current WHO guidance recommends giving a woman her next monthly injection if she is up to 7 days late, without the need for further evidence that she is not pregnant. Some women return even later for their repeat injection, however. Providers can use Further Options to Assess for Pregnancy (see p. 370) if a user of monthly injectables is more than 7 days late for her repeat injection.

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