“Come Back Anytime”: Reasons to Return Before the Next Injection

Assure every client that she is welcome to come back any time—for example, if she has problems, questions, or wants another method; if she has a major change in health status; or if she thinks she might be pregnant.

General health advice: Anyone who suddenly feels that something is seriously wrong with her health should immediately seek medical care from a nurse or doctor. Her contraceptive method is most likely not the cause of the condition, but she should tell the health worker what method she is using

Planning the Next Injection

1. Agree on a date for the client’s next injection in 3 months (13 weeks) for DMPA, or in 2 months (8 weeks) for NET-EN. Give her a paper with the date written on it (or dates, if she is self-injecting and taking home more than 1 injection device). Discuss how to remember the date of her next injection, perhaps putting it on the same date as a holiday or other event, or circling the date on a calendar.
2. Ask her to try to come on the agreed date. With DMPA, she may come up to 4 weeks after the scheduled injection date and still get an injection. With NET-EN, she may come up to 2 weeks after the scheduled injection date and still get an injection. With either DMPA or NET-EN, she can come up to 2 weeks before the scheduled injection date.
3. She should come back no matter how late she is for her next injection. See Managing Late Injections.

Repeat Injection Visits

1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything she’d like to discuss.     
2. In particular, ask if she is concerned about bleeding changes. Give her any information or help that she needs (see Managing Any Problems).
3. Give her the injection. Injection of DMPA can be given up to 4 weeks late. Injection of NET-EN can be given up to 2 weeks late. Either can be given up to 2 weeks early (See Question 14) .
4. Plan for her next injection. Agree on a date for her next injection (in 3 months for DMPA, 2 months for NET-EN). Remind her that she should try to come on that date (at the scheduled appointment, if there is one), but tell her that she should come back no matter how late she is. (See Managing Late Injections.)
5. Every year or so, check her blood pressure if possible (see Medical Eligibility Criteria, Question 3).
6. Ask long-term users of progestin-only injectables if they have had any new health problems. Address problems as appropriate. See New Problems That May Require Switching Methods.
7. Ask long-term clients about any major life changes that may affect family planning needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

Managing Late Injections

• If the client is up to 4 weeks late for a repeat injection of DMPA, or up to 2 weeks late for a repeat injection of NET-EN, she can receive her next injection. There is no need for tests, evaluation, or a backup method.
• A client who is more than 4 weeks late for DMPA or more than 2 weeks late for NET-EN can receive her next injection, if:
  • she has not had sex since 2 weeks after the scheduled date of her injection, or
  • she has used a backup method or has taken ECPs after any unprotected sex since 2 weeks after the scheduled date of her injection, or 
  • she is fully or nearly fully breastfeeding and she gave birth less than 6 months ago.

     However, in all 3 cases she will need a backup method for the first 7 days after the injection.  

• If the client is more than 4 weeks late for DMPA or more than 2 weeks late for NET-EN and she does not meet any of these three criteria, additional steps can be taken to be reasonably certain she is not pregnant (see Ruling Out Pregnancy). These steps are helpful because many women who have been using progestin-only injectables will have no monthly bleeding for at least a few months, even after discontinuation. Thus, asking her to come back during her next monthly bleeding means her next injection could be unnecessarily delayed and she may be left without contraceptive protection.
• Discuss the client’s reasons for being late for the repeat injection and explore solutions. Remind her that she should keep trying to come back every 3 months for DMPA, or every 2 months for NET-EN. If coming back on time is often a problem, discuss the option of self-injection with DMPA-SC, and discuss using a backup method when she is late for her next injection, taking ECPs, or choosing another method, such as an implant or IUD.