Clinical Review

UPDATE: CONTRACEPTION

OBG Manag. 2009 August;21(8):15-26

References

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33. Sangi-Haghpeykar H, Poindexter AN, 3rd, Bateman L, Ditmore JR. Experiences of injectable contraceptive users in an urban setting. Obstet Gynecol. 1996;88:227-233.

34. Cromer BA, Berg-Kelly KS, Van Groningen JP, Seimer BS, Ruusuvaara L. Depot medroxyprogesterone acetate (Depo-Provera) and levonorgestrel (Norplant) use in adolescents among clinicians in Northern Europe and the United States. J Adolesc Health. 1998;23:74-80.

35. Sheth A, Jain U, Sharma S, et al. A randomized, double-blind study of two combined and two progestogen-only oral contraceptives. Contraception. 1982;25:243-252.

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39. Belsey EM. The association between vaginal bleeding patterns and reasons for discontinuation of contraceptive use. Contraception. 1988;38:207-225.

	Months
Study	0–3	4–6	7–9	10–12	13–15	16–18	19–21	22–24	36
DMPA
Belsey (1988)¹¹	16*	9	4	3
Hubacher (2009)³¹	21	18	14	10
ENG implant
Affandi (1998)⁶	26	19	16	16	17	18	18	18
Zheng (1999)⁸	34	22	19–22
Funk (2005)⁷	31	22	19	19	18	19	17	20
LNG-IUS
Datey (1995)³²
Total days of bleeding	9	7	6	5				5	5
Total days of spotting	10	5	5	4				4	4
Progestin-only pill
Belsey (1988)¹¹	15–18
*All values in the table represent an average number of days in a 90-day reference period.
Key: DMPA, depot medroxyprogesterone acetate; ENG implant, etonogestrel implant; LNG-IUS, levonorgestrel intrauterine system.

TABLE 4

What percentage of women taking progestin-only contraception report amenorrhea?

	Months
Study	3	6	9	12	24
DMPA
Belsey (1988)¹¹	8%	22%	39%	45%
Sangi-Haghpeykar (1996)³³	46%	53%	59%
Cromer (1998)³⁴	34%	60%
Polaneczky (1998)¹⁴	23%	40%	65%	40%
Canto (2001)¹	35%			70%
Jain (2004)¹³ (DMPA-SC)	26%	38%		55%
Hubacher (2009)³¹	12%	25%	37%	46%
ENG implant
Affandi (1998)⁶	2%	19%	25%	23%	21%
Zheng (1999)⁸	2%	19%	10%	15%
Croxatto (2000)⁹		12-20%
Funk (2005)⁷	2%	14-20%
LNG-IUS
Andersson (1994)²¹				17%
Hidalgo (2002)²⁰		44%		50%	50%
Progestin-only pill
Belsey (1988)¹¹	0%	0%	0%	0%
Sheth (1992)³⁵	3-8%			0-2%
Kovacs (1996)²⁴		5-10%
Key: DMPA, depot medroxyprogesterone acetate; ENG implant, etonogestrel implant; LNG-IUS, levonorgestrel intrauterine system.

TABLE 5

What percentage discontinue progestin-only contraception
because of a change in bleeding pattern?

	Months
Study	3	6	9	12	24	36
DMPA
Potter (1997)³⁶				43%
Sangi-Haghpeykar (1996)³³	34.1%	58%*	78%*
Davidson (1997)³⁷	31%	49%*		58%
ENG implant
Croxatto (2000)⁹						19%
Zheng (1999)⁸				4%	6.1%*	8.4%*
Affandi (1998)⁶						23%
Funk (2005)⁷					13%
LNG-IUS
Datey (1995)³²				13.8%
Luukkainen (1987)³⁸				7.5%
Andersson (1994)²¹				5.8%*	8.3%*	9.6%*
Progestin-only pill
Belsey (1988)³⁹				10%
Sheth (1982)³⁵				25%	34.5%*
Graham (1992)²⁵	18%	25%	35%*
*Percentages are cumulative across the months studied.
Key: DMPA, depot medroxyprogesterone acetate; ENG implant, etonogestrel implant; LNG-IUS, levonorgestrel intrauterine system.

PERSPECTIVE AND GUIDANCE FOR YOUR PRACTICE

The pattern of bleeding seen with the ENG implant is like the activity of the heart in atrial fibrillation: irregularly irregular. Still, most (80%) women continue to use it beyond 1 year. In fact, the discontinuation rate for the ENG implant is less than that of depot medroxyprogesterone acetate (DMPA) and progestin-only pills.

Most ENG implant users report no difficulty tolerating the associated unpredictable bleeding; it’s possible that they had unpredictable bleeding at baseline, or were drawn to the improvement in their dysmenorrhea.⁶

Importantly, unpredictable bleeding does not affect efficacy; the ENG implant remains one of the most effective long-acting reversible contraceptives. For women who can tolerate unpredictable bleeding, the ENG implant is a highly effective contraceptive option.

Injectable contraception

Approved by the FDA in 1992, DMPA (Depo-Provera) has good efficacy and long-acting protection. Disadvantages include unpredictable bleeding, weight gain, acne, depression, hair loss, and the controversial issue of decreased bone loss with prolonged use.

What are the expected changes in bleeding patterns with DMPA? Women often have unpredictable patterns, with infrequent but prolonged bleeding-spotting episodes.¹¹ The overall incidence of irregular bleeding can be as high as 70% in the first year of use.¹² Irregular bleeding decreases with continued use, to as low as 10% after the first year (TABLE 2).

Although the number of bleeding-spotting days decreases over time, women have reported as many as 10 days of irregular bleeding-spotting between 9 and 12 months of use (TABLE 3). The rates of irregular bleeding and amenorrhea are similar for the subcutaneous formulation of DMPA.¹³

DMPA is often used because of the high likelihood of amenorrhea. However, amenorrhea is not accomplished in most women in a short time. At 3 months of use, 10% to 45% of women report amenorrhea; after 1 year, the rate increases to 40% to 70% (TABLE 4). At 5 years, 80% of women report amenorrhea.¹²

A source of frustration. DMPA’s high discontinuation rate, compared with what is seen with other contraceptives, can be frustrating for patients and clinicians. Irregular bleeding is the most common reason for discontinuation. Approximately 35% of women who start DMPA discontinue it during the first 3 months of use because of irregular bleeding (TABLE 5). The cumulative discontinuation rate rises over time: At 1 year, 40% to 60% of women who started DMPA will have discontinued it because of changes in bleeding patterns (TABLE 5). Furthermore, 70% of women reporting DMPA discontinuation due to bleeding changes stopped the method after the first injection.¹⁴

Paul and colleagues conducted a telephone survey to determine the patterns of use and reasons for discontinuation among DMPA users.¹⁵ Of 252 DMPA users surveyed, 20% cited menstrual disturbances as the reason for discontinuation. These changes were equally distributed: amenorrhea, irregular bleeding, and heavy bleeding, all 6.8%.

Of approximately 7,000 women who participated in the 2002 National Survey for Family Growth, 600 had used DMPA in the past. Thirty-four percent pointed to a dislike of changes in menstrual periods as the reason for discontinuation.¹⁶

Not surprisingly, helping your patient develop realistic expectations about bleeding patterns with DMPA can decrease the discontinuation rate. Women who received repeated, structured information about DMPA were less likely to discontinue it because of menstrual disturbances (amenorrhea and irregular and heavy bleeding) than were women in a routine counseling group (OR, 0.20; 95% CI: 0.11, 0.37).¹⁷

Other investigators have reported similar findings, with a fourfold to sixfold lower likelihood of discontinuation because of bleeding changes among women who received detailed counseling about DMPA.^1,2

PERSPECTIVE AND GUIDANCE FOR YOUR PRACTICE

DMPA is effective and convenient, but unpredictable bleeding in the first year of use is not uncommon. The irregularity is similar to that seen with the ENG implant in the first 6 months of use. Thereafter, DMPA users are more likely to achieve and maintain amenorrhea, compared to ENG implant users.