Abstract
Objective
To provide guidelines for health care providers on the use of contraceptive methods
to prevent pregnancy and on the promotion of healthy sexuality.
Outcomes
Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy
rate, safety, ease of use, and side effects; the effect of cited contraceptive methods
on sexual health and general well-being; and the relative cost and availability of
cited contraceptive methods in Canada.
Evidence
Published literature was retrieved through searches of Medline and The Cochrane Database
from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception,
sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal
contraception, emergency contraception). Results were restricted to systematic reviews,
randomized control trials/controlled clinical trials, and observational studies published
in English from January 1994 to January 2015. Searches were updated on a regular basis
in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified
through searching the websites of health technology assessment and health technology-related
agencies, clinical practice guideline collections, clinical trial registries, and
national and international medical specialty societies.
Values
The quality of the evidence in this document was rated using the criteria described
in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
Chapter 8: Progestin-Only Contraception
Summary Statements
- 15.Progestin implants have failure rates as low as permanent contraception. (II-2)
- 16.The use of a progestin implant immediately postpartum and post-abortion is an effective way of decreasing repeat pregnancy in adolescents and repeat abortions. (II-2)
- 17.The most common side effect of progestin-only contraceptive methods is menstrual cycle disturbances. (II-2) Amenorrhea is very common with depot medroxyprogesterone acetate and progestin implant use. (II-2)
- 18.The use of progestins given at contraceptive doses does not appear to increase the risk of venous thromboembolism, myocardial infarction, or stroke. (II-2)
- 19.The efficacy of progestin implants or depot medroxyprogesterone acetate is not decreased in overweight and obese women. (II-2)
- 20.Early weight gain with depot medroxyprogesterone acetate use is predictive of continued weight gain. (II-2)
- 21.Depot medroxyprogesterone acetate use is associated with a delay in resumption of ovulation. (II-2)
- 22.The use of depot medroxyprogesterone acetate (DMPA) is associated with a decrease in bone mineral density. This decrease is most rapid in the first 2 years of use and appears to be largely reversible once DMPA is discontinued. (I) There is no strong evidence that the use of DMPA causes osteoporosis (II-2) or increases the risk of fracture. (II-2)
- 23.The use of progestin-only preparations has not been shown to decrease breast milk production. (I) The small amounts of steroid hormones secreted in breast milk do not have an adverse effect on infant growth and development. (II-2)
- 24.Depot medroxyprogesterone acetate use is associated with a decreased risk of endometrial and ovarian cancer. (II-2)
Recommendations
- 12.Progestin-only methods of contraception should be considered in women with medical conditions where estrogen is contraindicated or less appropriate, such as women who are recently postpartum, breastfeeding, or in smokers over age 35. (III-A)
- 13.There should be no restriction on the use of depot medroxy-progesterone acetate (DMPA), including duration of use, among women of reproductive age who are otherwise eligible to use the method. The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at regular intervals throughout the course of treatment. (III-A)
- 14.Counselling regarding menstrual cycle disturbances should be done prior to initiating a progestin-only method of contraception. (I-A)
- 15.Health care providers should inform patients of the potential effects of depot medroxyprogesterone acetate on bone mineral density and counsel them on “bone health,” including calcium and vitamin D supplementation, smoking cessation, weight-bearing exercise, and decreased alcohol and caffeine consumption. (III-A)
- 16.If prolonged and/or frequent bleeding occurs in users of progestin-only contraceptives, pregnancy, sexually transmitted infection, and genital pathology should be ruled out. (III-B)
- 17.Ectopic pregnancy should be ruled out if a pregnancy occurs in a woman using a progestin-only method of contraception. (III-A)
Key Words
Abbreviations:
BMD (bone mineral density), BMI (body mass index), CDC (Centers for Disease Control and Prevention), CHC (combined hormonal contraception), COC (combined oral contraceptives), Cu-IUD (copper intrauterine device), DMPA (depot medroxyprogesterone acetate), EC (emergency contraception), ENG (etonogestrel), HIV (human immunodeficiency virus), HMB (heavy menstrual bleeding), IM (intra-muscular), IUC (intrauterine contraceptives), LARC (long-acting reversible contraceptive), LEEP (loop electrosurgical excision procedure), LNG (levonorgestrel), LNG-EC (Levonorgestrel emergency contraception), LNG-IUS (levonorgestrel-releasing intrauterine systems), NNRTI (nuceloside/nucleotide reverse transcriptase inhibitors), NSAIDs (non-steroidal anti-inflammatory drugs), PID (pelvic inflammatory disease), POP (progestin-only pills), RCT (randomized controlled trials), SARC (short-acting reversible contraceptive), STI (sexually transmitted infections), UPA-EC (ulipristal acetate emergency contraception), UPI (unprotected intercourse), VTE (venous thromboembolism), WHO (World Health Organization)To read this article in full you will need to make a payment
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References
- Clinician satisfaction and insertion characteristics of a new applicator to insert radiopaque Implanon: an open-label, noncontrolled, multicenter trial.Contraception. 2010; 82: 243-249
- Contraceptive failure in the United States.Contraception. 2011; 83: 397-404
- The contraceptive efficacy of Implanon: a review of clinical trials and marketing experience.Eur J Contracept Reprod Health Care. 2008; 13: 4-12
- Sino-implant (II)—a levonorgestrel-releasing two-rod implant: systematic review of the randomized controlled trials.Contraception. 2010; 81: 197-201
- Effectiveness, safety and acceptability of Sino-implant (II) during the first year of use: results from Kenya and Pakistan.Contraception. 2014; 89: 197-203
- Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy.Contraception. 2010; 81: 421-426
- Preventing unintended pregnancy among young women in Kenya: prospective cohort study to offer contraceptive implants.Contraception. 2012; 86: 511-517
- Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective?.Am J Obstet Gynecol. 2014; 211: 24.e1-24.e7
- Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy.BJOG. 2012; 119: 1074-1080
- Continuation of the etonogestrel implant in women undergoing immediate postabortion placement.Obstet Gynecol. 2012; 120: 1053-1059
- Immediate postabortion initiation of levonorgestrel implants reduces the incidence of births and abortions at 2 years and beyond.Contraception. 2015; 92: 17-25
- The pharmacodynamics and efficacy of Implanon. An overview of the data.Contraception. 1998; 58: 91S-97S
- Ovarian function during the use of a single contraceptive implant: Implanon compared with Norplant.Fertil Steril. 1998; 69: 714-721
- Mechanisms that explain the contraceptive action of progestin implants for women.Contraception. 2002; 65: 21-27
- U.S. Medical eligibility criteria for contraceptive use, 2010.MMWR Recomm Rep. 2010; 59: 1-86
- Medical eligibility criteria for contraceptive use.4th ed. World Health Organization, Geneva2009
- U.S. Medical eligibility criteria for contraceptive use.MMWR Recomm Rep. 2010; 59 (Appendix I): 73
- Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis—a pilot study.Contraception. 2009; 79: 29-34
- Treatment of pelvic endometriosis with etonogestrel subdermal implant (Implanon).J Fam Plann Reprod Health Care. 2005; 31: 67-70
- The effects of implanon in the symptomatic treatment of endometriosis.J Med Association Thai. 2005; 88: S7-S10
- The efficacy of Implanon for the treatment of chronic pelvic pain associated with pelvic congestion: 1-year randomized controlled pilot study.Arch Gynecol Obstet. 2009; 280: 437-443
- The effects of Implanon on menstrual bleeding patterns.Eur J Contracept Reprod Health Care. 2008; 13: 13-28
- Safety and efficacy of a single-rod etonogestrel implant (Implanon): results from 11 international clinical trials.Fertil Steril. 2009; 91: 1646-1653
- A randomized multicenter study comparing the efficacy and bleeding pattern of a single-rod (Implanon) and a six-capsule (Norplant) hormonal contraceptive implant.Contraception. 1999; 60: 1-8
- Effect of etonogestrel implant on serum lipids, liver function tests and hemoglobin levels.Contraception. 2010; 81: 510-514
- Tolerability and clinical safety of Implanon.Eur J Contracept Reprod Health Care. 2008; 13: 29-36
- An integrated analysis of nonmenstrual adverse events with Implanon.Contraception. 1998; 58: 109S-115S
- Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception.Hum Reprod. 2000; 15: 118-122
- Ovarian cysts in users of Implanon and Jadelle subdermal contraceptive implants.Contraception. 2006; 73: 532-536
- A multicenter randomized clinical trial of one-rod etonogestrel and two-rod levonorgestrel contraceptive implants with nonrandomized copper-IUD controls: methodology and insertion data.Contraception. 2013; 87: 113-120
- Nexplanon, a radiopaque etonogestrel implant in combination with a next-generation applicator: 3-year results of a noncomparative multicenter trial.Am J Obstet Gynecol. 2012; 207: 388.e1-388.e6
- Use of the etonogestrel-releasing implant is associated with hypoactivation of the coagulation cascade.Hum Reprod. 2007; 22: 2196-2201
- A prospective study of the forearm bone density of users of etonorgestrel- and levonorgestrel-releasing contraceptive implants.Hum Reprod. 2006; 21: 466-470
- A three-year longitudinal evaluation of the forearm bone density of users of etonogestrel- and levonorgestrel-releasing contraceptive implants.Reprod Health. 2007; 4: 11
- Body composition and bone mineral density in users of the etonogestrel-releasing contraceptive implant.Arch Gynecol Obstet. 2015; 292: 1387-1391
- A life-threatening ectopic pregnancy with etonogestrel implant.Contraception. 2012; 85: 215-217
- Implanon failure in an HIV-positive woman on antiretroviral therapy resulting in two ectopic pregnancies.Int J STD AIDS. 2011; 22: 413-414
- Ectopic pregnancy with Implanon.J Fam Plann Reprod Health Care. 2007; 33: 125-126
- J Gynecol Obstet Biol Reprod (Paris). 2005; 34: 608-609
- Contraceptive failure rates of etonogestrel subdermal implants in overweight and obese women.Obstet Gynecol. 2012; 120: 21-26
- Association of body mass index with removal of etonogestrel subdermal implant.Contraception. 2013; 87: 370-374
- Progestogen-only contraceptive use among breastfeeding women: a systematic review.Contraception. 2010; 82: 17-37
- Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial.Obstet Gynecol. 2011; 117: 1114-1121
- Effects of the etonogestrel-releasing contraceptive implant (Implanon on parameters of breastfeeding compared to those of an intrauterine device.Contraception. 2000; 62: 239-246
- U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition.MMWR Recomm Rep. 2013; 62: 1-60
- The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users.Contraception. 2011; 83: 202-210
- A randomized controlled trial of treatment options for troublesome uterine bleeding in Implanon users.Hum Reprod. 2009; 24: 1852-1861
- Treatment of vaginal bleeding irregularities induced by progestin only contraceptives.Cochrane Database Syst Rev. 2013; : CD003449
- Medical eligibility for contraceptive use. Executive Summary.5th ed. World Health Organization, Geneva2015: i-xiii
Truven Health Analytics Micromedex Solutions. Implanon drug interactions. 2014; Available at: Implanon drug interactions. In Drug Interaction [Electronic version]. Retrieved from Micromedex 2.0, 2014 Truven Health Analytics Inc. Capital Health Online Library Resources. Accessed June 15, 2015.
- Etonogestrel drug interactions.Canadian Pharmacists Association, Ottowa, Ontario2014 (Available at: Etonogestrel drug interactions. In Lexi-Interact [Electronic version]. Retrieved from e-Therapeutics, Canadian Pharmacists Association 2014. Dalhousie University Libraries. Accessed June 15, 2015)
- Contraceptive failure of etonogestrel implant in patients treated with antiretrovirals including efavirenz.Contraception. 2012; 85: 425-427
- Failure of Implanon contraception in a patient taking carbamazepin for epilepsia.Arch Gynecol Obstet. 2006; 273: 255-256
- World Contraception Use 2015.United Nations, New York2015 (Available at:) (Accessed June 29, 2015)
- Contraceptive use by Canadian women of reproductive age: results of a national survey.J Obstet Gynaecol Can. 2009; 31: 627-640
- Product monograph: Depo-Provera medroxyprogesterone acetate injectable suspension, USP sterile aqueous suspension 50 mg/mL and 150 mg/mL; Depo-Provera-SC medroxyprogesterone acetate injectable suspension, house std. sterile aqueous suspension 104 mg/0.65 mL.Pfizer Canada Inc, Kirkland, Quebec2013 (Available at:) (Accessed January 19, 2016)
- Self-administration of subcutaneous depot medroxyprogesterone acetate for contraception: feasibility and acceptability.Contraception. 2012; 85: 453-457
- Long-acting reversible contraception.National Institute for Health and Care Excellence, London2014 (Available at:) (Accessed July 25, 2015)
- Structured contraceptive counseling provided by the Contraceptive CHOICE Project.Contraception. 2013; 88: 243-249
- Efficacy of contraceptive methods: a review of the literature.Eur J Contracept Reprod Health Care. 2010; 15: S19-S31
- Effectiveness of long-acting reversible contraception.N Engl J Med. 2012; 366: 1998-2007
- Timing of onset of contraceptive effectiveness in Depo-Provera users. II. Effects on ovarian function.Fertil Steril. 1998; 70: 817-820
- Long-acting injectable contraception with depot medroxyprogesterone acetate.Am J Obstet Gynecol. 1994; 170: 1543-1549
- Timing of onset of contraceptive effectiveness in Depo-Provera users: part I. Changes in cervical mucus.Fertil Steril. 1998; 69: 252-257
- A comprehensive review of injectable contraception with special emphasis on depot medroxyprogesterone acetate.Med J Aust. 1981; 1: 3-19
- Contraceptive technology.20th ed. Ardent Media, New York2011
- Progestagens and anti-progestagens for pain associated with endometriosis.Cochrane Database Syst Rev. 2012; : CD002122
- Levonorgestrel-releasing intrauterine system (Mirena) and Depot medroxyprogesterone acetate (Depoprovera) as long-term maintenance therapy for patients with moderate and severe endometriosis: a randomised controlled trial.Aust N Z J Obstet Gynaecol. 2010; 50: 273-279
- Severe hemorrhagic corpus luteum complicating anticoagulation in antiphospholipid syndrome.Lupus. 2011; 20: 523-526
- Medical eligibility criteria for contraceptive use.5th ed. World Health Organization, Geneva2015
- Contraceptive use—efficacy study utilizing medroxyprogesterone acetate administered as an intramuscular injection once every 90 days.Fertil Steril. 1973; 24: 331-339
- Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population.Fam Plann Perspect. 1996; 28: 174-178
- Menstrual bleeding patterns in untreated women and with long-acting methods of contraception. Task Force on Long-Acting Systemic Agents for Fertility Regulation.Adv Contracept. 1991; 7: 257-270
- A multicentred phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1. Contraceptive efficacy and side effects. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Special Programme of Research, Development and Research Training in Human Reproduction.Contraception. 1986; 34: 223-236
- Depot-medroxyprogesterone acetate (DMPA) and risk of endometrial cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives.Int J Cancer. 1991; 49: 186-190
- Depot medroxyprogesterone acetate contraception and the risk of breast and gynecologic cancer.J Reprod Med. 1996; 41: 419-427
- Progestagens and anti-progestagens for pain associated with endometriosis.Cochrane Database Syst Rev. 2000; : CD002122
- Progestins for symptomatic endometriosis: a critical analysis of the evidence.Fertil Steril. 1997; 68: 393-401
- ESHRE guideline: management of women with endometriosis.Hum Reprod. 2014; 29: 400-412
- Interventions for treating chronic pelvic pain in women (Cochrane Review. The Cochrane Library).John Wiley & Sons Ltd, Chichester, United Kingdom2003
- Treatment of seizures with medroxyprogesterone acetate: preliminary report.Neurology. 1984; 34: 1255-1258
- Contraception in women with epilepsy: pharmacokinetic interactions, contraceptive options, and management.Int Rev Neurobiol. 2008; 83: 113-134
- Reduced risk of pelvic inflammatory disease with injectable contraceptives.Lancet. 1985; 1: 1046
- Hormonal contraception and risk of sexually transmitted disease acquisition: results from a prospective study.Am J Obstet Gynecol. 2001; 185: 380-385
- Progestogen-only contraceptive use among women with sickle cell anemia: a systematic review.Contraception. 2006; 73: 195-204
- Effect of Depo-Provera or Microgynon on the painful crises of sickle cell anemia patients.Contraception. 1997; 56: 313-316
- Contraception for individuals with sickle cell disease: a systematic review of the literature.Contraception. 2012; 85: 527-537
- Steroid hormones for contraception in women with sickle cell disease.Cochrane Database Syst Rev. 2007; : CD006261
- Use of depot medroxyprogesterone acetate and prevalent leiomyoma in young African American women.Hum Reprod. 2015; 30: 1499-1504
- Continuation rates among injectable contraceptive users.Fam Plann Perspect. 1996; 28: 275-277
- Multinational comparative clinical trial of long-acting injectable contraceptives: norethisterone enanthate given in two dosage regimens and depot-medroxyprogesterone acetate. Final report.Contraception. 1983; 28: 1-20
- Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.Obstet Gynecol. 1998; 91: 609-614
- Depo-Provera use in an Australian metropolitan practice.Med J Aust. 1994; 160: 553-556
- Experiences of injectable contraceptive users in an urban setting.Obstet Gynecol. 1996; 88: 227-233
- Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons.Contraception. 2009; 80: 113-118
- Strategies to improve adherence and acceptability of hormonal methods of contraception.Cochrane Database Syst Rev. 2013; : CD004317
- Determining risk between Depo-Provera use and increased uterine bleeding in obese and overweight women.J Am Board Fam Pract. 2002; 15: 7-10
- Amenorrhea associated with contraception—an international study on acceptability.Contraception. 2003; 67: 1-8
- Acceptability of contraceptive-induced amenorrhea in a racially diverse group of US women.Contraception. 2007; 75: 450-453
- Pre-optic and hypothalamic neurons accumulate [3H]medroxyprogesterone acetate in male cynomolgus monkeys.Life Sci. 1986; 39: 1353-1359
- Adolescents' reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant.J Adolesc Health. 1996; 19: 118-123
- Reasons for contraceptive discontinuation in women 20-39 years old in New Zealand.Contraception. 1999; 59: 227-231
- Postpartum contraceptive use among adolescent mothers.Obstet Gynecol. 2000; 95: 770-776
- Prospective study of weight change in new adolescent users of DMPA, NET-EN, COCs, nonusers and discontinuers of hormonal contraception.Contraception. 2010; 81: 30-34
- Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive.Contraception. 2010; 81: 107-111
- A comparative study of one-year weight gain among users of medroxyprogesterone acetate, levonorgestrel implants, and oral contraceptives.Contraception. 1995; 52: 215-219
- Metabolic parameter, bleeding, and weight changes in U.S. women using progestin only contraceptives.Contraception. 1995; 51: 149-153
- Effects of DMPA on weight and blood pressure in long term acceptors.Contraception. 1999; 59: 301-303
- Weight change at 12 months in users of three progestin-only contraceptive methods.Contraception. 2013; 88: 503-508
- Progestin-only contraceptives: effects on weight.Cochrane Database Syst Rev. 2013; : CD008815
- Progestogen-only contraceptive use in obese women.Contraception. 2009; 80: 346-354
- Retrospective review of the relationship between weight change and demographic factors following initial depot medroxyprogesterone acetate injection in adolescents.Clin Ther. 2011; 33: 182-187
- Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users.Contraception. 2013; 88: 169-176
- Early weight gain related to later weight gain in adolescents on depot medroxyprogesterone acetate.Obstet Gynecol. 2011; 117: 793-797
- Dietary intake and weight gain among adolescents on depot medroxyprogesterone acetate.J Pediatr Adolesc Gynecol. 2015; 28: 139-143
- A pilot study of depot medroxyprogesterone acetate pharmacokinetics and weight gain in adolescent females.Contraception. 2014; 89: 357-360
- Depressive symptoms in users and non-users of depot medroxyprogesterone acetate.Contraception. 2000; 61: 385-390
- Mood changes in adolescents using depot-medroxyprogesterone acetate for contraception: a prospective study.J Pediatr Adolesc Gynecol. 2001; 14: 71-76
- A prospective study of adolescents who choose among levonorgestrel implant (Norplant), medroxyprogesterone acetate (Depo-Provera), or the combined oral contraceptive pill as contraception.Pediatrics. 1994; 94: 687-694
- Depressive symptoms and Depo-Provera.Contraception. 1998; 57: 237-240
- Effect of depot medroxyprogesterone acetate on postpartum depression.Contraception. 2010; 82: 174-177
- The use of hormonal contraceptive agents and mood disorders in women.J Affect Disord. 2012; 140: 92-96
- Counseling issues and management of side effects for women using depot medroxyprogesterone acetate contraception.J Reprod Med. 1996; 41: 391-400
- Return of ovulation after the cessation of depot-medroxy progesterone acetate treatment in Thai women.J Med Assoc Thai. 1980; 63: 66-69
- Return to ovulation following the use of long-acting injectable contraceptives: a comparative study.Contraception. 1985; 31: 361-366
- Is previous use of hormonal contraception associated with a detrimental effect on subsequent fecundity?.Hum Reprod. 2004; 19: 344-351
- Return of fertility after use of the injectable contraceptive Depo Provera: Up-dated data analysis.J Biosoc Sci. 1984; 16: 23-34
- Return of fertility in women discontinuing injectable contraceptives.J Obstet Gynaecol. 1986; 6: s110-s115
- A randomized controlled trial of estrogen replacement therapy in long-term users of depot medroxyprogesterone acetate.J Clin Endocrinol Metab. 2003; 88: 78-81
- A 2-year prospective study on the effects of depot medroxyprogesterone acetate on bone mass—response to estrogen and calcium therapy in individual users.Contraception. 2003; 67: 79-86
- Double-blinded randomized controlled trial of estrogen supplementation in adolescent girls who receive depot medroxyprogesterone acetate for contraception.Am J Obstet Gynecol. 2005; 192: 42-47
- Depot medroxyprogesterone acetate use after peak bone mass is associated with increased bone turnover but no decrease in bone mineral density.Fertil Steril. 2010; 93: 697-701
- Bone mineral density in young women aged 19-24 after 4-5 years of exclusive and mixed use of hormonal contraception.Contraception. 2009; 80: 128-132
- Bone density in long term users of depot medroxyprogesterone acetate.Br J Obstet Gynaecol. 1998; 105: 790-794
- Bone mineral density in women aged 40-49 years using depot-medroxyprogesterone acetate, norethisterone enanthate or combined oral contraceptives for contraception.Contraception. 2005; 71: 170-175
- Bone mineral density in adolescent and young adult women on injectable or oral contraception.Curr Opin Obstet Gynecol. 2003; 15: 353-357
- Spinal bone density in women using depot medroxyprogesterone contraception.Obstet Gynecol. 1998; 92: 569-573
- Bone mineral density in women using depot medroxyprogesterone acetate for contraception.Obstet Gynecol. 1999; 93: 233-238
- A prospective, controlled study of the effects of hormonal contraception on bone mineral density.Obstet Gynecol. 2001; 98: 576-582
- Injectable hormone contraception and bone density: results from a prospective study.Epidemiology. 2002; 13: 581-587
- Bone mineral density in a cohort of adolescent women using depot medroxyprogesterone acetate for one to two years.J Adolesc Health. 2003; 32: 257-259
- Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception.Arch Pediatr Adolesc Med. 2005; 159: 139-144
- Bone mineral density changes over two years in first-time users of depot medroxyprogesterone acetate.Fertil Steril. 2004; 82: 1580-1586
- Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls.J Adolesc Health. 2004; 35: 434-441
- Bone mineral density in adolescent females using depot medroxyprogesterone acetate.J Pediatr Adolesc Gynecol. 2004; 17: 17-21
- Bone mineral density in women aged 25-35 years receiving depot medroxyprogesterone acetate: recovery following discontinuation.Contraception. 2006; 74: 90-99
- Bone density recovery after depot medroxyprogesterone acetate injectable contraception use.Contraception. 2008; 77: 67-76
- Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections.Contraception. 2010; 81: 281-291
- Bone mineral density in adolescent females using injectable or oral contraceptives: a 24-month prospective study.Fertil Steril. 2008; 90: 2060-2067
- The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health.Contraception. 2009; 79: 167-177
- Changes in bone density with lactation.JAMA. 1993; 269: 3130-3135
- Ad Hoc DMPA Committee of the Society of Obstetricians and Gynaecologists of Canada. Canadian contraception consensus: update on depot medroxyprogesterone acetate (DMPA).J Obstet Gynaecol Can. 2006; 28: 305-313
- Bone mineral density loss and recovery during 48 months in first-time users of depot medroxyprogesterone acetate.Fertil Steril. 2006; 86: 1466-1474
- Bone status after cessation of use of injectable progestin contraceptives.Contraception. 2007; 76: 425-431
- Recovery of bone density in women who stop using medroxyprogesterone acetate.BMJ. 1994; 308: 247-248
- Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density.Contraception. 2009; 80: 7-17
- Steroidal contraceptives and bone fractures in women: evidence from observational studies.Cochrane Database Syst Rev. 2015; : CD009849
- Hormonal contraception and bone health.World Health Organization, Geneva2007 (Available at:) (Accessed January 19, 2016)
- Depot medroxyprogesterone acetate and bone mineral density in adolescents—The Black Box Warning: a position paper of the Society for Adolescent Medicine.J Adolesc Health. 2006; 39: 296-301
- An assessment tool for predicting fracture risk in postmenopausal women.Osteoporos Int. 2001; 12: 519-528
- Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities.Womens Health Issues. 2006; 16: 346-352
- The impact of lifestyle factors on stress fractures in female Army recruits.Osteoporos Int. 2001; 12: 35-42
- The effects of depot medroxyprogesterone acetate and intrauterine device use on fracture risk in Danish women.Contraception. 2008; 78: 459-464
- Use of depot medroxyprogesterone acetate and fracture risk.J Clin Endocrinol Metab. 2010; 95: 4909-4916
- Use of depot medroxyprogesterone acetate contraception and incidence of bone fracture.Obstet Gynecol. 2013; 121: 593-600
- Hormonal contraception and bone metabolism: a systematic review.Contraception. 2012; 86: 606-621
- Association between caffeine intake and bone mass among young women: potential effect modification by depot medroxyprogesterone acetate use.Osteoporos Int. 2008; 19: 519-527
- Bone mineral density in postmenarchal adolescent girls in the United States: associated biopsychosocial variables and bone turnover markers.J Adolesc Health. 2007; 40: 44-53
- Bone mineral density in a cohort of adolescents during use of norethisterone enanthate, depot-medroxyprogesterone acetate or combined oral contraceptives and after discontinuation of norethisterone enanthate.Contraception. 2009; 79: 345-349
- Predictors of higher bone mineral density loss and use of depot medroxyprogesterone acetate.Obstet Gynecol. 2010; 115: 35-40
- Relationship between weight and bone mineral density in adolescents on hormonal contraception.J Pediatr Adolesc Gynecol. 2011; 24: 35-38
- Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. Results of an international, multicenter, case-control study. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.Contraception. 1998; 57: 315-324
- The risk of deep venous thrombosis associated with injectable depot-medroxyprogesterone acetate contraceptives or a levonorgestrel intrauterine device.Arterioscler Thromb Vasc Biol. 2010; 30: 2297-2300
- Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis.BMJ. 2012; 345: e4944
- Limited knowledge on progestogen-only contraception and risk of venous thromboembolism.Acta Obstet Gynecol Scand. 2009; 88: 261-266
- Increased risk of HIV-1 transmission in pregnancy: a prospective study among African HIV-1-serodiscordant couples.AIDS. 2011; 25: 1887-1895
- Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study.Lancet Infect Dis. 2012; 12: 19-26
- Effects of hormonal contraceptive use on HIV acquisition and transmission among HIV-discordant couples.AIDS. 2013; 27: S27-S34
- Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence.Lancet Infect Dis. 2013; 13: 797-808
- Injectable and oral contraceptives and risk of HIV acquisition in women: an analysis of data from the MDP301 trial.Hum Reprod. 2014; 29: 1810-1817
- Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis.PLoS Med. 2015; 12: e1001778
- Hormonal contraceptive use and women's risk of HIV acquisition: a meta-analysis of observational studies.Lancet Infect Dis. 2015; 15: 181-189
- Long-term effect of depot medroxyprogesterone acetate on vaginal microbiota, epithelial thickness and HIV target cells.J Infect Dis. 2014; 210: 651-655
- Molecular mechanisms linking high dose medroxyprogesterone with HIV-1 risk.PLoS One. 2015; 10: e0121135
- Progestin-containing contraceptives alter expression of host defense-related genes of the endometrium and cervix.Reprod Sci. 2015; 22: 814-828
- Depot medroxyprogesterone acetate use is associated with elevated innate immune effector molecules in cervicovaginal secretions of HIV-1-uninfected women.J Acquir Immune Defic Syndr. 2015; 69: 1-10
- Hormonal contraceptive methods for women at high risk of HIV and living with HIV. 2014 Guidance statement.World Health Organization, Geneva2014
- The long-term growth and development of children exposed to Depo-Provera during pregnancy or lactation.Contraception. 1992; 45: 313-324
- Pregnancies diagnosed during Depo-Provera use.Contraception. 2002; 66: 169-172
- Pharmacokinetics of depot medroxyprogesterone acetate contraception.J Reprod Med. 1996; 41: 381-390
- Progestogen-only contraceptives during lactation: II. Infant development. World Health Organization, Task Force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development, and Research Training in Human Reproduction.Contraception. 1994; 50: 55-68
- Progestogen-only contraceptives during lactation: I. Infant growth. World Health Organization Task force for Epidemiological Research on Reproductive Health; Special Programme of Research, Development and Research Training in Human Reproduction.Contraception. 1994; 50: 35-53
- Gene regulation of UDP-galactose synthesis and transport: potential rate-limiting processes in initiation of milk production in humans.Am J Physiol Endocrinol Metab. 2012; 303: E365-E376
- ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015.Breastfeed Med. 2015; 10: 3-12
- Depot-medroxyprogesterone acetate (DMPA) and the risk of epithelial ovarian cancer.Int J Cancer. 1991; 49: 191-195
- Depot medroxyprogesterone acetate and epithelial ovarian cancer: A multicentre case-control study.BJOG. 2012; 119: 672-677
- Breast cancer and depot-medroxyprogesterone acetate. WHO Collaborative Study of Neoplasia and Steroid C.Lancet. 1991; 338: 833-838
- Depot medroxyprogesterone acetate and breast cancer. A pooled analysis of the World Health Organization and New Zealand studies.JAMA. 1995; 273: 799-804
- Absence of an effect of injectable and implantable progestin-only contraceptives on subsequent risk of breast cancer.Contraception. 2004; 69: 353-360
- Risk of breast cancer in relation to the use of injectable progestogen contraceptives and combined estrogen/progestogen contraceptives.Am J Epidemiol. 2000; 151: 396-403
- Depot-medroxyprogesterone acetate and combined oral contraceptive use and cervical neoplasia among women with oncogenic human papillomavirus infection.Am J Obstet Gynecol. 2009; 200: 489.e1-489.e8
- Depot-medroxyprogesterone acetate (DMPA) and risk of invasive adenocarcinomas and adenosquamous carcinomas of the uterine cervix.Contraception. 1995; 52: 307-312
- Cervical carcinoma in situ and use of depot-medroxyprogesterone acetate (DMPA).Contraception. 1995; 51: 25-31
- Differences in cervical cytologic and histologic findings between women using depot-medroxyprogesterone acetate and oral contraceptives.J Low Genit Tract Dis. 2011; 15: 219-223
- Steroidal contraceptives: effect on bone fractures in women.Cochrane Database Syst Rev. 2011; : CD006033
- Intramuscular gluteal injections in the increasingly obese population: retrospective study.BMJ. 2006; 332: 637-638
- Recognizing the evidence and changing practice on injection sites.Br J Nurs. 2010; 19: 1170-1174
- Intramuscular injection technique: an evidence-based approach.Nurs Stand. 2014; 29: 52-59
- Depo Now: preventing unintended pregnancies among adolescents and young adults.J Adolesc Health. 2007; 40: 22-28
- Immediate start of hormonal contraceptives for contraception.Cochrane Database Syst Rev. 2012; : CD006260
- Injectable contraception: what should the longest interval be for reinjections?.Contraception. 2008; 77: 410-414
- A comparison of mechanisms underlying disturbances of bleeding caused by spontaneous dysfunctional uterine bleeding or hormonal contraception.Hum Reprod. 1996; 11: 165-178
- Progestogen only contraception and endometrial break through bleeding.Angiogenesis. 2005; 8: 117-126
- Successful treatment of depot medroxyprogesterone acetate-related vaginal bleeding improves continuation rates in adolescents.ScientificWorldJournal. 2006; 6: 353-355
- Doxycycline in the treatment of bleeding with DMPA: a double-blinded randomized controlled trial.Contraception. 2012; 86: 224-230
- Effect of mifepristone on endometrial matrix metalloproteinase expression and leukocyte abundance in new medroxyprogesterone acetate users.Contraception. 2007; 76: 57-65
- Depo-Provera in adolescents: effects of early second injection or prior oral contraception.J Adolesc Health. 1995; 16: 379-384
- Missed hormonal contraceptives: new recommendations.J Obstet Gynaecol Can. 2008; 30 (63–77): 1050-1062
HRA Pharma. EllaOne. Paris: HRA Pharma. Available at: http://www.hra-pharma.com/index.php/en/our_products/womens_health/emergency_contraception/ellaone#. Accessed January 19, 2016.
- Pharmacokinetic interactions between depot medroxyprogesterone acetate and combination antiretroviral therapy.Fertil Steril. 2008; 90: 965-971
- Depot medroxyprogesterone acetate in combination with a twice-daily lopinavir-ritonavir-based regimen in HIV-infected women showed effective contraception and a lack of clinically significant interactions, with good safety and tolerability: results of the ACTG 5283 study.Antimicrob Agents Chemother. 2015; 59: 2094-2101
- Contraception for the HIV-positive woman: a review of interactions between hormonal contraception and antiretroviral therapy.Infect Dis Obstet Gynecol. 2012; 2012: 890160
- Influence of aminoglutethimide on the metabolism of medroxyprogesterone acetate and megestrol acetate in postmenopausal patients with advanced breast cancer.Cancer Chemother Pharmacol. 1990; 27: 101-105
- Influence of aminoglutethimide on plasma levels of medroxyprogesterone acetate.Med Oncol Tumor Pharmacother. 1990; 7: 241-247
- Contraindications to progestin-only oral contraceptive pills among reproductive-aged women.Contraception. 2012; 86: 199-203
- Ovulation-inhibiting effects of dienogest in a randomized, dose-controlled pharmacodynamic trial of healthy women.J Clin Pharmacol. 2012; 52: 1704-1713
- Product monograph. Visanne dienogest tablets 2 mg progestin.Bayer Inc., Mississauga, Ontario2015 (Available at:) (Accessed July 25, 2015)
- Clinical experience with the progestogen-only pill.Contraception. 1990; 42: 489-495
- Progestin-only pills for contraception.Cochrane Database Syst Rev. 2013; : CD007541
- Contraceptive mechanism of microdose norethindrone.Obstet Gynecol. 1973; 41: 585-594
- Effects of microdose progestogens on endogenous gonadotrophic and steroid hormones, cervical mucus properties, vaginal cytology and endometrium.Fertil Steril. 1971; 22: 424-434
- Progestin-Only Pills.in: Hatcher R.A. Trussell J. Nelson A.L. Cates W. Kowal D. MS P. Contraceptive technology. 20th ed. Ardent Media, New York2011: 237-247
- Influence of various hormonal contraceptives on sperm migration in vivo.Fertil Steril. 1971; 22: 584-603
- Effects of steroids on the in vitro forward migration of human spermatozoa.Contraception. 1981; 24: 183-194
- High progesterone levels and ciliary dysfunction—a possible cause of ectopic pregnancy.J Assist Reprod Genet. 2000; 17: 103-106
- Hormonal effects of the 300 mcg norethisterone minipill.Contraception. 1980; 21: 87-113
- Progestin-only oral contraception: a comprehensive review.Contraception. 1994; 50: S1-S195
- A comparison of the inhibition of ovulation achieved by desogestrel 75 micrograms and levonorgestrel 30 micrograms daily.Hum Reprod. 1999; 14: 982-985
- Progestin-only contraceptive pill use among women in the United States.Contraception. 2012; 86: 653-658
- Pregnane progestin contraception in systemic lupus erythematosus: a longitudinal study of 187 patients.Contraception. 2011; 83: 229-237
- Over-the-counter access to oral contraceptives as a reproductive healthcare strategy.Curr Opin Obstet Gynecol. 2013; 25: 500-505
- A comparison of progestogens or oral contraceptives and gonadotropin-releasing hormone agonists for the treatment of endometriosis: a systematic review.Expert Opin Pharmacother. 2014; 15: 767-773
- Progestogen-only contraceptive pill compared with combined oral contraceptive in the treatment of pain symptoms caused by endometriosis in patients with migraine without aura.Eur J Obstet Gynecol Reprod Biol. 2014; 179: 63-68
- Desogestrel-only contraceptive pill versus sequential contraceptive vaginal ring in the treatment of rectovaginal endometriosis infiltrating the rectum: a prospective open-label comparative study.Acta Obstet Gynecol Scand. 2014; 93: 239-247
- Positive effects of the progestin desogestrel 75 μg on migraine frequency and use of acute medication are sustained over a treatment period of 180 days.J Headache Pain. 2015; 16: 522
- Hormonal contraception in women with migraine: is progestogen-only contraception a better choice?.J Headache Pain. 2013; 14: 66
- Progestin-only contraception compared with extended combined oral contraceptive in women with migraine without aura: a retrospective pilot study.Eur J Obstet Gynecol Reprod Biol. 2014; 183: 178-182
- Progestin-only contraception prevents bone loss in postpartum breastfeeding women.Contraception. 2012; 85: 374-380
- The progestogen only pill: acceptability and continuation rates.Br J Fam Plann. 1992; 18: 47-49
- Special uses of oral contraception: emergency contraception. The progestin-only minipill.in: Health W.K. A clinical guide for contraception. Lippincott Williams and Wilkins, Philadelphia, PA2011: 158-166
- Vaginal bleeding patterns among women using one natural and eight hormonal methods of contraception.Contraception. 1988; 38: 181-206
- Side effects unrelated to disease activity and acceptability of highly effective contraceptive methods in women with systemic lupus erythematosus: a randomized, clinical trial.Contraception. 2014; 90: 147-153
- Progestogen-only contraceptives and the risk of acute myocardial infarction: a meta-analysis.J Clin Endocrinol Metab. 2011; 96: 1169-1174
- Contraceptive technology.20th ed. Ardent Media, New York2011
- Risk of idiopathic venous thromboembolism in users of progestagens alone.Lancet. 1999; 354: 1610-1611
- Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001–9.BMJ. 2011; 343: d6423
- Oral progestogen-only contraceptives and cardiovascular risk: results from the Transnational Study on Oral Contraceptives and the Health of Young Women.Eur J Contracept Reprod Health Care. 1999; 4: 67-73
- Comparative pharmacology of newer progestogens.Drugs. 1996; 51: 188-215
- A randomized controlled double-blind study of the effects on hemostasis of two progestogen-only pills containing 75 microgram desogestrel or 30 microgram levonorgestrel.Contraception. 1998; 57: 385-392
- Progestogen-only contraception in women at high risk of venous thromboembolism.Contraception. 2004; 70: 437-441
- Progestin-only contraception and venous thromboembolism.Thromb Res. 2012; 129: e257-e262
- Contraception: your questions answered.Pitman, New York NY1985
- Drug interactions between antiretrovirals and hormonal contraceptives.Expert Opin Drug Metab Toxicol. 2013; 9: 559-572
- Norethindrone drug interactions.Canadian Pharmacists Association, Ottawa, Ontario2014 (Available at: Norethindrone drug interactions. In Lexi-Interact [Electronic version]. Retrieved from e-Therapeutics, Canadian Pharmacists Association 2014. Dalhousie University Libraries. Accessed June 15, 2016)
- Effect of protease inhibitors on steady-state pharmacokinetics of oral norethindrone contraception in HIV-infected women.J Acquir Immune Defic Syndr. 2014; 65: 72-77
- The effect of protease inhibitors on the cervical mucus of HIV-positive women taking norethindrone contraception.Eur J Contracept Reprod Health Care. 2015; 20: 149-153
Article info
Publication history
Published online: March 30, 2016
No. 329 (Replaces No. 143, April 2004)Footnotes
Canadian Contraception Consensus (Part 3 of 4)
This clinical practice guideline has been prepared by the Contraception Consensus Working Group, reviewed by the Family Physicians Advisory, Aboriginal Health Initiative, Clinical Practice – Gynaecology, and the Canadian Paediatric and Adolescent Gynaecology and Obstetricians (CANPAGO) Committees, and approved by the Executive and Board of the Society of Obstetricians and Gynaecologists of Canada.
Disclosure statements have been received from all members of the committee(s).
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© 2015 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.
