DMPA Self Injection

Self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA) lets a trained patient give her own 104 mg injection every 13 weeks at home. It is a safe, high-quality self-care option that widens access, reduces clinic visits and keeps the contraceptive effect of provider-given DMPA.

Product. Medroxyprogesterone acetate 104 mg in a prefilled single-use injection system, given subcutaneously. It is the same drug and action as intramuscular DMPA: ovulation suppression, thickened cervical mucus and thin endometrium.

Effectiveness. Typical use 4 and perfect use 0.2 pregnancies in 100 women in the first year. Effectiveness depends on reinjecting on time.

Return to fertility. Delayed for four months or longer after the last dose.

Ideal candidates. Patients eligible for DMPA who want self-care, can follow a reinjection calendar, can learn the technique, and can store and dispose of the system safely.

Assessment. The intramuscular DMPA assessment applies: history, blood pressure, pregnancy exclusion and HIV test offer. Patients may self-measure blood pressure and self-test for pregnancy where supported.

Eligibility. The categories match DMPA: category 1 for BMI 30 or more, smoking, HIV, epilepsy and rifampicin use, breastfeeding from 6 weeks; category 2 under 18 or over 45 years and controlled hypertension; category 3 breastfeeding under 6 weeks, ischaemic heart disease, stroke, blood pressure 160/100 mm Hg or more, acute deep vein thrombosis, severe cirrhosis, unexplained bleeding before evaluation and past breast cancer; category 4 current breast cancer.

Selection checks. Confirm she can read the dose label and handle the device, understands the calendar and warning signs, has a safe place for storage, and has a puncture-proof container. Patients unwilling or unable to self-inject receive provider-given DMPA.

Counselling. Consent, confidentiality and absence of coercion; assent for adolescents under 18 years. Explain bleeding change, delayed fertility, condoms for infection protection, and that doses must not be shared.

Regimen.

• Medroxyprogesterone acetate 104 mg prefilled single-use injection system, subcutaneous, every 13 weeks.
• First injection: given at the facility under supervision. Later doses are given at home.
• Grace window: up to 2 weeks early and up to 4 weeks late without backup.
• Over 4 weeks late: the patient comes in. Exclude pregnancy and switch to provider-given intramuscular DMPA; use backup for 7 days.
• Start within 7 days of menses without backup; later, backup for 7 days. Switching from another hormonal method used correctly needs no overlap.

Training steps observed and rated at the first visit.

1. Check the expiry date and the packaging for damage.
2. Wash and dry hands.
3. Identify the site (abdomen or front of thigh) and clean it.
4. Shake the system for 30 seconds.
5. Activate the system.
6. Pinch the skin fold.
7. Insert the needle downward until the port touches the skin.
8. Squeeze the reservoir slowly over 5 to 7 seconds.
9. Withdraw, discard the system into a puncture-proof container without recapping.
10. Record the date and the next due date on the card or calendar.

Resupply. At the second and later visits, collect used systems, check technique, dispense 4 doses, record resupply, give a follow-up card and reinjection calendar, and provide a facility check at least once a year. Link to cancer screening and HIV testing.

Storage and waste. Keep in a cool, dry place away from children. Discard the used system at once in a puncture-proof container with a tight lid, never recapped. Return the container for disposal; household packaging goes in general waste. Returning used systems is not a condition of resupply. Trained community providers may collect containers.

Stopping or switching. Stop on request; if she prefers an injectable but not self-injection, give provider-administered DMPA.

Expected effects. These match intramuscular DMPA: bleeding changes, weight change, headache, mood swings, acne, breast tenderness, injection site reactions.

Problems specific to self-injection.

• Suspected incomplete dose or device fault: report to the facility for assessment and early review; the clinician decides whether to repeat the injection, and condoms are used meanwhile.
• Injection site pain, swelling or infection: examine, give site care and rotate sites.
• Needle-stick injury: wash, report, and provide post-exposure care.
• Missed date: up to 4 weeks late needs no backup; over 4 weeks late needs pregnancy exclusion, provider-given DMPA and backup for 7 days.

Bleeding management. Exclude gynaecological disease and pregnancy. Ibuprofen 400 to 800 mg orally three times daily with food for 7 to 14 days, maximum 2400 mg in 24 hours, avoiding it in peptic ulcer, renal impairment, severe liver disease and NSAID-sensitive asthma; or a combined oral contraceptive, one active tablet daily for 1 to 3 cycles, if oestrogen is not contraindicated and not breastfeeding under 6 months. If unacceptable, change method.

Red flags. Severe lower abdominal pain, severe headache, chest pain, calf swelling, jaundice.

Referral and escalation. Refer anyone with these warning signs or suspected pregnancy to the facility. Review technique at every resupply visit.