Pretreatment counseling keeps patients on Depo
What is the best way to make sure your patients stay on Depo Provera? Make sure they understand the common side effects associated with the method before they get their first shot, say family planners.
The Essentials of Contraceptive Technology, a new international handbook published by the Johns Hopkins Population Information Program of Baltimore, says common side effects associated with Depo Provera (depo medroxyprogesterone, or DMPA), include changes in menstrual bleeding, such as light spotting and bleeding, most often experienced in the first months of use; and amenorrhea, which may take place after the first year of use.1 (The December 1995 issue of Contraceptive Technology Update, pp. 145-148, explains how some family planners manage irregular bleeding, the leading DMPA side effect.) Use of the injectable progestin also may cause an average annual weight gain of two to four pounds.
While pretreatment counseling enhances the compliance rate of any contraceptive choice, it’s especially important with a long-acting method such as DMPA, says Mitchell Creinin, MD, assistant professor and director of family planning at the University of Pittsburgh.
"Very few people outside of academic centers realize or talk to their patients about [the fact] that even though we’re talking about contraception for three months, we’re talking about a hormone that is going to be in the patient’s body for six to nine months," Creinin notes. "So these problems can persist, even though contraceptive protection has dissipated. Part of handling all this is upfront preparation."
Pretreatment counseling on expected side effects does increase the acceptability of Depo-Provera, a study of 421 Chinese women reveals.2 Women in one group received detailed pretreatment information, as well as ongoing counseling during the study, with those in another group receiving only routine counseling. At one year, total cumulative termination rates were 11% for the women in the pretreatment counseling group, compared with a 42% discontinuation rate for those receiving only routine counseling.
When it comes to weight, even five extra pounds can become a stumbling stone in DMPA continuation, especially with adolescents, says Katherine Jensen, CNM, a nurse midwife in private practice with Roseburg (OR) Women’s Health Center. Jensen currently sees about 120 DMPA patients a year.
Jensen is very carefully to counsel about weight when she reviews contraceptive options with her patients. Even though she does not see the weight gain as significant in general for DMPA, it is one of the loudest complaints.
Jensen teaches patients to recognize that the progestin injection may increase their appetite, and she takes time to review healthy eating choices.
"I tell patients, You have a choice whether or not you are going to pay attention to that [feeling of hunger]. If it increases your appetite, and you eat more, you will gain weight. You can take a deep breath and make different choices, because I don’t think women should have to be hungry. You can make different choices about what you eat, so you don’t have to live with being hungry in the presence of this drug,’" she explains.
Women who are naturally thin and typically don’t have weight problems don’t seem to have a problem on DMPA, Jensen observes. But for those patients who have a tendency to gain easily and have problems shedding pounds, Depo can be troublesome.
Weight gain complaints are common among patients seen by JoAnn Woodward, RNC, BSN, NP, a nurse practitioner with Seaside Women’s Services in Manhattan Beach, CA. Woodward sees about 10 women a month on DMPA.
"As far as how much weight people actually gain, I don’t see that many people gain a lot of weight," she notes. "I have had some people gain three to five pounds over a year’s period, which is what we educate people to expect."
If women do gain weight, Woodward has them keep a food diary for a week or so to help them monitor their food intake.
By writing down everything they eat, patients become aware of both the amount and the kinds of food they eat, Woodward says. They learn to cut back on high-fat fast food and replace alcohol and soft drinks with water. She also questions patients about their activity level and encourages them to take advantage of walking or a number of free or low-cost fitness classes available in the area.
Patients can be prepared for weight gain, but when it comes to dealing with it, that’s another matter, Creinin observes. He addresses weight gain in pretreatment counseling and tells patients that those who exercise and watch what they eat tend not to gain weight.
(Editor’s note: Women may learn about DMPA side effects directly from the source if Pharmacia and Upjohn, manufacturer of Depo Provera, decides to use television ads recently test marketed in four U.S. cities. For details, see story, p. 127.)
References
1. Hatcher RA, Rinehart W, Blackburn R, et al. The Essentials of Contraceptive Technology. Baltimore: Johns Hopkins School of Public Health, Population Information Program; 1997.
2. Lei Z-W, Wu SC, Garceau RJ, et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception. Contraception 1996; 53:357-361.
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