[Editor’s note: Contraceptive Technology Update readers have questions, and members of the CTU Editorial Advisory Board have the answers. Commenting this month are Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville, and Sharon Schnare, RN, FNP, CNM, MSN, women’s health consultant and clinician with the Seattle King County Health Department in women’s and adolescent health care and the International District Community Health Center in Seattle. (Readers can submit questions either through the CTU web site, www.contraceptiveupdate.com; or by mailing "Ask the Experts," Contraceptive Technology Update, P.O. Box 740056, Atlanta, GA 30374.)]
Question: The time frame given for Depo Provera (depot medroxyprogesterone acetate, DMPA, Phar-macia Corp., Peapack, NJ) injections in A Pocket Guide to Managing Contraception (Bridging the Gap Foundation, 2001) is 11-13 weeks. Is there any latitude in this time frame so the drug may be given at 10 weeks? If so, is there a reference in the literature to substantiate the shorter time frame?
Kaunitz: The recommended reinjection schedule for DMPA injections is every 12 weeks or three months. Earlier reinjection (e.g., eight to 11 weeks following the prior injection) for convenience reasons is perfectly appropriate. Indeed, substantial and reassuring experience with doses and schedules higher and more frequent than 150 mg every 12 weeks exists in clinical settings, including treatment of endometrial and breast neoplasia as well as for other conditions. Clinicians and users, however, should be aware that regular administration of DMPA at intervals of fewer than 12 weeks can increase the likelihood of such side effects as increased appetite and bloating.
Schnare: The reason DMPA is given at 11-13 weeks is because this schedule provides the highest effectiveness of the contraceptive; although the contraceptive levels are maintained for up to 14 weeks in most women.1,2,3 It has been standard practice in many clinics to provide DMPA as early as 10 weeks, based on patients’ requirements or request. For example, women leaving for vacations may need to have their injection given earlier. Use of early injection has been studied. A study by Harel et al. showed that giving DMPA earlier did not affect bleeding patterns in adolescents.4
Question: I am an OB/GYN at a university student health center. Since the release of the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines on management of women with cytological abnormalities, I have continued to read articles and have been trying to decide the best course of action when caring for college women. We do have liquid Pap tests available to us. Normally, we proceed directly to colposcopy for low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion Pap tests. We have been repeating atypical squamous cells of undetermined significance (ASC-US) Paps in six months. Do you think college-aged women with ASC-US Paps should have human papillomavirus (HPV) reflex testing? Cost is always a concern for the students.
Schnare: The answer is multifaceted: 1) No, you do not need to do liquid-based reflex HPV testing on women with ASC-US; you may repeat the Pap in four months, unless the woman is at high risk for dysplasia (HIV-positive or has AIDS; previous abnormal Paps; history of cryotherapy or loop electrosurgical excision; or multiple sex partners, especially with men whose previous partners have cervical dysplasia or cancer.) Remember that women who smoke also increase their risk of cervical dysplasia — perhaps doubling their risk. 2) Research has shown that doing the reflex HPV typing is more cost-effective than repeat Paps5; however, if your students receive their care for free, but must pay for their Paps, then to the student, it is more costly. (CTU covered the new ASCCP guidelines in its article, "Improve cervical cancer screening: Review new terminology, guidelines," July 2002, p. 73. To review the guidelines, visit the ASCCP web site: www.asccp.org.)
References
1. World Health Organization. A multicentered phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: I. Contraceptive efficacy and side effects. Contraception 1986; 34:223-235.
2. World Health Organization. Multinational comparative clinical evaluation of two long-acting injectable steroids: Northisterone enanthate and medroxyprogesterone acetate. Final report. Contraception 1983; 28:1-20.
3. Speroff L, Darney PD. A Clinical Guide for Contraception. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins; 2001.
4. Harel Z, Biro FM, Kollar LM. Depo-Provera in adolescents: Effects of early second injection or prior oral contraception. J Adolesc Health 1995; 16:379-384.
5. Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of Alternative Triage Strategies for Atypical Squamous Cells of Undetermined Significance. JAMA 2002; 287:2,382-2,390.
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