Depot medroxyprogesterone acetate (Depo-Provera) is a convenient option for patients who want a contraceptive that is both effective and can last for several months. But one drawback is that it requires a clinic visit for an injection.
“In many ways, Depo is like the little engine that could,” says Julia E. Kohn, PhD, MPA, an independent researcher and fellow of the Society of Family Planning.
Other than long-acting reversible contraceptives (LARC) like intrauterine devices, Depo is the only method that can last three months with an injection. “As long as you’re not afraid of needles, it’s a huge benefit — no having to do something every day. It’s really helpful to a lot of people,” explains Kohn, an adjunct associate professor at New York University Robert F. Wagner Graduate School of Public Service.
Another benefit is that the contraceptive can reduce or eliminate heavy menstrual bleeding and painful cramping. “With perfect use, it’s 99% effective at preventing pregnancy,” Kohn says. “When talking about actual use, it goes down to 94%, which still is very effective.”
The difference in its potential and actual efficacy is due to the barrier of patients having to visit a clinic every three months for the injection. This is where an option to self-administer Depo could improve access to and continuation of the contraceptive.
“People don’t always come back in time, and life gets in the way,” Kohn says. “It has a nice grace period of 12 to 15 weeks.”
But when the COVID-19 pandemic began, it was clear that the clinic visit can be a major obstacle to continuation and proper use of the injectable.
“When it came to COVID, this became a big issue,” Kohn explains. “We were trying, as family planning providers, to avoid unnecessary visits, avoid unnecessary contact, and to ensure access at a time when access was really threatened by the pandemic.”
That was when the idea of self-administration gained speed. “The option of self-administration, which had already been proven safe, feasible, and effective, all of a sudden became a little more interesting to people during the COVID pandemic,” Kohn says.
Self-administration of injectables already is common in treating diabetes and infertility. “We thought, ‘Why should birth control be any different?’” Kohn notes.
Earlier research showed that self-administered contraception was feasible, safe, and liked by patients. One large randomized, controlled trial of 400 Depo users in Texas and New Jersey showed positive results. Patients who gave themselves shots were more likely to continue using the contraceptive for one year.2
“The percent of [self-administering] people who were continuing Depo at the end of the year was 15% higher than it was for the people who had to return to the clinic for injections,” Kohn says.
About 2% of reproductive-age women in the United States use the injectable. It is possible more people would be interested in it if they did not have to return to a clinic every three months, Kohn notes. Self-administration is off-label use, but the research supports its safety and efficacy.
“After we did the study, we made sure national guidelines allowed for self-administration,” Kohn says.
Family planning providers can decide whether to prescribe patients a year of injectable Depo to self-administer until they return for their annual check-up.
There are two different versions of the contraceptive. One is an intramuscular version, and the other is a subcutaneous version. The subcutaneous version was used in the self-administration study, Kohn says.
The dosage of the intramuscular version is a little higher, and that was the first version available. But people usually believe subcutaneous injections are less painful and easier to administer. That is why investigators studied self-administration of the subcutaneous Depo.
“I want to reassure people that this has been well-established as a safe, feasible, and effective method. It’s been endorsed by not only the Society of Family Planning, but also by the Centers for Disease Control and Prevention and the World Health Organization,” Kohn says. “[R]esearch shows this can actually improve continuation, and that means it can help people who want to prevent pregnancy actually do better at preventing unintended pregnancies.”
From an equity standpoint, self-administration of Depo is more feasible for people who live in rural areas where traveling to the nearest family planning clinic or OB/GYN office could be costly or challenging.
“There are people who can’t take time off work or school to go to a doctor’s appointment every three months,” Kohn says. “There are many people who can’t afford these visits but could afford supplies and take them home to give to themselves.”
This is all about providing patients with options, and self-administration of Depo is another option that helps meet patients’ needs and preferences, Kohn says.
REFERENCES
- Kohn JE, Berlan ED, Tang JH, Beasley A. Society of Family Planning committee consensus on self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC). Contraception 2022;112:11-13.
- Kohn JE, Simons HR, Badia LD, et al. Increased 1-year continuation of DMPA among women randomized to self-administration: Results from a randomized controlled trial at Planned Parenthood. Contraception 2018;97:198-204.
Depo-Provera is a convenient option for patients who want a contraceptive that is both effective and can last for several months. But one drawback is that it requires a clinic visit for an injection. This is where an option to self-administer Depo could improve access to and continuation of the contraceptive.
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