1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.

2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs (see Managing Any Problems, below).

3. Give her the injection. Injection can be given up to 7 days early or late.

4. Plan for her next injection. Agree on a date for her next injection (in 4 weeks). Remind her that she should try to come on time, but she should come back no matter how late she is.

5. Every year or so, check her blood pressure if possible (see Medical Eligibility Criteria, Question 5).

6. Ask a long-term client if she has had any new health problems. Address problems as appropriate. For new health problems that may require switching methods, see below.

7. Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

If the client is less than 7 days late for a repeat injection, she can receive her next injection. No need for tests, evaluation, or a backup method.

A client who is more than 7 days late can receive her next injection if:

– She has not had sex since 7 days after she should have had her last injection, or

– She has used a backup method or has taken emergency contraceptive pills (ECPs) after any unprotected sex since 7 days after she should have had her last injection.

She will need a backup method for the first 7 days after the injection.

If the client is more than 7 days late and does not meet these criteria, additional steps can be taken to be reasonably certain she is not pregnant (see Further Options to Assess for Pregnancy).

Discuss why the client was late and solutions. If coming back on time is often a problem, discuss using a backup method when she is late for her next injection, taking ECPs, or choosing another method.

May or may not be due to the method.

Problems with side effects affect women’s satisfaction and use of injectables. They deserve the provider’s attention. If the client reports side effects, listen to her concerns, give her advice, and, if appropriate, treat.

Offer to help the client choose another method—now, if she wishes, or if problems cannot be overcome.

• Reassure her that many women using monthly injectables experience irregular bleeding. It is not harmful and usually becomes less or stops after the first few months of use.
• For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other nonsteroidal anti-inflammatory drug (NSAID), beginning when irregular bleeding starts. NSAIDs provide some relief of irregular bleeding for implants, progestin-only injectables, and IUDs, and they may also help for monthly injectables.
• If irregular bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding, below).

• Reassure her that many women using monthly injectables experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after a few months.
• For modest short-term relief, she can try 800 mg ibuprofen 3 times daily after meals for 5 days or other NSAID, beginning when heavy bleeding starts. NSAIDs provide some relief of heavy bleeding for implants, progestin only injectables, and IUDs, and they may also help for monthly injectables.
• To help prevent anemia, suggest she take iron tablets and tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).
• If heavy or prolonged bleeding continues or starts after several months of normal or no monthly bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding, below).

No monthly bleeding

Reassure her that some women using monthly injectables stop having monthly bleeding, and this not harmful. There is no need to lose blood every month. It is similar to not having monthly bleeding during pregnancy. She is not infertile. Blood is not building up inside her. (Some women are happy to be free from monthly bleeding.) 

Weight gain

Review diet and counsel as needed.

Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.

Any headaches that get worse or occur more often during use of injectables should be evaluated.

• Recommend that she wear a supportive bra (including during strenuous activity and sleep).
• Try hot or cold compresses.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever.
• Consider locally available remedies.

Consider locally available remedies.

May or may not be due to the method.

• Refer or evaluate by history and pelvic examination. Diagnose and treat as appropriate.
• She can continue using monthly injectables while her condition is being evaluated.
• If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using monthly injectables during treatment.

• Regardless of her age, a woman who develops migraine headaches, with or without aura, or whose migraine headaches become worse while using monthly injectables, should stop using injectables.
• Help her choose a method without estrogen.

Circumstances that will keep her from walking for one week or more

If she is having major surgery, or her leg is in a cast, or for other reasons she will be unable to move about for several weeks, she should:

– Tell her doctors that she is using monthly injectables.

– Stop injections one month before scheduled surgery, if possible, and use a backup method during this period.

– Restart monthly injectables 2 weeks after she can move about again. 

• Do not give the next injection.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care.

• Assess for pregnancy.
• Stop injections if pregnancy is confirmed.
• There are no known risks to a fetus conceived while a woman is using injectables (see Question 3).