Ask the client the questions below about known medical conditions. Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can start monthly injectables if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still start monthly injectables.
1. Are you breastfeeding a baby less than 6 months old?
No.
Yes - if fully or nearly fully breastfeeding: She can start 6 months after giving birth or when breast milk is no longer the baby’s main food—whichever comes first (see Fully or nearly fully breastfeeding).
If partially breastfeeding: she can start monthly injectables as soon as 6 weeks after giving birth (see Partially breastfeeding).
2. Have you had a baby in the last 3 weeks that you are not breastfeeding?
No.
Yes - she can start monthly injectables as soon as 3 weeks after childbirth (see Not breastfeeding).
3. Do you smoke 15 or more cigarettes a day?
No.
Yes - if she is 35 years of age or older and smokes more than 15 cigarettes a day, do not provide monthly injectables. Urge her to stop smoking and help her choose another method.
4. Do you have severe cirrhosis of the liver, a liver infection, or liver tumor? (Are her eyes or skin unusually yellow? [signs of jaundice])
No.
Yes - if she reports serious active liver disease (jaundice, active hepatitis, severe cirrhosis, liver tumor), do not provide monthly injectables. Help her choose a method without hormones. (If she has mild cirrhosis or gall bladder disease, she can use monthly injectables.)
5. Do you have high blood pressure?
No.
Yes - if you cannot check blood pressure and she reports a history of high blood pressure, or if she is being treated for high blood pressure, do not provide monthly injectables. Refer her for a blood pressure check if possible or help her choose another method without estrogen.
Check her blood pressure if possible:
-
If blood pressure is below 140/90 mm Hg, provide monthly
injectables.
-
If systolic blood pressure is 140 mm Hg or higher or diastolic blood pressure is 90 or higher, do not provide monthly
injectables. Help her choose a method without estrogen, but not progestin-only
injectables if systolic blood pressure is 160 or higher or diastolic pressure is 100 or higher.
(One blood pressure reading in the range of 140–159/90–99 mm Hg is not enough to diagnose high blood pressure. Provide a backup method to use until she can return for another blood pressure check, or help her choose another method now if she prefers. Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms. If blood pressure at next check is below 140/90, she can use monthly injectables.)
6. Have you had diabetes for more than 20 years or damage to your arteries, vision, kidneys, or nervous system caused by diabetes?
No.
Yes - do not provide monthly injectables. Help her choose a method without estrogen but not progestin-only injectables.
7. Have you ever had a stroke, blood clot in your legs or lungs, heart attack, or other serious heart problems?
No.
Yes -if she reports heart attack, heart disease due to blocked or narrowed arteries, or stroke, do not provide monthly injectables. Help her choose a method without estrogen but not progestin-only injectables. If she reports a current blood clot in the deep veins of the leg or in the lung (not superficial clots), help her choose a method without hormones.
8. Do you have or have you ever had breast cancer?
No.
Yes - do not provide monthly injectables. Help her choose a method without hormones.
9. Do you sometimes see a bright area of lost vision in the eye before a very bad headache (migraine aura)? Do you get throbbing, severe head pain, often on one side of the head, that can last from a few hours to several days and can cause nausea or vomiting (migraine headaches)? Such headaches are often made worse by light, noise, or moving about.
No.
Yes - if she has migraine aura at any age, do not provide monthly injectables. If she has migraine headaches without aura and is age 35 or older, do not provide monthly injectables. Help these women choose a method without estrogen. If she is under 35 and has migraine headaches without aura, she can use monthly injectables (see Identifying Migraine Headaches and Auras).
10. Are you planning major surgery that will keep you from walking for one week or more?
No.
Yes - if so, she can start monthly injectables 2 weeks after the surgery. Until she can start monthly injectables, she should use a backup method.
11. Do you have several conditions that could increase your chances of heart disease (coronary artery disease) or stroke, such as older age, smoking, high blood pressure, or diabetes?
No.
Yes - do not provide monthly injectables. Help her choose a method without estrogen, but not progestin-only injectables.
For complete classifications, see Medical Eligibility Criteria for Contraceptive Use. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.
Using Clinical Judgment in Special Cases
Usually, a woman with any of the conditions listed below should not use monthly injectables. In special circumstances, however, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use monthly injectables. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.
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Not breastfeeding and less than 3 weeks since giving birth
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Primarily breastfeeding between 6 weeks and 6 months since giving birth
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Age 35 or older and smokes more than 15 cigarettes a day
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High blood pressure (systolic blood pressure between 140 and 159 mm
-
Hg or diastolic blood pressure between 90 and 99 mm Hg)
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Controlled high blood pressure, where continuing evaluation is possible
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History of high blood pressure, where blood pressure cannot be taken (including pregnancy-related high blood pressure)
-
Severe liver disease, infection, or tumor
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Age 35 or older and has migraine headaches without aura
-
Younger than age 35 and has migraine headaches that have developed or have got worse while using monthly
injectables -
Had breast cancer more than 5 years ago, and it has not returned
-
Diabetes for more than 20 years or damage to arteries, vision, kidneys, or nervous system caused by diabetes
-
Multiple risk factors for arterial cardiovascular disease, such as older age, smoking, diabetes, and high blood pressure
Monthly Injectables for Women With HIV
-
Women who are infected with
HIV, have
AIDS, or are on antiretroviral (ARV) therapy can safely use monthly injectables.
-
Urge these women to use condoms along with monthly
injectables. Used consistently and correctly, condoms help prevent transmission of
HIV and other STIs.
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