Self-administration of subcutaneous depot medroxyprogesterone acetate by adolescent women

Provision of DMPA-SC for self-administration in different practice settings during the COVID-19 pandemic: Data from providers across the United States

OBJECTIVES

Depot medroxyprogesterone acetate-subcutaneous (DMPA-SC) can be prescribed through telemedicine and self-administered, but data about availability, particularly during the COVID-19 pandemic, are limited. This study assessed changes in the availability of DMPA-SC for self-administration during the pandemic.

STUDY DESIGN

This study used survey data from a convenience sample of US providers engaged in contraceptive care and participating in a Continuing Medical Education-accredited contraceptive training (April 2020-April 2022; n = 849). Providers were recruited from across 503 clinics, including primary care and family planning clinics, public health departments, college and school-based health centers, independent abortion care clinics, and outpatient clinics in hospital settings. Measures included the availability of DMPA-SC for self-administration before and during the pandemic and the use of telemedicine. We used Poisson regression models and cluster-robust errors by clinic, adjusting for region, time of survey, and clinic size, to assess clinic availability of DMPA-SC for self-administration by practice setting.

RESULTS

Compared to the prepandemic period (4%), the availability of DMPA-SC for self-administration increased significantly during the pandemic (14%) (adjusted prevalence ratios [aPR] 3.43, 95% CI [2.43-4.85]). During the pandemic, independent abortion clinics were more likely to offer DMPA-SC for self-administration compared to primary care clinics (aPR 2.44, 95% CI [1.10-5.41]). Clinics receiving Title X funds were also more likely to provide DMPA-SC for self-administration during the pandemic compared to other clinics (aPR 2.32, 95% CI [1.57-3.43]), and more likely to offer DMPA-SC for self-administration through telemedicine (aPR 2.35, 95% CI [1.52-3.63]). Compared to the early pandemic period (April-September 2022), telemedicine access to DMPA-SC for self-administration was highest during the later pandemic time period (October 2021-April 2022) (aPR 2.10, 95% CI [1.06-4.17]).

CONCLUSIONS

The availability of DMPA-SC for self-administration significantly increased during the pandemic with differences by practice setting and Title X funding. However, overall method availability remains persistently low.

IMPLICATIONS

Despite increased availability of DMPA-SC for self-administration among US contraceptive providers during the COVID-19 pandemic, there remains a need to train providers, educate patients, and remove barriers to ensure broader availability of this method across different practice settings.

A Pilot Study of Adolescent and Young Adult Experience with Subcutaneous Depot Medroxyprogesterone Acetate

STUDY OBJECTIVE

To describe satisfaction with and preference for subcutaneous depot medroxyprogesterone acetate (DMPA-SC), along with adherence and feasibility, in adolescents and young adults (AYAs) METHODS: Survey of a sample of AYA patients who received DMPA-SC prescription and injection RESULTS: Of 108 eligible patients, 34 completed the survey, and 29 respondents received at least 1 DMPA-SC injection. The mean age was 16.9 years. Seventy-nine point three percent used it for gynecologic reasons, 27.6% for gender dysphoria, and 20.7% for contraception (multiple responses allowed); 93.1% were satisfied with DMPA-SC; 78.6% gave DMPA-SC on time; 88.9% reported that giving the injection was easy; 89.7% reported no problems with administration; 89.3% reported no problems obtaining DMPA-SC; and 76.9% plan to continue using DMPA-SC.

CONCLUSION

In this small sample of patients within a children's hospital, the overall experience with DMPA-SC was favorable. Clinicians caring for adolescents should consider including DMPA-SC in counseling when depot medroxyprogesterone acetate (DMPA) is indicated.

Clinically established biodegradable long acting injectables: An industry perspective

Long acting injectable formulations have been developed to sustain the action of drugs in the body over desired periods of time. These delivery platforms have been utilized for both systemic and local drug delivery applications. This review gives an overview of long acting injectable systems that are currently in clinical use. These products are categorized in three different groups: biodegradable polymeric systems, including microparticles and implants; micro and nanocrystal suspensions and oil-based formulations. Furthermore, the applications of these drug delivery platforms for the management of various chronic diseases are summarized. Finally, this review addresses industrial challenges regarding the development of long acting injectable formulations.

Ugandan providers' views on the acceptability of contraceptive self-injection for adolescents: a qualitative study

BACKGROUND

Self-injection of subcutaneous depot medroxyprogesterone acetate may offer greater discretion and increase access to injectable contraception, particularly for those who face challenges accessing clinic services. In particular, unmarried adolescents often encounter stigma when seeking services, and may also lack the financial means to travel to clinics on the quarterly basis that injectable contraception requires. Whether self-injection is offered to women on a wide scale basis, and to adolescents specifically, will depend in part upon the willingness of providers to train clients of diverse ages and educational backgrounds. This study explores the views of providers with regard to self-injection as an option for women and adolescents in Uganda.

METHODS

In-depth qualitative interviews were conducted with family planning providers in Gulu district, to understand their views on injectable self-injection for women, with a specific focus on unmarried adolescents ages 15 to 19 years. The in-depth interviews, which lasted up to 60 min were audio-recorded, translated and transcribed simultaneously, and analyzed using Atlas.ti software to identify key themes and common perspectives.

RESULTS

A total of 40 health care providers were interviewed with equal numbers of each type (public, NGO, and private clinics, pharmacies, and community-based health workers). While most providers were receptive to self-injection for adult women, fewer than half were supportive of adolescent self-injection. Their reservations focused on age, marital status and parity concerns around adolescent use of the injectable more broadly, and concerns about the ability of adolescents to self-inject safely.

CONCLUSIONS

Self-injection presents an opportunity to reduce the enormous burden on the public sector health system in Uganda, which is particularly compounded by the heavy reliance on injectable contraception requiring quarterly clinic visits. The results of this study reveal a level of cautious support for self-injection among providers when it comes to self-injection by adult women. With respect to adolescent clients, family planning policymakers and program implementers should design, implement, and evaluate self-injection interventions with the needs of adolescent clients uppermost in mind, recognizing that extra attention will likely be needed to reduce provider-imposed restrictions on adolescent access to this injectable delivery modality.

Interest in self-administration of subcutaneous depot medroxyprogesterone acetate in the United States

OBJECTIVE

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is a low-dose formulation of depot medroxyprogesterone acetate (DMPA) that nonmedical personnel can administer safely and effectively. We sought to determine United States women's interest in self-administration of DMPA-SC to understand whether such use can overcome barriers to contraceptive access.

STUDY DESIGN

We analyzed survey data on contraceptive attitudes collected in March-July 2011 from 1592 women at 13 family planning and six abortion clinics throughout the US. A mixed-effects logistic regression model with random site effects examined the determinants of interest in self-administering DMPA-SC.

RESULTS

Overall, 21% [95% confidence interval (CI): 19%-23%] of women reported interest in self-administration. A multivariable model found that women currently using DMPA (Adjusted Odds Ratio [AOR]=3.93, 95% CI: 2.37-6.53, p<.001) and women who previously used DMPA (AOR=1.71, 95% CI: 1.26-2.32, p<.001) were more likely to have an interest in DMPA-SC than those who never used it. Women reporting difficulty obtaining or refilling a prescription were almost twice as likely to have interest in DMPA-SC as women who reported no difficulty (AOR=1.99, 95% CI: 1.43-2.77, p<.001). Women surveyed at abortion sites were more likely to report interest in self-administration than women surveyed at family planning sites (AOR=1.55, 95% CI: 1.05-2.30, p<.05). Interest in DMPA-SC was primarily driven by a desire to eliminate unnecessary return visits to a facility for repeat injections.

CONCLUSIONS

Offering women the option to self-administer DMPA-SC at home can expand access and tailor contraceptive provision to the needs of clients, thus supporting client-centered care. To the extent that self-administration may improve contraceptive continuation, DMPA-SC can prevent unintended pregnancies among women who discontinue DMPA use because of difficulty returning for repeat injections.

IMPLICATIONS

There is substantial interest in self-administration of DMPA-SC among current DMPA users, women who have recently had an abortion and women reporting difficulty returning to a family planning provider. Offering self-administration of DMPA-SC could potentially increase contraceptive continuation, reduce unintended pregnancies and enhance reproductive autonomy among DMPA users.

Evaluating the attractiveness of the availability of injectable progestogen contraceptives at the community pharmacy setting in the United Kingdom

INTRODUCTION

Pharmacists have extended opening hours and are located in communities. Many offer sexual and reproductive health services such as emergency contraception. The opportunity to receive injectable contraception from community pharmacists would improve availability of this method and might increase uptake and continuation. A self-administered survey of women attending a large urban sexual and reproductive health clinic was undertaken to determine the acceptability of receiving contraceptive injections from a community pharmacist.

METHODS

Women aged 16-50 years attending an NHS walk-in sexual and reproductive health clinic were invited to complete questionnaires while they were waiting to attend an appointment with a clinician. Questionnaires asked women if they were current, previous or never users of the progestogen only injectable, their method of contraception and whether availability of the injectable from a local pharmacist would influence their decision to use this method.

RESULTS

Two hundred and forty questionnaires were distributed and 220 completed (92%). A total of 9% of respondents were past users of the injectable (n = 21), 4% were current users (n = 8) and the remaining 87% were never users. Of those 191 current non-users, 33% (n = 64) indicated that they would consider using this method if it was available at the pharmacy. The main perceived advantages of attending the pharmacy were quicker appointments (52%) and easier access (47%).

CONCLUSION

Provision of the injectable contraceptive from a pharmacist might make this method attractive to almost one in three women who are not currently using it. This could be a strategy to improve uptake and continuation of this method.

Injectable agents for pre-exposure prophylaxis: lessons learned from contraception to inform HIV prevention

PURPOSE OF REVIEW

Long-acting injectable (LAI) forms of preexposure prophylaxis (PrEP) are in clinical trials, generating much hope for HIV prevention. But this is not the first time that an injectable form of preventive medication has emerged: the contraceptive agent depomedroxyprogesterone acetate (DMPA) has an important precedent. DMPA's long journey, its initial reception, and ongoing implementation challenges can help inform the field of HIV prevention as we plan for approval, acceptance, and scale-up of LAI-PrEP.

RECENT FINDINGS

DMPA faced a long regulatory journey in the USA, with a lag of 25 years from initial application (1967) to approval (1992). Acceptance after introduction was rapid, but challenges hampered scale-up. Specific lessons learned include that extensive acceptability work is needed in parallel to product development. Also, low continuation rates, challenges with timing of initiation, and difficulty ensuring access for the most vulnerable populations have limited DMPA's impact. A new subcutaneous formulation presents opportunities for administration outside of clinical settings and for self-administration.

SUMMARY

Those involved in LAI-PrEP development and those who plan to be involved in its future implementation must consider these lessons and possible solutions from DMPA to ensure a successful future for this new HIV prevention modality.

The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review

CONTEXT

Depot medroxyprogesterone acetate (DMPA), a progestogen-only contraceptive injectable, has traditionally been formulated as a crystalline suspension delivered intramuscularly (IM) at a dose of 150mg/1.0mL. A new, lower dose formulation of DMPA (104mg/0.65mL) has been developed for subcutaneous administration (SC). Given its increasing global availability and public health relevance, DMPA-SC was prioritized for inclusion as a new method referenced in the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC), 5th Edition.

OBJECTIVE

This systematic review evaluated the published peer-reviewed literature regarding the safety of DMPA-SC among women with various characteristics or medical conditions. Results of this review informed the decision-making of a WHO Guideline Development Group in order to include recommendations on contraceptive eligibility within the revised MEC.

METHODS

We searched PubMed and Cochrane Library databases to identify all relevant evidence published in peer-reviewed journals regarding the safety of DMPA-SC when used by women of reproductive age, particularly those with select characteristics or conditions specified in the MEC, from inception through June 2015. The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force.

RESULTS

Fourteen studies met criteria for inclusion. Ten reported results relevant to DMPA users of varying age or with obesity, endometriosis or HIV; four compared the safety of DMPA-SC and DMPA-IM when used by general populations of healthy women. A randomized trial evaluating changes in bone mineral density among adult DMPA-SC and DMPA-IM users demonstrated no differences at 2years of follow-up. Limited evidence reported no consistent differences in weight change or bleeding patterns according to age; however, adolescents (<18years) were not included in any studies. Similar contraceptive efficacy, weight change, bleeding patterns and occurrence of other adverse effects among obese and nonobese DMPA-SC users were observed. Women with endometriosis using DMPA-SC over 6months had minimal decreases in bone mineral density, weight gain, few serious adverse events and experienced improved pain symptoms. Women living with HIV tolerated injection of DMPA-SC with rare complications. DMPA-SC and DMPA-IM also show therapeutic equivalence and similar effects on weight gain, changes in bleeding patterns and reports of other adverse effects when these different delivery systems were used by general populations of women.

CONCLUSION

Evidence for use of DMPA-SC by women with select conditions and characteristics including age, obesity, endometriosis or HIV demonstrates that this method can generally be used safely in these contexts. Further, DMPA-SC and DMPA-IM appear to be therapeutically equivalent with similar safety profiles when used by healthy women.

Hormonal and intrauterine methods for contraception for women aged 25 years and younger

BACKGROUND

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods.

OBJECTIVES

To compare the contraceptive failure (pregnancy) rates and to examine the continuation rates for hormonal and intrauterine contraception among young women aged 25 years and younger.

SEARCH METHODS

We searched until 4 August 2015 for randomized controlled trials (RCTs) that compared hormonal or intrauterine methods of contraception in women aged 25 years and younger. Computerized databases included the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS. We also searched for current trials via ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We considered RCTs in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared with another contraceptive method, for women aged 25 years and younger. The other contraceptive method could have been another intrauterine contraceptive, another hormonal contraceptive or different dose of the same method, or a non-hormonal contraceptive. Treatment duration must have been at least three months. Eligible trials had to include the primary outcome of contraceptive failure rate (pregnancy). The secondary outcome was contraceptive continuation rate.

DATA COLLECTION AND ANALYSIS

One author conducted the primary data extraction and entered the information into Review Manager. Another author performed an independent data extraction and verified the initial entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Because of disparate interventions and outcome measures, we did not conduct meta-analysis.

MAIN RESULTS

Five trials met the inclusion criteria. The studies included a total of 1503 women, with a mean of 301 participants. The trials compared the following contraceptives: combined oral contraceptive (COC) versus transdermal contraceptive patch, vaginal contraceptive ring, or levonorgestrel intrauterine system 20 µg/day (LNG-IUS 20); LNG-IUS 12 µg/day (LNG-IUS 12) versus LNG-IUS 16 µg/day (LNG-IUS 16); and LNG-IUS 20 versus the copper T380A intrauterine device (IUD). In the trials comparing two different types of methods, the study arms did not differ significantly for contraceptive efficacy or continuation. The sample sizes were small for two of those studies. The only significant outcome was that a COC group had a higher proportion of women who discontinued for 'other personal reasons' compared with the group assigned to the LNG-IUS 20 (OR 0.27, 95% CI 0.09 to 0.85), which may have little clinic relevance. The trial comparing LNG-IUS 12 versus LNG-IUS 16 showed similar efficacy over one and three years. In three trials that examined different LNG-IUS, continuation was at least 75% at 6 to 36 months.

AUTHORS' CONCLUSIONS

We considered the overall quality of evidence to be moderate to low. Limitations were due to trial design or limited reporting. Different doses in the LNG-IUS did not appear to influence efficacy over three years. In another study, continuation of the LNG-IUS appeared at least as high as that for the COC. The current evidence was insufficient to compare efficacy and continuation rates for hormonal and intrauterine contraceptive methods in women aged 25 years and younger.

Contraception and endometriosis: challenges, efficacy, and therapeutic importance

Endometriosis is a benign gynecological condition that is estimated to affect 10% of women in the general population and appears to be increasing in incidence. It is an estrogen-dependent inflammatory disease, and is primarily characterized by dysmenorrhea, deep dyspareunia, chronic pelvic pain, and variable effects on fertility. The symptoms may greatly affect quality of life, and symptom control may be the primary aim of initial management, while contraceptive effect is often secondary. It is estimated that 30%–50% of women with endometriosis have an infertility problem, so a considerable number of endometriosis sufferers will require effective, planned contraception to maximize “protection of fertility” and prevent progression of the endometriotic condition. Ideally, this contraception should also provide symptom relief and improvement of physical, mental, and social well-being. At the present time, long-term progestogens appear to be the most effective choice for meeting all of these requirements, but other options need to be considered. It is becoming increasingly recognized that hormonal contraceptive systems are necessary for prevention of disease recurrence following surgical treatment of endometriosis. The personal preferences of the woman are an integral part of the final contraceptive choice. This article discusses the advantages and disadvantages of the contraceptive options available to women with endometriosis.

Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate

OBJECTIVES

To evaluate feasibility, acceptability, continuation, and trough serum levels following self-administration of subcutaneous (sc) depot medroxyprogesterone acetate (DMPA).

STUDY DESIGN

Women presenting to a family planning clinic to initiate, restart or continue DMPA were offered study entry. Participants were randomized in a 2:1 ratio to self- or clinician administered sc DMPA 104 mg. Those randomized to self-administration were taught to self-inject and were supervised in performing the initial injection; they received printed instructions and a supply of contraceptive injections for home use. Participants randomized to clinician administration received usual care. Continued DMPA use was assessed by self-report and trough medroxyprogesterone acetate levels at 6 and 12 months.

RESULTS

Two hundred fifty women were invited to participate, and 137 (55%) enrolled. Of these, 91 were allocated to self-administration, and 90/91 were able to correctly self-administer sc DMPA. Eighty-seven percent completed follow-up. DMPA use at 1 year was 71% for the self-administration group and 63% for the clinic group (p=0.47). Uninterrupted DMPA use was 47% and 48% for the self and clinic administration groups at 1 year (p=0.70), respectively. Serum analyses confirmed similar mean DMPA levels in both groups and therapeutic trough levels in all participants.

CONCLUSIONS

Sixty-three percent of women approached were interested in trying self-administration of DMPA, even in the context of a randomized trial, and nearly all eligible for enrollment were successful at doing so. Self-administration and clinic administration resulted in similar continuation rates and similar DMPA serum levels. Self-administration of sc DMPA is feasible and may be an attractive alternative for many women.

IMPLICATIONS

Self-administration of sc DMPA is a feasible and attractive option for many women. Benefits include increased control over contraceptive measures and less time spent on contracepting behaviors. Globally, self-administration has the potential to revolutionize contraceptive uptake by increasing the number of women with access to DMPA.