Contraceptive Technology and Reproductive Health Series:

Injectable Contraceptives
Patient Scenarios
The following patient scenarios are to be used with Activities III and IV in the
narrative. Make copies and cut them so that each question is on an individual
strip of paper. Distribute them to the participants. An Answer Key follows.

1. A 20-year-old woman who is recently married wants to postpone her first

pregnancy for one year, so she can finish her education. She wants to
use DMPA. What information does she need to know before making a
decision about her contraceptive choice?
2. A 37-year-old woman who smokes heavily wants to use DMPA as a
method of contraception. What would be your recommendation and
why?
3. A 26-year-old woman has one child and wants to use DMPA as a method
of contraception. She has insulin dependent (Type I) diabetes. What
would be your recommendation and why?
4. A 30-year-old woman is thinking about using DMPA as a method of
contraception. Her mother was diagnosed with endometrial cancer and
she is concerned about using a hormonal method. How you would
address her concern?
5. A 37-year-old woman has four children and is considering DMPA as a
method of contraception. She has a long history of high blood pressure,
sometimes up to 190/100. What would be your advice and why?
6. A 36-year-old woman is using DMPA as a method of contraception. She
is five weeks late for her next injection. What do you do?
7. A 32-year-old woman has three children and does not want any more.
She previously used an IUD, but after three months had it removed
because she experienced severe cramping and heavy menstrual
bleeding. She also tried COCs, but stopped using them after two cycles
because she experienced headaches and nausea. A friend of hers is
using DMPA and has convinced her it is a good method. She wants to
try this method. What information does she need to know about the
method prior to making a decision?
8. A 28-year-old woman gave birth to her third child two weeks ago. She is
breastfeeding, but does not feel she can use LAM as a method of
contraception. She wants to use another method, possibly DMPA. What
would you recommend and why?
9. A 32-year-old woman has three children and is not planning to have any
more. She has prolonged and heavy menstrual periods and clinical
signs of anemia. She would like to use DMPA. What would you
recommend and why?

10. A 28-year-old woman has received counseling at a family planning

center.
As a result, she has decided that she wants to use DMPA.
She has come to your clinic today for her first injection. She is in the
middle of her menstrual cycle. What additional information will you
need? What would you do?
11. A woman presents who has been using NET-EN. You are out of
supplies but do have DMPA. What do you do?
12. A 25-year-old woman gave birth to her third child six weeks ago. She is
breastfeeding, but does not want to rely on LAM as a method of
contraception. She wants to use another method, possibly Cyclofem.
What would you recommend and why?
Contraceptive Technology and Reproductive Health Series:
Injectable Contraceptives
Patient Scenarios Answer Key
1. A 20-year-old woman who is recently married wants to postpone her first
pregnancy for one year, so she can finish her education. She wants to use
DMPA. What information does she need to know before making a decision
about her contraceptive choice?
Tell her that there may be a delay in her return to fertility of
approximately nine months after her last DMPA injection.

2. A 37-year-old woman who smokes heavily wants to use DMPA as a method of

contraception. What would be your recommendation and why?
She can use DMPA because smoking is not a contraindication for
progestin-only methods (advise her to quit smoking for general health
reasons).

3. A 26-year-old woman has one child and wants to use DMPA as a method of
contraception. She has insulin dependent (Type I) diabetes. What would be
your recommendation and why?
She can use DMPA. Insulin dependent diabetes without vascular
complications is not a contraindication. She falls under WHO Category
2, which means that some follow-up may be reasonable.

4. A 30-year-old woman is thinking about using DMPA as a method of

contraception. Her mother was diagnosed with endometrial cancer and she is
concerned about using a hormonal method. How you would address her
concern?
There is no need for her to worry. DMPA does not cause endometrial
cancer but, on the contrary, provides some protection from it.

5. A 37-year-old woman has four children and is considering DMPA as a method

of contraception. She has a long history of high blood pressure, sometimes
up to 190/100. What would be your advice and why?
According to the WHO Guidelines this falls under Category 3. It is
preferable for her to choose a method of nonhormonal contraception.
DMPA still could be used if nothing else is available or acceptable.
Careful follow-up is required.
6. A 36-year-old woman is using DMPA as a method of contraception. She is five
weeks late for her next injection. What do you do?
If you can be reasonably sure that the woman is not pregnant, give her
the next injection and advise her to use a backup method for seven
days. If you are uncertain whether or not she is pregnant, give her a
backup method and ask her to come back after menses (if
menstruating) or in three weeks to rule out pregnancy. Then, give her
the injection.

7. A 32-year-old woman has three children and does not want any more. She
previously used an IUD, but after three months had it removed because she
experienced severe cramping and heavy menstrual bleeding. She also tried
COCs, but stopped using them after two cycles because she experienced
headaches and nausea. A friend of hers is using DMPA and has convinced
her it is a good method. She wants to try this method. What information does
she need to know about the method prior to making a decision?
She must know that she will probably experience side effects with
DMPA as well. Further, she will not be able to discontinue this method
immediately if she experiences unpleasant side effects. It takes at least
three months for the hormone to be completely absorbed and
eliminated from the body.

8. A 28-year-old woman gave birth to her third child two weeks ago. She is
breastfeeding, but does not feel she can use LAM as a method of
contraception. She wants to use another method, possibly DMPA. What
would you recommend and why?
It is preferable that breastfeeding women wait six weeks after delivery to
initiate DMPA because the infants liver cannot yet adequately
metabolize the small amount of hormone received through breast milk.
Theoretically, this could have adverse effects. There is no risk of
pregnancy in the first six weeks after delivery. However, if she is
concerned, or if her return to the clinic might be delayed, suggest that
she should use a barrier method, such as a condom, until she is able to
use DMPA.

9. A 32-year-old woman has three children and is not planning to have any more.
She has prolonged and heavy menstrual periods and clinical signs of anemia.
She would like to use DMPA. What would you recommend and why?
According to the WHO Guidelines, this falls under Category 3, which
means this woman should not use DMPA unless other methods are not
available or acceptable. Potentially serious underlying conditions
should be considered and ruled out. Explain that DMPA could change
her bleeding pattern making her periods heavier, longer or irregular.
These changes can contribute to already present anemia. If she still
wants to use DMPA, careful follow-up and iron supplements are
required.

10. A 28-year-old woman has received counseling at a family planning center.

As a result, she has decided that she wants to use DMPA. She has come
to your clinic today for her first injection. She is in the middle of her menstrual
cycle. What additional information will you need? What would you do?

You should first try to establish the possibility of pregnancy by asking

questions or using a checklist. If you are then reasonably sure she is
not pregnant (for example, she did not have sexual intercourse since
her last menses), you can give her an injection. If you cant rule out
pregnancy, give her a backup method (condoms) and ask her to come
during her next menses for her first injection.

11. A woman presents who has been using NET-EN. You are out of supplies but
do have DMPA. What do you do?
She can switch from NET-EN to DMPA if only DMPA is available. Explain
the differences between NET-EN and DMPA, and advise her that once
she switches, it is preferable for her to remain on DMPA rather than
switch back to NET-EN.

12. A 25-year-old woman gave birth to her third child six weeks ago. She is
breastfeeding, but does not want to rely on LAM as a method of
contraception. She wants to use another method, possibly Cyclofem. What
would you recommend and why?
It is recommended that breastfeeding women wait six months after
delivery to initiate combined injectables. This is because they contain
estrogen, which may reduce the production of breast milk. Counsel her
on the availability of other methods such as progestin-only
contraceptives, barrier methods and IUDs. Explain that if she still wants
to use Cyclofem, she can initiate this method at six months postpartum.