In 2017, the government of India introduced the DMPA aka Depo-Provera into the public health sector to reduce total fertility rate by year 2025, and since then has become one of the most widely used contraceptives in India. Here’s a look at the drug’s journey in India so far and points to take into consideration while prescribing them to patients.

Injectable contraceptives were introduced in the global market in the mid-1960s. At present, they are the fourth most commonly used method of contraception globally with the number of users rising rapidly worldwide. The most used injectable contraceptive is depot medroxyprogesterone acetate (DMPA), which was also introduced into India's public health system last year. Here’s a brief history of the injectable contraceptive era in India and DMPA.

Entry of DMPA in the Indian public health sector

The year 2017 witnessed the entry of 3 modern contraceptives into India's National Family Planning Programme, DMPA, an injectable contraceptive being one among them. Through this public mission, DMPA was to be made available free of cost in 145 districts of 7 states which have a total fertility rate of more than or equal to 3.

In parallel, the government also launched the ANTARA programme in the year 2017, which promoted the use of DMPA injection under the brand name Antara. The Antara injection was made available freely in medical colleges and district hospitals of the 10 target states of India (Maharashtra, Uttar Pradesh, Madhya Pradesh, Rajasthan, Karnataka, Haryana, West Bengal, Odisha, Delhi, and Goa).

Why DMPA for the Indian public health sector?

DMPA was introduced in an effort to control population explosion and high maternal mortality rates in India. The contraceptive has high efficacy, with five clinical trials having reported that 12 months failure rate in women taking DMPA was only 0 to 0.7. Also, the efficacy of the injectable contraceptive was far higher than those of the traditional oral birth control methods that have existed in the country so far.

A multinational randomised control trial comparing DMPA with norethisterone-enanthate showed that DMPA has a significantly lower failure rate (0.1%) when compared to norethisterone-enanthate (0.4%). Therefore, the use of DMPA was viewed as the most feasible step to control the rapidly-growing population in the country. In hindsight DMPA also seemed like a good contraceptive in a country where rural population still lacks knowledge about reproductive health and fertility.

DMPA prescriptions

Injectable Depot Medroxyprogesterone Acetate can prevent pregnancy for up to 3 months and while it does so effectively, there are many other risks associated with pushing it as the contraceptive of choice in the country.

It is therefore important that a doctor educates patients on a few basics of the DMPA to enable them to be better prepared and better equipped at reporting side effects, so as to reduce complications if any.

The mechanism of DMPA

Patients need to be educated about how DMPA works by suppressing the follicle stimulating hormone (FSH) and Luteinizing hormone (LH), thereby inhibiting ovulation, also causing thickening of cervical mucus, or by altering the endometrium for conception.

Initiating contraception via DMPA

• DMPA should be preferably given within 5 days of menstrual bleeding, if not usage of other contraceptive methods, such as spermicide or condoms should be advised to the patient.
• DMPA can be given immediately to the women who had discontinued the use of other contraceptives and can also be started after 7-days of an abortion. It can also be administered after 6 weeks of delivering a baby and is not harmful to use while breastfeeding.
• Though DMPA can be administered without any pelvic examination, it is best to take the patient’s reproductive history before prescribing the contraceptive.
• However, DMPA can be the preferred method of contraception in women who are not eligible for oestrogen-based contraceptives, but for that there are also the PoPs (progesterone only pills).

Communication pointers to discuss with patients

• Once administered, DMPA effect cannot be stopped immediately
• Menstrual cycle changes will be observed due to its direct effect on the hormones
• Fertility mostly returns only after 7-10 months
• DMPA is not effective in preventing STDs like other methods of contraception like condoms do and is also not for treating HIV or other sexually-transmitted infections
• Other side effects to warn about include, menstrual cycle disturbances, headaches, weight gain, nausea, abdominal discomfort, breast tenderness, nervousness, dizziness, depression, hair (loss/growth) on face or body, increased or decreased sex drive, decrease in bone density, allergic reactions (rare), decrease in HDL lipid values, skin rash or dark spots on the skin.

Some doctors believe that though DMPA can be highly effective and has prolonged action, more than four to five consecutive injections may not be advisable as long term use of the contraceptive has been linked with bone loss or decreased bone-mineral density. Government of India guidelines also clearly mention a few side effects like menstrual changes, erratic bleeding, amenorrhea, weight gain, and much more. Of course, the occurence/non-occurrence of side effects vary from patient to patient. Nevertheless, these have to be clearly communicated to the patient before administration.

Contraindications

Obviously DMPA cannot be used if an individual is pregnant, suspected to have breast cancer, liver disorders, undiagnosed vaginal bleeding, a known allergy to DMPA or if the patient has a current or any history of thromboembolic disorders and cerebral vascular disease. This is why taking a patient’s detailed medical history before prescribing and administering the contraceptive becomes all the more necessary.

Follow-up care

Patients should also be instructed on regular follow-ups for routine monitoring and best management of adverse events. Doctors should elaborate on the importance of follow-up and should also inform that DMPA should be received once in every three months.

DMPA may be a controversial contraceptive, but as per the World Health Organization (WHO), its benefits definitely outweigh its risks. And while the Indian government has included it in the national family planning program to control the population explosion in India, doctors should definitely play an integral role in monitoring its prescription and usage among patients.