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Progesterone Depot Injection Counselling – OSCE Guide

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Contraceptive counselling often features in OSCEs and it’s therefore important to be familiar with the various types of contraception available. This article focuses on counselling patients about the progesterone depot injection including the common questions patients ask, the answers you’ll be expected to articulate and how best to structure the consultation.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Check the patient’s understanding of the types of contraception available.

Explore the reasons why the patient wants the progesterone depot injection.


Ideas, concerns and expectations

It is important to explore the patient’s ideasconcerns and expectations early in the consultation, as you may need to correct any misconceptions about the progesterone depot injection and address the patient’s concerns. When exploring concerns, it is important to do so in a sensitive and honest manner.

It’s also important to clarify the patient’s expectations of the progesterone depot injection because if these are unrealistic, other forms of contraception may be better able to meet their needs.

Ideas

Explore what the patient currently understands about the progesterone depot injection:

  • “Have you heard of the progesterone depot injection?”
  • “What do you already know about the progesterone depot injection?”

Concerns

Ask if the patient has any concerns about the progesterone depot injection:

  • “Is there anything that worries you about the progesterone depot injection”

Expectations

Explore the patient’s expectations of the progesterone depot injection:

  • “What are you hoping the progesterone depot injection can do for you?”
  • “Why do you think the progesterone depot injection is the best choice for you?”

What is the progesterone depot injection?

Using patient-friendly language, explain that the progesterone depot injection contains a hormone called progesterone.

“The progesterone depot injection contains a hormone called progesterone. This hormone is almost exactly the same as the natural hormone that is produced by your ovaries.” ¹


What types of depot injection are there?

The main types of depot injections available in the UK include:

  • Depo-Provera (most commonly used)
  • Sayana Press

How does the depot injection work?

Explain that the depot injection works by inhibiting ovulation, thickening cervical mucus and thinning the lining of the endometrium, making it difficult for a fertilised egg to implant. ²

“The depot injection works by preventing your ovaries from releasing an egg every month. It also causes thickening of mucus at the entrance of your womb which stops sperm from moving through it. Lastly, it thins the lining of your womb, so even if an egg is fertilised, it would not be able to implant.”


How effective is the depot injection?

Patients understandably want to know how effective contraception is and this is often a major factor in their decision as to which type of contraception they want to use. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess!

The depot injection is 99% effective. ¹

“If you have your injections at the right time, then the depot injection is 99% effective.”


Pros and cons of the depot injection

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of the progesterone depot injection.

“If it is okay with you, I’d like to tell you about the benefits and disadvantages of the depot injection, then hopefully you will have enough information to make a decision.”

Advantages of the depot injection

Long-acting contraception

“The depot injection is a long-acting contraceptive method, this means that you don’t have to think about contraception for as long as the injection lasts.”

Effective contraception

“The depot injection is 99% effective when administered correctly.”

Not associated with ovarian cysts

“Unlike some other contraceptive methods, the depot injection is not associated with ovarian cysts as it prevents ovulation.”

Less painful periods

“Your periods may become less painful.”

Useful if oestrogens can’t be taken

“The depot injection is useful if you can’t take oestrogen-containing contraceptives such as the combined oral contraceptive pill.”

Safe during breastfeeding

“The depot injection will not harm your baby if you choose to breastfeed.”

Disadvantages of the depot injection

Side effects

“To start off with, you may experience some side effects such as a headache, nausea, acne, mood changes and breast tenderness.” ¹

Change in periods

“When you take the depot injection, your periods may change. You may experience irregular, light or more frequent periods. There is also a chance that your periods may last longer and become heavier.” ¹

Protection from STIs

“Unfortunately, the depot injection does not protect you from sexually transmitted infections.”

Weight gain

“Depo-Provera and Sayana Press are associated with weight gain, especially if you are under 18 or have a high BMI before starting the depot injections.”

Fertility

“After stopping the depot injection, there can be up to a one year delay before your fertility returns and you are able to become pregnant.”

Risks of the depot injection

It is important to explain the risks of the depot injection so that the patient is aware and can make an informed decision.

Osteoporosis

“Depo-Provera or Sayana Press may cause thinning of your bones. If you are at higher risk of developing osteoporosis (long-term steroid use, family history of the condition) then we would normally advise you to choose another type of contraception.”

Breast cancer

“Research shows that there may be a very slight increase in the risk of breast cancer if you use the depot injection.”

Infection

“All injections come with a very small risk of infection. In most cases, this could be easily treated with some antibiotics.”


Contraindications of the depot injection

A patient should not have the depot injection if they: 2

  • are pregnant
  • are thinking of becoming pregnant within the next year
  • have breast cancer
  • have severe cirrhosis
  • have liver tumours
  • have a history of severe arterial disease
  • have risk factors for osteoporosis
  • are experiencing unexplained vaginal bleeding

How is the depot injection administered?

Depo-Provera

“The Depo-Provera injection is administered into the muscle, often via your buttock or the side of your thigh.”

Sayana Press

“Sayana Press is injected beneath the skin via the front of your thigh or abdomen. Some women can be taught how to administer these injections themselves at home.”

Timing

Depo-Provera and Sayana Press injections are given once every 13 weeks.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any further questions or concerns that haven’t been addressed.

Throughout the consultation you should check the patient’s understanding at regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.

It may also be useful to direct the patient to any websites or leaflets with further information.

Offer the patient time to consider their decision.

Encourage the patient to use condoms if they are not currently using contraception.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Common patient questions

Below are some common questions that patients may have regarding the depot injection. Sometimes, in an OSCE situation, they may ask you one or two questions at the end of your consultation. Having a good answer can demonstrate to the examiner that you have a solid understanding of the topic.

When can the patient start using the contraceptive injection?

The patient can start using the injection at any time of their menstrual cycle as long as they are not pregnant. However, if they start on any day other than the first five days of their period, they would need to use condoms.

What should the patient do if they want to try and become pregnant?

Patients are usually advised to omit further injections once they have decided they want to get pregnant. There can be up to a one year delay between stopping the depot injection and normal fertility resuming. Don’t forget to advise the patient on pre-pregnancy care such as folic acid and smoking cessation.

Can the patient restart depot injections after having a baby?

Patients can restart the injection after having a baby. If the injection is started after day 21 advise them to use condoms for seven days.


References

  1. Fpa.org.uk. (2018). Your guide to Contraceptive Injections [online] Available at: [LINK].
  2. Payne, J (2015). Progestogen-onlyI Injectable Contraceptives. Patient. [online] Patient.info. Available at: [LINK].

 

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