title: The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland. Electronic address: dragomanm@who.int.
authors.forename: Monica V
authors.initials: MV
authors.lastname: Dragoman
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Gaffield
mesh_terms: D015519:Bone Density / Q000187:drug effects*; D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000009:adverse effects; D003692:Delayed-Action Preparations / Q000008:administration & dosage; D004715:Endometriosis / Q000150:complications; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D007273:Injections, Intramuscular; D007279:Injections, Subcutaneous; D017258:Medroxyprogesterone Acetate / Q000008:administration & dosage* / Q000009:adverse effects; D009765:Obesity / Q000150:complications; D010146:Pain / Q000139:chemically induced; D017060:Patient Satisfaction; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D015430:Weight Gain / Q000187:drug effects*; D014944:World Health Organization
chemical_list: D003271:Contraceptive Agents, Female; D003692:Delayed-Action Preparations; D017258:Medroxyprogesterone Acetate
keywords: DMPA; Depot medroxyprogesterone; Progestogen-only injectables; Safety; Subcutaneous