Long-acting contraceptives (injectable, subcutaneous implants, intrauterine devices). Injectable (long-acting) contraceptives What is the choice

Contraception, which does not require regular and constant use of contraceptive tablet forms and is designed for a long period of action, is called prolonged (from the Latin prolongus - ongoing). Interest in this method of preventing pregnancy and its use for medicinal purposes arose in the late 80s of the 20th century; today it is very popular in many countries. The effectiveness of the method is beyond doubt and, according to clinical studies, is 99-99.7%.

What is the basis of long-acting contraception?

Prolonged contraception is based on the action of exclusively progestin preparations, which are analogues of the hormone progesterone, which is produced in the ovaries. The estrogenic component, which often leads to disruption of metabolic processes, is absent. This means that the likelihood of such serious side effects as hypertension and thromboembolism is reduced or completely absent. Indicated in the presence of contraindications for the use of estrogen and intrauterine device.

What choice do you have?

Modern medicine offers two types of long-acting contraceptives, differing in the method of administration to the female body:

  • subcutaneous implants;
  • injectable gestagens.

Both have the same principle of action for all gestagenic contraceptives: the receptivity of the endometrium is reduced and ovulation is suppressed, the penetration of sperm is difficult due to the thickening of cervical mucus in the cervix.

Long-term contraception with Norplant: pros and cons

Norplant is used as an implantable agent, which is capable of continuously providing pregnancy-preventive effects for 5 years. The active substance levonorgestrel is placed in a capsule (there are six in the set), from which it methodically (at a constant speed) penetrates into the blood. Externally, the capsule resembles a 34 mm long match. Norplant is transplanted surgically into the forearm area in the first 5-7 days after the onset of menstruation or immediately after an abortion. Being located on the inside, the capsules are not visible from the outside and do not cause any discomfort. Novocaine is usually used as a local anesthesia. After implantation, you need to keep the area dry for several days and avoid pressure.

The advantages include:

  1. safety;
  2. high reliability;
  3. minimum complications;
  4. disappearance of PMS and menstrual pain;
  5. uncomplicated menopause in the future;
  6. reduction of exacerbations of chronic inflammatory diseases of the female genital area, including regression of myomatous and fibrocystic nodes;
  7. reducing the risk of cancer, including endometrial cancer.

There are also disadvantages:

  1. the likelihood of slight weight gain;
  2. changes in the menstrual cycle (scanty or absent periods);
  3. bloody discharge.

These side effects gradually subside without causing harm to health. At the end of the five-year period, the capsules are removed by a doctor.

The method is aimed at women under 40 who are firmly convinced that they are not planning a child in the next few years.

Long-acting drug Depo-Provera: pros and cons

Prolonged contraception by intramuscular injection of depot medroxyprogesterone acetate is a good alternative to estrogen-containing forms. The drug should be administered at a dose of 150 mg, observing a three-month interval.

First of all, Depo-Provera is indicated for women who are breastfeeding and in the late reproductive period, as well as those at risk of developing cardiovascular complications.

Once introduced into the body, Implanon begins to release an effective contraceptive substance in small doses, which prevents the growth of eggs and their release from the ovaries. It also modifies the cervical mucus, making it thicker, which significantly impedes the movement of sperm.

Iplanon is also a very convenient contraceptive. With its help, women can be spared the need to regularly take birth control pills. This reliable contraceptive works without failure. Implanon remains in the body for the specified period and reliably protects against unplanned pregnancy.

Implanon - a convenient means of contraception

The Implanon subcutaneous implant reliably prevents egg fertilization in 99% of women who use it. In terms of its characteristics, it is not inferior to the oral contraceptives familiar to everyone. Implanon is administered under local anesthesia under the skin of the arm. Manipulations are carried out exclusively by a doctor who is fluent in this technique.

The duration of the procedure for introducing a contraceptive is less than one minute. After its completion, a special bandage is applied to the arm, which is removed after a few hours. The subcutaneous contraceptive is also removed exclusively by a doctor through a small incision, no larger than 2 mm, using local anesthesia.

Price

Implanon costs from 8,600 to 10,500 rubles. The price for it varies depending on the size of the pharmacy markup and the region of sale.

Side effects

The installation of this contraceptive may affect the nature of menstrual flow. They become more scarce, less painful, and in some patients they disappear completely. Even breastfeeding women can use it, and it can be administered as early as four to five weeks after birth. Side effects are described in the instructions for the drug and can occur if the hormone or its dosage is incorrectly selected. Only a doctor should select Implanon or another hormonal drug.

If a woman decides to switch to another method of contraception or simply remove Implanon for some other reason, this can be done at any convenient time, even without waiting for its expiration date.

This group of contraceptives gets its name from the Latin word prolongus, which means “long-lasting, ongoing.” Unlike hormonal birth control pills, which must be taken daily, long-acting drugs are introduced into a woman’s body at once and protect against pregnancy for a period of time. long term: from three months to five years.

The most common type of long-acting contraception is the injection of the hormonal drug Depo-Provera. This procedure is popularly known as the "three-month syringe" because one injection prevents pregnancy for three months. The hormonal agent Netoen (“Net-en”) is used in the same capacity. It is an oily solution that is injected intramuscularly (into the buttock) once every 2 months. These drugs inhibit the maturation of the egg, thereby preventing pregnancy. These drugs are suitable for women over 35 years of age.

Recently, the Finnish contraceptive Norplant has become widespread. It consists of six 3.4 cm long capsules that contain special hormones. The effect of the drug is designed for 5 years; it is injected under the skin of the forearm. Contraceptive effect is that the required dose of hormones is released from the capsules every day, and ovulation does not occur. It is recommended to administer Norplant from the first to the seventh day of the menstrual cycle, after a medical abortion or 6-8 weeks after childbirth.

What are the benefits of long-acting contraception?

Long-term methods are highly effective. Their reliability is 98-99%. In the case of Norplant, pregnancy was observed in only four women out of 10 thousand using this drug. These contraceptives protect against pregnancy for a long time, without requiring any additional hassle or effort. Injections and implants (implantation of a capsule) do not affect sex life. Long-acting preparations do not contain estrogen hormones and therefore can be recommended for those women who cannot take birth control pills with estrogen components.

Unlike pills, long-acting contraceptives can be used for:

  • Chronic diseases of various systems.
  • Liver diseases.
  • Hypertension.
  • Diabetes
  • Obesity
  • Varicose veins.
  • Thrombophlebitis (inflammation of blood vessels).
  • Over the age of 35
  • During breastfeeding (but not earlier than 6-8 weeks after birth).

The use of these drugs reduces the number of inflammatory diseases of the genitourinary organs and contributes to the attenuation of chronic sexual diseases. The drugs have a therapeutic effect in certain liver diseases (incipient cirrhosis, chronic hepatitis). The ability to conceive is restored 6 months after cessation of the drug, the menstrual cycle returns to normal after 3 months.


For quotation: Kuznetsova I.V., Konovalov V.A. Long-term regimens for combined oral contraceptives in the treatment of genital endometriosis // Breast Cancer. Mother and child. 2009. No. 16. P. 1053

Combined oral contraception (COC) has existed for almost 50 years and is the most popular method of birth control, highly effective, safe, as well as a number of additional advantages that allow this group of drugs to be used not only for the purpose of protection from pregnancy, but also for the prevention and treatment of certain gynecological and extragenital diseases.

Combined oral contraception is a type of hormonal contraception that involves cyclic oral administration of drugs containing estrogens (ethinyl estradiol) and various synthetic progestogens (progestins).
The gestagenic effects of combined drugs significantly exceed the estrogenic ones. The contraceptive effect of COCs is due to the gestagenic component. The role of estrogens is to enhance the effect of progestins by increasing the expression of progesterone receptors, which allows reducing the dose of progestogen in COCs, and to control the menstrual cycle. In addition, ethinyl estradiol replaces the effects of endogenous estradiol, since the synthesis of the latter during COC use is minimal.
The medicinal properties of COCs lie in the same mechanisms that provide the contraceptive effect. Inhibition of the secretion of gonadotropic hormones of the pituitary gland, folliculogenesis and steroidogenesis in the ovaries, suppression of endometrial proliferation and mitotic activity of the myometrium, influence on the processes of intercellular and intracellular interaction - all this together provides the so-called “rest” of the reproductive system during the use of the drugs, which is extremely useful for its full functioning.
A similar state is achieved during pregnancy and lactation, when cyclic fluctuations of hormones in the reproductive system stop and the same components of “rest” are ensured.
The portrait of a woman has undergone significant changes over the past 100 years. The woman from the past had about 100 periods in her entire life, and the remaining years were during pregnancy and breast-feeding. A modern woman has 350-400 menstruation in her life. And this endless cyclical functioning of the reproductive system determines the growth of gynecological morbidity in areas of pathology dependent on hormonal fluctuations. Ovulation and fluctuations in hormone levels throughout the cycle increase the likelihood of ovarian cancer (continuous ovulation theory), the risk of anemia (menstrual blood loss), arthritis, bronchial asthma, dysmenorrhea, endometriosis, uterine fibroids and premenstrual syndrome.
It is possible to create conditions of “rest” for the reproductive system not only through pregnancy, but also using hormonal contraceptives that turn off the ovulatory function of the ovaries and inhibit cyclic processes in the reproductive system. The preventive effect of COCs has been proven by a number of studies.
Thus, a reduction in the risk of uterine cancer is observed already after 6 months of taking COCs and persists for 5-15 years after discontinuation of contraception. The use of COCs protects the ovary from the development of benign tumors and tumor-like formations, as well as carcinoma, the risk of which is reduced by 40%. The use of any combined oral contraceptives reduces the risk of developing iron deficiency anemia, which is associated with a decrease in menstrual blood loss while taking the drugs.
The beneficial therapeutic effects of COCs associated with the antiproliferative effect on the endometrium and myometrium are due to the progestogen component, the pronounced antiproliferative activity of which compensates for the effect of ethinyl estradiol. These effects are most pronounced in monophasic contraceptives, which contain a progestin with a high capacity for secretory transformation of the endometrium. Monophasic COCs are used in the treatment of simple endometrial hyperplasia; in some cases, they can be used for complex hyperplasia. The effectiveness of treatment of small forms of endometriosis with monophasic drugs containing a strong progestin is 58%.
Women with manifestations of hyperandrogenism syndrome are also advised to prescribe COCs, because At the same time, there is a decrease in the production of androgens by the ovaries. The content of a progestin with antiandrogenic properties in the drug increases the potential of COCs for the treatment of androgen-dependent dermatopathies.
In general, the benefits of taking COCs far outweigh the risks of using them. Epidemiological studies show that 5 years of COC use in women under 30 years of age increases their life expectancy.
The most commonly used regimen for taking COCs is the standard regimen, which involves the use of 21 tablets containing active substances, with 7-day breaks. During these 7 days, menstrual-like bleeding usually subsides. This bleeding is not necessary to ensure contraception; moreover, shortening this “free” gap increases the contraceptive effect, as it reduces the risk of spontaneous ovulation, especially if active pills are accidentally missed. The meaning of withdrawal bleeding is largely psychological, since it gives the woman confidence in the absence of pregnancy and imitates the correct rhythmic functioning of the reproductive system. But recently, the number of women who want to manage their menstrual cycle, rather than adapt their social, sexual life and plans to withdrawal bleeding, has been increasing. Therefore, the so-called extended or long-acting regimens, whose users take COCs for 42 days or more, up to 1-1.5 years, are becoming increasingly popular.
The basis for recommending prolonged regimens for the use of COCs is the pathogenesis of diseases that are in one way or another associated with hormonal fluctuations. Without a doubt, the task of creating a constant hormonal background is better achieved using a prolonged regimen, since with standard scheme Taking the drug on days off, estradiol levels quickly rise to the level of the early follicular phase, reflecting the immediate resumption of folliculogenesis. In the presence of a pathological condition dependent on an increase in estrogen levels or on fluctuations in the level of sex hormones, hormonal fluctuations caused by a break in taking medications adversely affect the course of the disease. On the other hand, against the background of a prolonged regimen, such effects of COCs as a decrease in menstrual blood loss, the severity of dysmenorrhea, premenstrual symptoms and other positive medicinal properties are enhanced.
Wiegratz I. et al. review 26 publications on long-acting COCs published in international journals between 1977 and 2006. Analysis of publications allowed the authors to indicate the following reasons for choosing a prolonged regimen: the need to delay menstruation; therapeutic indications ( premenstrual syndrome, polycystic ovary syndrome, endometriosis, uterine fibroids); the presence of complaints and deterioration in well-being during the 7-day hormone-free interval with the usual 21/7 schedule; menorrhagia; taking medications that reduce the effectiveness of COCs.
One of the main therapeutic indications for the use of prolonged regimens is considered to be endometriosis, a pathological condition characterized by benign growth of tissue with morphofunctional properties similar to endometrial tissue. The prevalence of endometriosis in the population of women of reproductive age reaches 10%, increasing to 25% among women with infertility and up to 80% in patients with chronic pelvic pain. The main clinical manifestations of the disease are pelvic pain, various options abnormal uterine bleeding, infertility.
The clear dependence of the symptoms of endometriosis on hormonal fluctuations during the menstrual cycle and its regression during pregnancy and after menopause allows us to substantiate the dishormonal nature of the disease. Based on this, the main principle of drug therapy for endometriosis is the suppression of estradiol secretion. For this purpose, hormonal therapy options such as synthetic progestins, antigonadotropins, and GnRH agonists will be used.
While highly effective treatments for endometriosis, all of these treatment options have side effects that reduce their tolerability and adherence to therapy. Therefore, in some cases it is considered rational to resort to well-tolerated methods of therapy, such as combined oral contraceptives. These cases include the presence of moderate or mild pelvic pain in clinical symptoms, as well as abnormal uterine bleeding.
The therapeutic effectiveness of COCs for endometriosis is determined by its gestagenic component. Progestins in COCs reduce cell proliferation and induce apoptosis in endometrioid heterotopias. Ethinyl estradiol ensures endometrial stability and at the same time potentiates the effect of progestin by increasing the concentration of intracellular progesterone receptors.
As a result of taking low-dose COCs, normal proliferative changes in the endometrium are suppressed and an inactive (devoid of proliferative activity) or atrophic endometrium is formed. The morphological and functional similarity of the endometrium and endometrial-like tissue allows us to hope for similar processes in endometrioid heterotopias.
The clinical advantages of using COCs include their good tolerability and the presence of additional positive effects useful in the treatment of patients with endometriosis. Thus, low-dose contraceptives help reduce menstrual blood loss, as well as the severity of dysmenorrhea, which increases women's adherence this method treatment. There is an opinion that endometriosis is associated with a slight increase in the likelihood of ovarian cancer and another positive effect of COCs is a reduction in this likelihood to values ​​comparable to the population. The undoubted advantage of COCs over other types of hormonal therapy for endometriosis is the possibility of long-term, many-year use. The listed properties of COCs allow us to consider them as an alternative to surgical treatment of endometriosis.
Combined oral contraceptives have a long history of use in endometriosis, but the emergence of antigonadotropins and GnRH agonists has almost completely replaced them from clinical practice. Interest in COCs has renewed with the synthesis of a new progestin - dienogest, which has additional positive properties against endometriosis and is part of the drug "Zhanin®".
Dienogest successfully combines the properties of members of the 19-nortestosterone family and progesterone derivatives, and has progestogenic and antiandrogenic effects. A feature of dienogest is its metabolic neutrality, which is especially important when planning long-term treatment. The ability of the drug to have a pronounced peripheral antiproliferative effect turned out to be clinically significant. This antiproliferative effect of dienogest involves more than a progesterone-like effect. Dienogest has the additional ability to normalize intracellular signaling systems and suppress angiogenesis, proven experimentally. Realizing its effect through gene expression, the formation of specific proteins, cytokines and growth factors, dienogest leads to an increase in the processes of apoptosis simultaneously with a decrease in the proliferative activity of endometrioid heterotopic cells.
In the practice of treating endometriosis, oral contraceptives should be recommended for daily use, without pauses or withdrawal bleeding. This recommendation is based on the following observation.
Despite the expected achievement of atrophic processes in the endometrium, with standard use of COCs, more than half of women experience proliferative or secretory transformations. This fact is difficult to interpret, given that the data obtained relate to the use of a variety of drugs, which include progestins that differ in the strength of their antigonadotropic and antiproliferative potential. However, it should be taken into account that the incomplete suppression of folliculogenesis in the ovaries owes its existence to the standard regimen of taking low-dose drugs, the active substances of which are completely eliminated from the body during a 7-day break. Based on this, prolonged regimens for taking COCs are considered appropriate from the standpoint of achieving the maximum therapeutic effect.
In a number of prospective studies of women with endometriosis and persistent dysmenorrhea (persisting despite cyclic use of oral contraceptives), a significant reduction in endometriosis symptoms was noted with daily, continuous use. Therefore, in the presence of dysmenorrhea, as the main complaint of a patient with endometriosis, a prolonged dosage regimen is optimal. Long-term use of Zhanine for 3-6 months without interruption significantly reduces the severity of pain and helps improve the quality of life of patients.
Janine is highly effective as a method of anti-relapse therapy after surgical treatment of external genital endometriosis. Sufficient relief of pain syndrome was noted with prolonged use of Zhanine. The metabolic neutrality of dienogest avoids potential side effects associated with disorders of carbohydrate and fat metabolism. The antiandrogenic activity of progestin appears to be beneficial in patients with androgen-dependent skin problems. Thus, Janine has a wide range of positive effects, which, along with its high activity against endometriosis, allows us to recommend it as the first choice among combined oral contraceptives for prolonged use.
The disadvantage of prolonged drug regimens is the occurrence of breakthrough bleeding, which reduces patient adherence to this type of therapy. According to the results of clinical studies of various COCs in a prolonged regimen (42-63 days), a slight increase in breakthrough bleeding was noted with regular withdrawal bleeding, which, as a rule, was mild and occurred during the interval in taking pills.
Overcoming this disadvantage is possible through counseling patients, during which the origin of the bleeding should be explained and the woman should be convinced that bleeding while taking COCs do not reflect the likely ineffectiveness of therapy and do not pose a threat to health. Flexible, without a fixed maximum number of days of cyclic administration, prescription of prolonged regimens, “adjusting” to the body’s reaction, is also acceptable.
Opinion about the greater effectiveness of long-acting COC regimens in risk reduction and prevention gynecological diseases established in modern literature. Long-acting contraception is a reliable method of fertility control that allows you to regulate the menstrual cycle, prevent unplanned pregnancy and protect against a number of gynecological and extragenital diseases. But if, from the standpoint of choosing a method of birth control, a woman’s desire to have or not have regular withdrawal bleeding is considered as the main criterion for preferring a standard or prolonged regimen, then when prescribing COCs with therapeutic purpose it is necessary to take into account the higher therapeutic potential of prolonged regimens and recommend their use.

Literature
1. Adamyan L.V. Genital endometriosis. Operative gynecology. Ed. V.I. Kulakova. N.Novgorod: Publishing house of NGMA, 1999.
2. Gevorkyan M.A., Manukhin I.B., Grigorova L.V., Gorbunova E. Prevention of relapse of external genital endometriosis. Gynecology 2008; 10(4): 49-51.
3. Gynecology: national guidelines. Ed. V.I. Kulakova, I.B. Manukhina, G.M. Savelyeva. M.: GEOTAR-Media, 2007.
4. Kulakov V.I., Serov V.N., Zharov E.V. Hormonal contraception and women's health. M.: ORGYN, 2006.
5. Manukhin I.B., Tumilovich L.G., Gevorkyan M.A. Clinical lectures on gynecological endocrinology. M.: Geotarmedia, 2006.
6. Prilepskaya V.N. Long-term contraception - a new approach to the solution women's problems. Gynecology 2005; 7(4): 224-226.
7. Prilepskaya V.N. and others. Guide to contraception. M.: MEDpress-inform, 2006.
8. Serov V.N., Prilepskaya V.N., Ovsyannikova T.V. Gynecological endocrinology. M.: MEDpressinform, 2004; 528 pp.
9. Anderson F.D., Hait H., Hsiu J. et al. Endometrial microstructure after long-term use of a extended-cycle oral contraceptive regimen. Contraception 2005; 71: 55-59.
10. Clarke A.K., Miller S.J. The debate regarding continuous use of oral contraceptives. Ann Pharmacoter 2001; 35: 1480-1484.
11. Gnoth C. et al. Cycle characteristics after discontinuation of oral contraceptives. Gynecol Endocrinol, 2002; 16: 307-317.
12. Halbe H.W., de Melo N.R., Bahamondes L. et al. Effucacy and acceptability of two monophasic oral contraceptives containing ethinylestradiol and either desogestrel or gestodene. Eur J Contracept Reprod Health Care 1998; 3: 113-120.
13. Ludicke F., Johannison E. et al. Effect of oral combined contraceptive containing 3 mg of drospirenone and 30 microg of ethinyl estradiol on the human endometrium. Fertil Steril 2001; 76: 102-107.
14. Moore J., Kennedy S., Prentice A. Modern combined oral contraceptives for pain associated with endometriosis (Cochrane Review). In the Cochrane Library; Oxford, Issue 1. Oxford: Update Software, 2003.
15. Pierson R. A., Archer D. E., Moreau M. et al. Ortho Evra/Evra versus oral contraceptives: follicular development and ovulation in normal cycles and after an intentional dosing error. Fertil Steril 2003; 80: 34-42.
16. Sillem M., Schneidereit R., Heither R., Mueck A.O. Continuous use of contraceptive containig drospirenone. Europ J Contracept Reprod Health Care 2003; 8: 162-169.
17. Sulak P.J., Kuehl T.J., Ortiz M., Shull B.L. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. Am J Obstet Gynecol 2002; 186: 1142-1149.
18. The Royal College of Obstetricians and Gynecologist (2000). The investigation and management of endometriosis. Guideline July, 2000.
19. Thomas S.L. Ellertsone C. Nuisanceor natural and healthy: should monthly menstruation be optional for women. Lancet 2000; 355: 922-924.desensitize mu-opioid receptors on dorsal root ganglia heurons. J Immunol 2004; 173: 594-599.
20. Wiegratz I. et al. Extended and continuous use of Yasmin to reduce menstruation. Women's Health 2006; 2(5): 705-716.


Injectable contraception (IC) is used by more than 18 million women worldwide. The composition of the IR includes long-acting progestogens, devoid of estrogenic and androgenic activity:

    depot medroxyprogesterone acetate (Tsepo-Provera),

    norsthisterone enanthate ("NET-EN"). Mechanism of contraceptive action of IR:

    suppression of ovulation (inhibitory effect on the hypothalamic-pituitary system),

    changes in the physicochemical properties of the mucus of the cervical canal (its viscosity and fibrousness increase), preventing the penetration of sperm,

    disruption of the level of enzymes “responsible” for the fertilization process,

    transformations in the endometrium that prevent implantation.

Contraceptive effectiveness of IC- 0.5-1.5 pregnancies per 100 women/years. IR usage mode: "Depo-provera-.150"- the first dose of the drug (150 mg/1 ampoule) is administered in the first 5 days of the menstrual cycle: subsequent injections are made every 12 weeks (3 months + 5 days); "NET-EN" - injections of the drug are performed once every 8 weeks (200 mg/1 ampoule). Before administering IR, shake the bottle. The drug is injected deep into the gluteal muscle. The injection area is not massaged. Fertility restoration occurs within 4-24 months after the last injection. Indications:

 inability to regularly take other hormonal medications on a daily basis if you want to increase the interval between births.

 late reproductive age (over 35 years),

 contraindications to the prescription of estrogens (a number of extragenital diseases or a history of estrogen-dependent complications),

 lactation period (6 weeks after birth),

 use as “post-abortion” contraception.

Contraindications:

    pregnancy

    pathological uterine bleeding of unknown origin,

    planning pregnancy in the near future (especially in patients aged 30 to 40 years),

    malignant diseases of the reproductive system (with the exception of endometrial cancer) and mammary glands,

    NET-EN is not acceptable during lactation. Side effects:

    menstrual irregularities (especially in the first months of contraception),

    galactorrhea,

    dizziness, headache,

    fatigue,

    irritability,

    depression,

    weight gain.

    decreased libido.

Limitations of the method:

    menstrual irregularities, especially in the first months of contraception (dysmenorrhea, acyclic uterine bleeding, oligomenorrhea, amenorrhea),

    the need for regular injections. Advantages of the method:

    high contraceptive effect,

    simplicity and confidentiality of use,

    low incidence of metabolic disorders (due to the absence of an estrogenic component),

    therapeutic effect for endometriosis. premenstrual and menopausal syndromes, dysfunctional uterine bleeding, algomenorrhea. hyperpolymenorrhea. hyperplastic processes in the endometrium. recurrent inflammatory diseases of the internal genital organs.

 injections of the drug should be carried out every 3 months (+5 days) in a medical institution.

 if you have any complaints (profuse uterine bleeding, headaches, depression, weight gain, frequent urination deserve special attention), consult a doctor,

 stop administering the drug several months before the planned pregnancy (it must be taken into account that fertility after stopping injections of the drug is restored after 4-24 months),

 in case of prolonged amenorrhea, consult a doctor to exclude pregnancy.