How to avoid barriers for user-administered injectable contraceptives, with Jennifer Karlin, MD, PhD

Systemic barriers—including outdated regulatory language, insurance uncertainty, and lack of clinic workflows—continue to limit broader adoption of subcutaneous depot medroxyprogesterone acetate (DMPA) for user administration, according to Jennifer Karlin, MD, PhD, associate professor at the University of California, San Francisco, and co-author of a national mixed-methods study published in O & G Open.

The study previously identified a substantial gap between awareness and use of self-injected DMPA, with 74.5% of clinicians reporting awareness but only 34.8% actively prescribing it. In additional interview data, Karlin said many of the remaining barriers are not clinical, but structural.

“Other issues that come up are systemic,” Karlin said. “Right now, the FDA label for the subcutaneous version of DMPA is for provider-administered. That’s the label that it was given in 2004.”

Although off-label prescribing is routine across medicine, Karlin said the label itself creates hesitation and confusion. “That came up among many people in our survey. ‘Well, isn’t this just for provider-only administration?’ So that kind of education is really needed,” she said.

She described how this confusion can extend beyond the clinic. “The providers would prescribe the subcutaneous version for the pharmacy, and the pharmacist would then be handing it over to the patient and say, ‘But this is for provider-only administration,’” Karlin said. “And then the patient would feel confused and nervous. They were getting different information.”

Insurance coverage was another commonly cited barrier. “Some of the providers in this study said, ‘Well, I don’t even know if it’s paid for by my state Medicaid program or by the insurance or if it will take a prior approval,’” Karlin said. She noted that this concern stands in contrast to how clinicians approach other medications. “There are tons of medications that we prescribe every day that we don’t know if a particular insurance is going to cover it or not.”

Importantly, the study found a statistically significant difference in prescribing among clinics that had implemented formal workflows for subcutaneous DMPA. “Any clinic that has implemented a workflow—that is really important,” Karlin said, noting that these systems help ensure clinicians know how to prescribe the medication, pharmacists know how to dispense it, and patients receive consistent information.

“It takes leadership to make those things available so that the providers know about it, they can easily prescribe it in their electronic health record, and they know that that will go to a pharmacy and the pharmacist will dispense it,” she said. “And that it will be covered by insurance.”

Karlin emphasized that similar logistical challenges exist throughout health care but are rarely used to limit options outside of contraception. “If we’re talking about medications for high blood pressure or diabetes, we don’t say, ‘I’m worried it’s not going to be at the pharmacy,’” she said. “We don’t use those kinds of biases to limit our patients from getting options.”

Ultimately, Karlin framed expanded access to self-injected DMPA as a quality-of-care issue. “This is an option. It has been out there for a long time,” she said. “To take steps to make sure that there are workflows so that everybody who’s working inside of a clinic knows that they can actively prescribe a safe, effective medication… that helps with our quality of care across the board.”

Reference:

Chase C, An-Lin C, Creason L, Karlin J. Barriers and facilitators to expanding user-administered injectable contraceptives in the United States. O & G Open. 3(1):e141. February 2026. doi:10.1097/og9.0000000000000141