When should Depo-Provera (medroxyprogesterone acetate) be discontinued in a woman with normal Bone Mineral Density (BMD) after more than 10 years of use?

From the Guidelines

Depo-Provera can be safely continued beyond age 48 in a patient with normal bone mineral density (BMD), even after more than 10 years of use. According to the American College of Obstetricians and Gynecologists (ACOG), as mentioned in the study 1, there is no mandatory age at which Depo-Provera must be discontinued. The medication can be used until natural menopause occurs, which typically happens around age 51-52.

To determine if menopause has occurred while on Depo, the injection can be stopped, and if no menses returns after 6-12 months, menopause has likely occurred. Alternatively, FSH levels can be checked just before the next scheduled injection is due; elevated levels (>30 mIU/mL) on two occasions suggest menopause. The concern about long-term Depo use primarily relates to bone density loss, but since this patient has normal BMD despite extended use, this risk appears minimal, as studies have shown that bone mineral density recovers substantially after discontinuation of DMPA 1.

Some key points to consider when continuing Depo-Provera beyond age 48 include:

• Monitoring bone health through daily intake of 1300 mg of calcium and 600 IU of vitamin D and regular weight-bearing exercise, as recommended in the study 1
• Discussing the risks and benefits of continued Depo-Provera use with the patient, including the potential for weight gain and menstrual irregularities
• Considering alternative contraceptive options if the patient experiences adverse effects or if menopause is suspected. After menopause, if hormonal contraception is no longer needed, the patient should discuss with her provider whether to transition to menopausal hormone therapy if appropriate, or discontinue hormonal treatments altogether.

From the FDA Drug Label

Medroxyprogesterone Acetate Injectable Suspension, USP should be used as a long-term birth control method (e. g. longer than 2 years) only if other birth control methods are inadequate. BMD should be evaluated when a woman needs to continue to use Medroxyprogesterone Acetate Injectable Suspension, USP long term.

The patient has been on Depo-Provera for more than 10 years and has a normal BMD. However, the label recommends that Medroxyprogesterone Acetate Injectable Suspension, USP should be used as a long-term birth control method only if other birth control methods are inadequate.

• The label does not provide a specific recommendation for discontinuation of Depo-Provera in women with normal BMD who have been using it for more than 10 years.
• It is recommended to evaluate BMD when a woman needs to continue to use Medroxyprogesterone Acetate Injectable Suspension, USP long term.
• Considering the patient's long duration of use, it would be prudent to consider alternative birth control methods and monitor BMD 2.

From the Research

Discontinuation of Depo-Provera

• The decision to discontinue Depo-Provera (DMPA) in a 48-year-old woman who has been using it for over 10 years with a normal bone mineral density (BMD) should be based on individual factors, including her overall health, medical history, and personal preferences.
• According to a study published in 2004, the FDA added a black box warning to DMPA package labeling, warning of the risk of significant bone loss and cautioning against long-term use (> 2 years) 3.
• A cross-sectional study published in 2015 found that long-term DMPA use was associated with low bone mass and osteoporosis in women who had used the method for 10 years or more, and that BMD decreased as the number of years of DMPA use increased 4.
• Another study published in 2008 found that DMPA users lost more bone mineral density than nonhormonal contraceptive users over 3 years, but that this loss was largely reversible at the spine after discontinuation 5.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have been using DMPA for more than 2 years should be counseled about the potential risks of bone loss and the importance of maintaining a healthy lifestyle, including a balanced diet and regular exercise 3.
• In terms of specific guidance on when to discontinue DMPA, the evidence suggests that women who have been using DMPA for over 10 years should consider alternative contraceptive methods, especially if they have other risk factors for osteoporosis or bone loss 4, 3, 5.

Factors to Consider

• Age: As women approach menopause, their bone density naturally decreases, and the use of DMPA may exacerbate this loss 3, 5.
• BMD: Women with a normal BMD may be able to continue using DMPA for a longer period than those with low bone mass or osteoporosis 4, 5.
• Medical history: Women with a history of osteoporosis, fractures, or other medical conditions that affect bone health may need to consider alternative contraceptive methods 3, 5.
• Lifestyle factors: Women who maintain a healthy lifestyle, including a balanced diet and regular exercise, may be able to mitigate the potential risks of bone loss associated with DMPA use 3, 5.