Counseling a 15-Year-Old About Depo-Provera
You should counsel this adolescent about bleeding irregularities (which occur in nearly all patients initially), potential weight gain (particularly in the first 6 months), bone density effects requiring calcium/vitamin D supplementation, and the delayed return to fertility (9-18 months), while emphasizing that pre-injection counseling significantly improves continuation rates. 1
Critical Discussion Points
Bleeding Pattern Changes (Most Important for Continuation)
- Nearly all patients experience menstrual irregularities initially 1
- Irregular bleeding typically improves over time and often progresses to amenorrhea (which is not harmful) 1, 2
- Studies demonstrate patients are more likely to continue DMPA if counseled about these effects BEFORE the first injection 1
- This is the most common reason for discontinuation, making pre-counseling essential
Weight Gain Risk
- 21% of adolescents experience "early weight gain" (>5% increase at 6 months) 1
- Early gainers at 6 months had mean BMI increase of 7.6 vs 2.3 for non-early gainers over 18 months 1
- Consider alternatives to DMPA if she has eating disorders, obesity concerns, or conditions requiring chronic corticosteroids 1
- Weight gain at 6 months strongly predicts future excessive weight gain 3
Bone Health Requirements (Adolescent-Specific Concern)
All adolescent DMPA users must be counseled to: 1
- Take 1300 mg calcium daily (food and/or supplements)
- Take 600 IU vitamin D daily
- Participate in regular weight-bearing exercise
- Avoid smoking and alcohol
The FDA black-box warning about bone mineral density exists 3, but subsequent data show substantial BMD recovery after discontinuation 3. ACOG does not recommend limiting use to 2 years or routine bone density monitoring 3, recognizing that pregnancy risks outweigh theoretical bone concerns.
Fertility Considerations
- Delayed return to fertility is typical: 9-18 months after last injection 1
- However, this delay "does not usually pose a major deterrent" for adolescent patients 1
- Emphasize this is reversible, just delayed
Practical Advantages to Highlight
- Injection every 13 weeks (can extend to 15 weeks) 1
- No daily adherence required (major advantage over pills)
- Improves dysmenorrhea 1
- Protects against iron-deficiency anemia and endometrial cancer 1
- Safe for most chronic illnesses 1
STI Protection
Emphasize that DMPA provides NO protection against STIs 3
- Condoms must be used consistently for STI prevention
- Use backup method (condoms or abstinence) for first 7 days after injection 3
When to Consider Alternatives
More strongly encourage alternatives if she has: 1
- Eating disorders
- Obesity or significant weight concerns
- Chronic corticosteroid use
- Chronic alcohol or tobacco use
- Concerns about irregular bleeding
In these situations, discuss IUDs or implants as LARC alternatives with higher continuation rates (75%+ at 1 year for IUDs 1) and fewer metabolic concerns.
Common Pitfall to Avoid
Do not require a second visit for DMPA initiation - this serves as a barrier to contraceptive care, with only 68% receiving DMPA at return visits and 7% becoming pregnant before returning 4. Provide same-day initiation when possible.
Additional Counseling Points
- Other possible side effects: headache, breast tenderness, hair loss, libido changes 3
- Recent data suggest possible increased meningioma risk with >4 years use or starting after age 31 5, though number needed to harm is 1,152 patients
- Self-administration of subcutaneous DMPA is now an option that improves continuation rates 6