What are the potential side effects of a depot (medroxyprogesterone acetate) shot and what diagnostic tests should be ordered in the emergency room for a patient presenting with abdominal pain, back pain, and leg pain?

From the Guidelines

Depot medroxyprogesterone acetate (DMPA) injections can cause several side effects, and for a patient presenting to the emergency room with abdominal pain, back pain, and leg pain, it is crucial to order diagnostic tests to rule out serious conditions. The potential side effects of a depot shot include irregular menstrual bleeding, weight gain, headaches, mood changes, decreased bone mineral density, and rarely blood clots that could lead to deep vein thrombosis, pulmonary embolism, or stroke. For a patient on DMPA presenting with these symptoms, the following diagnostic tests should be ordered:

• A complete blood count, comprehensive metabolic panel, urinalysis, pregnancy test, and coagulation studies.
• Imaging studies such as an abdominal ultrasound or CT scan to evaluate for intra-abdominal pathology, and Doppler ultrasound of the legs to rule out deep vein thrombosis.
• If pulmonary embolism is suspected, a CT pulmonary angiogram should be ordered.
• Additional tests may include a pelvic examination, pelvic ultrasound to evaluate for ovarian pathology or ectopic pregnancy, and spine imaging if vertebral pathology is suspected. These tests are crucial because DMPA users have a slightly increased risk of thromboembolic events, and the combination of abdominal, back, and leg pain could indicate serious conditions like DVT with possible pulmonary embolism, ectopic pregnancy, or other gynecological emergencies that require prompt diagnosis and treatment 1. Some key points to consider when evaluating a patient with low back pain include:
• Conducting a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause 1.
• Not routinely obtaining imaging or other diagnostic tests in patients with nonspecific low back pain, but considering diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination 1.
• Evaluating patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1.
• Providing patients with evidence-based information on low back pain with regard to their expected course, advising patients to remain active, and providing information about effective self-care options 1.

From the FDA Drug Label

Thromboembolic Disorders The physician should be alert to the earliest manifestations of thrombotic disorders (thrombophlebitis, pulmonary embolism, cerebrovascular disorders, and retinal thrombosis). 7 Ectopic Pregnancy Health-care providers should be alert to the possibility of an ectopic pregnancy among women using Medroxyprogesterone Acetate Injectable Suspension, USP who become pregnant or complain of severe abdominal pain. Anaphylaxis and Anaphylactoid Reaction Anaphylaxis and anaphylactoid reaction have been reported with the use of Medroxyprogesterone Acetate Injectable Suspension, USP. If an anaphylactic reaction occurs appropriate therapy should be instituted. Serious anaphylactic reactions require emergency medical treatment.

The potential side effects of a depot (medroxyprogesterone acetate) shot that may be relevant to the patient's symptoms include:

• Thromboembolic disorders: such as thrombophlebitis, pulmonary embolism, cerebrovascular disorders, and retinal thrombosis
• Ectopic pregnancy: which may cause severe abdominal pain
• Anaphylaxis and anaphylactoid reaction: which can be life-threatening

In the emergency room, the following diagnostic tests should be considered:

• Imaging studies: such as ultrasound or CT scan to rule out ectopic pregnancy or thromboembolic disorders
• Laboratory tests: such as complete blood count, blood chemistry, and coagulation studies to evaluate for anaphylaxis or thromboembolic disorders
• Physical examination: to evaluate for signs of anaphylaxis or thromboembolic disorders 2 2

From the Research

Potential Side Effects of Depot Medroxyprogesterone Acetate

• Weight gain
• Increased body fat mass
• Irregular bleeding
• Amenorrhea
• Mood or libido changes (inconsistent evidence)
• Decreased risk of cancers and tubal infertility (limited evidence) 3

Diagnostic Tests in the Emergency Room

For a patient presenting with abdominal pain, back pain, and leg pain after receiving a depot medroxyprogesterone acetate shot, the following steps can be taken:

• Take a comprehensive patient history to gather relevant information and inform diagnosis and treatment 4
• Perform an initial assessment and triage using the Pediatric Assessment Triangle (PAT) or a similar systematic approach to define urgency of care and priorities in management 5
• Conduct a primary assessment, including a detailed physical examination of airway, breathing, circulation, neurologic abnormalities, and head-to-toe examination 5
• Consider diagnostic tests such as venography to evaluate pelvic congestion, which may be a cause of pain in some cases 6

Management and Treatment

• Treatment with medroxyprogesterone acetate may be effective in reducing pelvic congestion and associated pain 6
• Patient-centered counseling should incorporate available evidence and acknowledge its limitations, recognizing the value of women's lived experiences 3