What checklist should be used before initiating Depo‑Provera (medroxyprogesterone acetate) contraception, including pregnancy testing, contraindications, baseline assessments, counseling points, and follow‑up requirements?

Pre-Initiation Checklist for Depo-Provera (DMPA)

Before initiating Depo-Provera, you need only to ensure the patient is not pregnant and measure blood pressure if using combined hormonal contraceptives previously—no pelvic exam, Pap smear, breast exam, or STI screening is required. 1

Timing of First Injection

• Administer ONLY during the first 5 days of a normal menstrual period 2
• Within first 5 days postpartum (non-breastfeeding) 2
• During or after the sixth postpartum week (exclusively breastfeeding mothers) 2
• If starting anytime else: Use backup contraception (abstinence or condoms) for 7 days 1

Pregnancy Exclusion (Required)

The provider must be "reasonably certain" the patient is not pregnant 1. This does not require a pregnancy test in all cases—clinical assessment based on timing within menstrual cycle is sufficient when initiating during the first 5 days of menses 2.

Required Examinations: NONE

No physical examination is needed before DMPA initiation 1. This is a critical point that distinguishes DMPA from IUDs:

• No pelvic/bimanual examination required 1
• No cervical inspection needed 1
• No Pap smear required 3
• No clinical breast examination needed 3
• No STI screening mandated 1
• Blood pressure measurement is NOT required for DMPA 1 (only needed for combined hormonal contraceptives)

Contraindications Assessment (Required)

Screen for absolute contraindications 2:

• Active thrombophlebitis or current/history of thromboembolic disorders or cerebrovascular disease
• Known or suspected breast malignancy
• Hypersensitivity to medroxyprogesterone acetate
• Significant liver disease
• Undiagnosed vaginal bleeding

Mandatory Counseling Points

Bone Mineral Density Warning (Black Box)

Critical counseling required by FDA 2:

• DMPA causes significant bone mineral density loss
• Loss increases with duration of use and may not be completely reversible
• Not recommended for >2 years unless other methods inadequate 2
• Unknown if adolescent/young adult use reduces peak bone mass and increases future osteoporotic fracture risk 2

Menstrual Changes

• Most patients experience menstrual disturbances 4
• Amenorrhea is common and expected
• Irregular bleeding typically improves over time
• Reassure this is not medically dangerous 1

Return to Fertility

• Delayed return to fertility after discontinuation (average 10 months, but variable)
• Not permanent—fertility returns

Weight Changes

• Weight gain is possible and should be discussed 4

Injection Schedule

• Every 3 months (13 weeks) 2
• Can be given up to 2 weeks late (15 weeks total) without backup contraception 5
• If >15 weeks: confirm not pregnant before next injection 2

Administration Technique

• Shake vial/syringe vigorously immediately before use to ensure uniform suspension 2
• Deep intramuscular injection using strict aseptic technique 2
• Gluteal or deltoid muscle, rotating sites 2
• Assess body habitus to determine if longer needle needed (especially for gluteal injection) to avoid inadvertent subcutaneous administration 2
• Dose: 150 mg 2
• No dose adjustment for body weight 2

Follow-Up Requirements

No routine follow-up required 5. However, patient should be encouraged to contact provider:

• To discuss side effects or problems
• If desires method change
• With questions about reinjection timing 5

Self-Administration Option

Self-administered subcutaneous DMPA-SC is available as an alternative 5:

• Requires initial instruction on self-injection technique
• Same medical eligibility criteria apply
• Same reinjection schedule (every 13 weeks, up to 15 weeks acceptable) 5
• Sharps disposal education needed

Common Pitfalls to Avoid

• Do not require unnecessary pelvic exams—16-23% of providers incorrectly require this 3
• Do not require Pap smears, breast exams, or STI screening before initiation unless clinically indicated for other reasons 3
• Do not forget the >2 year limitation counseling—this is FDA-mandated 2
• Do not administer if >5 days from menses start without backup contraception plan 2
• Do not forget to shake the vial/syringe vigorously—this is essential for proper dosing 2