Contraindications for Depo-Provera (DMPA)
Depo-Provera is absolutely contraindicated in women with active thrombophlebitis, current or history of thromboembolic disorders, cerebral vascular disease, known or suspected breast malignancy, significant liver disease, undiagnosed vaginal bleeding, or known hypersensitivity to medroxyprogesterone acetate. 1
Absolute Contraindications (FDA-Labeled)
The FDA drug label explicitly lists the following as contraindications 1:
- Active thrombophlebitis or current/history of thromboembolic disorders or cerebral vascular disease - This is critical as DMPA carries increased VTE risk (3.6-fold increased risk compared to non-users) 2
- Known or suspected breast malignancy
- Known hypersensitivity to medroxyprogesterone acetate or any ingredients
- Significant liver disease - Since progestins are metabolized in the liver
- Undiagnosed vaginal bleeding - Must rule out pathology before initiation
Conditions Where Risks Generally Outweigh Benefits (US MEC Category 3)
Beyond absolute contraindications, certain conditions warrant extreme caution or alternative methods 3:
- Diabetes with vascular complications (nephropathy, retinopathy, or established vascular disease) - DMPA falls under US MEC 3 due to concerns about hypoestrogenic effects and reduction of HDL-cholesterol levels 3
- Heart failure - Monthly injectables containing medroxyprogesterone acetate are inappropriate due to fluid retention tendency 4
- Advanced HIV disease - While HIV itself is not a contraindication (US MEC 2), advanced HIV disease with severe immunosuppression is US MEC 3 until clinical status improves with antiretroviral therapy 5
Important Clinical Considerations
Cardiovascular disease context: Women with diabetes using estrogen-containing contraceptives have absolute VTE rates of 10.0 events per 1000 woman-years (age <35) versus 3.4 in non-users, though progestin-only methods like DMPA show lower but still elevated risk 3. For women with established vascular disease from diabetes, this represents an unacceptable risk.
Bone health concerns: While the 2004 FDA black-box warning about bone mineral density remains, this is NOT a contraindication 6, 7. However, consider avoiding DMPA in women with additional osteoporosis risk factors (chronic corticosteroid use, eating disorders, chronic alcohol/tobacco use, family history) and strongly encourage alternatives in these cases 7.
Common Pitfalls to Avoid
- Don't confuse relative with absolute contraindications: Obesity alone is NOT a contraindication 3, 8. Age alone is NOT a contraindication, though adolescents need counseling about bone health 6.
- Don't unnecessarily restrict based on BMD concerns: ACOG does not advise limiting DMPA use to 2 years or routinely monitoring bone density 6. BMD substantially recovers after discontinuation 6.
- Pregnancy is not required to be ruled out with absolute certainty before starting: If reasonably certain the patient is not pregnant, benefits of starting DMPA likely exceed any risk 9.