What are the considerations for prescribing Depo-Provera (medroxyprogesterone acetate) to a patient?

Prescribing Considerations for Depo-Provera (Medroxyprogesterone Acetate)

Depo-Provera is a highly effective contraceptive option with a typical failure rate of 6% that should be administered every 13 weeks (up to 15 weeks) as a 150 mg intramuscular injection. 1

Key Benefits and Effectiveness

• Highly effective with typical failure rates of approximately 6% with typical use and 0.2% with perfect use
• Convenient administration schedule (every 13 weeks)
• User-independent method that doesn't require daily adherence
• Can be used by women who cannot use estrogen-containing contraceptives
• Provides additional benefits including:
  • Improvement in dysmenorrhea
  • Protection against iron-deficiency anemia
  • Protection against endometrial cancer
  • May raise seizure threshold and decrease sickle cell crises in affected patients 1

Medical Eligibility and Contraindications

Appropriate Candidates:

• Women seeking long-acting, reversible contraception
• Lactating women
• Most women with chronic illnesses
• Women with contraindications to estrogen-containing contraceptives

Contraindications (FDA Label):

• Current thrombosis or thromboembolic disorders (discontinue immediately)
• History of or current breast cancer
• Undiagnosed abnormal vaginal bleeding
• Known or suspected pregnancy
• Liver dysfunction or disease
• Known hypersensitivity to medroxyprogesterone acetate 2

Important Side Effects and Management

Menstrual Changes:

• Nearly all users experience menstrual irregularities initially
• Bleeding patterns typically improve over time
• Amenorrhea develops in many long-term users 1, 3
• Pre-use counseling about these changes is essential to improve continuation rates 1

Bone Mineral Density (BMD) Concerns:

• FDA black box warning regarding BMD loss
• BMD decreases with use but substantially recovers after discontinuation
• Not recommended to limit use to 2 years or routinely monitor bone density
• Recommend adequate calcium (1300 mg/day) and vitamin D (600 IU/day) intake
• Encourage regular weight-bearing exercise
• Advise smoking cessation 1, 2

Weight Gain:

• Weight gain is a common side effect
• Studies show weight gain status at 6 months predicts future excessive weight gain
• Not all patients experience weight gain 1, 4
• Consider alternative methods for patients with obesity or at risk for weight-related complications 1

Return to Fertility:

• Delayed return to fertility (typically 9-18 months)
• MPA can be detected in serum for up to 9 months after injection
• Ovulation resumes when MPA levels fall below 0.1 ng/mL 5

Administration Protocol

1. Initial Injection:

   • Can be started anytime during the menstrual cycle if reasonably certain patient is not pregnant
   • If started >7 days after menses began, use backup contraception for 7 days 1

2. Follow-up Injections:

   • Administer every 13 weeks (up to 15 weeks)
   • If >2 weeks late (>15 weeks from previous injection), rule out pregnancy before administering next dose 1

3. Self-Administration Option:

   • Self-administered subcutaneous DMPA (104 mg) is available
   • Requires proper instruction on injection technique and sharps disposal
   • Considered "off-label" per FDA labeling 1

Special Populations

Adolescents:

• Appropriate option for adolescents
• Counsel about potential side effects, particularly menstrual changes and weight gain
• Consider calcium and vitamin D supplementation 1

HIV-Infected Women:

• Safe and effective for women with HIV
• No evidence of increased infectious complications
• No significant interactions with antiretroviral medications 1

Women with Hereditary Angioedema:

• Can be used in women with hereditary angioedema caused by C1 inhibitor deficiency 1

Common Pitfalls to Avoid

1. Inadequate Counseling: Failure to provide thorough pre-use counseling about menstrual changes and other side effects leads to higher discontinuation rates. Always counsel patients about expected side effects before first injection.

2. Ignoring Weight Gain: Monitor weight at follow-up visits. Consider alternative methods if significant weight gain occurs.

3. Overlooking Bone Health: Recommend calcium and vitamin D supplementation, weight-bearing exercise, and smoking cessation to all DMPA users.

4. Missing the Injection Window: Emphasize the importance of returning for injections every 13 weeks. If more than 15 weeks have elapsed, pregnancy testing is required before the next injection.

5. Forgetting STI Protection: Remind patients that DMPA does not protect against HIV or other STIs, and condoms should be used if at risk 2.