What are the uses and dosages of Medroxyprogesterone (Depo-Provera) in clinical practice?

Medroxyprogesterone (Depo-Provera): Uses and Dosages in Clinical Practice

Medroxyprogesterone acetate (Depo-Provera) should be administered as 150 mg intramuscular injection every 13 weeks (up to 15 weeks) or 104 mg subcutaneous injection every 13 weeks, with self-administration of the subcutaneous formulation now recommended as an additional option to improve continuation rates and reproductive autonomy. 1, 2

Primary Uses

Contraception

• Highly effective contraceptive with failure rate <1% with perfect use and approximately 6% with typical use 2
• Can be used long-term without mandatory time limits 2
• Appropriate for women who cannot use estrogen-containing contraceptives 2
• Particularly useful for:
  • Younger women (aged 15-24 years)
  • Women seeking user-independent contraception
  • Patients with medical contraindications to estrogen

Endometriosis and Pelvic Pain Management

• Effective for relieving symptoms and objectively improving endometriosis 3, 4
• Recommended as primary treatment for patients with pelvic pain that improves with this medication 2
• Mechanism of action includes:
  • Inducing pseudodecidualized reaction and atrophic changes in endometrium and ectopic implants
  • Suppressing ovulation and serum levels of LH and estradiol 3

Administration Options

Intramuscular (IM) Formulation

• Standard dosing: 150 mg IM injection every 3 months (13 weeks) 5
• Administered by deep injection in the gluteal or deltoid muscle 5
• Provider-administered

Subcutaneous (SC) Formulation

• Alternative dosing: 104 mg SC injection every 13 weeks 2
• Can be self-administered or provider-administered 1
• Self-administration shows higher continuation rates compared to provider-administered DMPA 1, 2
• Self-administered DMPA-SC should be offered through shared decision-making, focusing on patient preferences 1

Monitoring and Follow-up

• No routine follow-up required beyond scheduled injections every 13 weeks 2
• Patients should contact healthcare providers for:
  • Discussion of side effects
  • Desire to change contraceptive method
  • Questions about re-injection timing 2
• For pelvic pain management: follow-up every 3 months to assess pain control effectiveness 2

Important Side Effects and Management

Menstrual Changes

• Nearly all users experience menstrual irregularities initially 2
• Bleeding patterns typically improve over time
• Amenorrhea develops in many long-term users 2
• Pitfall: Inadequate counseling about menstrual changes leads to higher discontinuation rates 2

Bone Health Considerations

• FDA recommends:
  • Adequate calcium (1300 mg/day) and vitamin D (600 IU/day) intake
  • Regular weight-bearing exercise
  • Smoking cessation 2
• ACOG no longer advises limiting DMPA use to 2 years or routinely monitoring bone density 2

Weight Changes

• Weight gain is a common side effect 2
• Weight gain at 6 months is a strong predictor of future excessive weight gain 2
• Consider alternative methods for patients with obesity or at risk for weight-related complications 2

Return to Fertility

• Median time for return to ovulation after discontinuation is approximately 30 weeks 2
• 97.4% cumulative rate of return to ovulation at 12 months 2
• Pitfall: Patients should be counseled about potential delay in return to fertility

Common Pitfalls to Avoid

1. Missing the injection window: Ensure injections are given within the 13-15 week timeframe 2
2. Inadequate counseling about side effects: Thorough pre-use counseling about expected menstrual changes reduces discontinuation rates 2
3. Overlooking bone health: Consider calcium and vitamin D supplementation 2
4. Forgetting STI protection: Depo-Provera provides contraception but not STI protection 2
5. Improper self-injection technique: Patients should be instructed on proper self-injection technique and sharps disposal if self-administering 2