Is it safe to administer a depo (depo medroxyprogesterone acetate (DMPA)) shot before 13 weeks postpartum?

Administration of DMPA Before 13 Weeks Postpartum

DMPA (depo medroxyprogesterone acetate) can be safely administered at any time postpartum, including before 13 weeks, with different recommendations based on breastfeeding status. 1

Timing Guidelines Based on Breastfeeding Status

For Breastfeeding Women

• DMPA can be given at any time postpartum, including immediately after delivery 1
• Medical Eligibility Criteria (MEC) classification:
  • MEC 2 (benefits generally outweigh risks) if <1 month postpartum
  • MEC 1 (no restrictions) if ≥1 month postpartum

For Non-Breastfeeding Women

• DMPA can be given at any time postpartum, including immediately after delivery (MEC 1 - no restrictions) 1

Backup Contraception Requirements

For Breastfeeding Women

• No additional contraceptive protection needed if:
  • <6 months postpartum
  • Amenorrheic
  • Fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds)
• Otherwise, if ≥21 days postpartum:
  • Abstain from sexual intercourse or use additional contraceptive protection for 7 days

For Non-Breastfeeding Women

• If ≥21 days postpartum and no menstrual cycles have returned:
  • Abstain from sexual intercourse or use additional contraceptive protection for 7 days
• If menstrual cycles have returned and >7 days since menstrual bleeding started:
  • Abstain from sexual intercourse or use additional contraceptive protection for 7 days

FDA Labeling Considerations

The FDA label for DMPA specifies that for breastfeeding women, the first injection should be given only at the sixth postpartum week 2. This is more restrictive than the CDC guidelines, which allow earlier administration. This discrepancy represents a common situation where clinical practice guidelines may differ from FDA labeling based on accumulated evidence and expert consensus.

Important Clinical Considerations

Efficacy and Administration

• DMPA is highly effective with a 6% failure rate with typical use 1
• Standard dosing is 150 mg IM every 13 weeks (up to 15 weeks) 1, 2
• Can also be administered as 104 mg subcutaneously with similar effectiveness 1

Side Effects and Counseling Points

• Menstrual irregularities are common initially and should be discussed before administration 1
• Weight gain may occur in some patients 1
• DMPA causes reductions in bone mineral density, though substantial recovery occurs after discontinuation 1
• Patients should be counseled about calcium intake (1300 mg daily) and vitamin D (600 IU daily) 1

Return to Fertility

• Return to fertility is delayed after DMPA discontinuation
• Average time to conception is 10 months after the last injection, but can take up to 22 months 3

Clinical Decision Algorithm

1. Determine breastfeeding status
2. For breastfeeding women:
   • If <1 month postpartum: Can administer DMPA (MEC 2)
   • If ≥1 month postpartum: Can administer DMPA (MEC 1)
3. For non-breastfeeding women:
   • Can administer DMPA at any time (MEC 1)
4. Determine need for backup contraception based on criteria above
5. Provide thorough counseling about expected side effects

In conclusion, while the FDA label recommends waiting until 6 weeks postpartum for breastfeeding women, CDC guidelines support earlier administration of DMPA with appropriate consideration of medical eligibility criteria.