What are the criteria for a woman to be considered a suitable candidate for the Depo (medroxyprogesterone acetate) shot?

Criteria for Suitability of Depot Medroxyprogesterone Acetate (DMPA) Injection

Depot medroxyprogesterone acetate (DMPA) injection is suitable for most women of reproductive age, with specific considerations for age groups, medical conditions, and lifestyle factors that determine appropriateness of use.

Patient Selection Criteria

Age Considerations

• 18-45 years: No restrictions (Category 1) 1
• <18 years or >45 years: Generally acceptable but requires additional consideration (Category 2) due to potential bone mineral density concerns 1, 2

Medical Eligibility

Suitable Candidates (Category 1-2):

• Women who need highly effective contraception (typical failure rate 3-6%) 1
• Women who cannot or prefer not to use estrogen-containing contraceptives 1
• Breastfeeding women ≥1 month postpartum 1
• Women with medical conditions where estrogen is contraindicated 1
• Women who prefer a method that doesn't require daily adherence 3

Contraindicated (Category 3-4):

• Pregnancy (suspected or confirmed) 2
• Unexplained vaginal bleeding (until evaluated) 4
• Known or suspected breast cancer 2
• History of thromboembolic disorders 2
• Severe liver dysfunction 4
• Women with positive antiphospholipid antibodies 1
• Women with advanced HIV disease (until condition improves) 1

Bone Health Considerations

• Not recommended for long-term use (>2 years) unless other methods are inadequate 2
• Use with caution in women with risk factors for osteoporosis:
  • Chronic alcohol/tobacco use
  • Family history of osteoporosis
  • Chronic use of medications that reduce bone mass (e.g., anticonvulsants, corticosteroids)
  • Anorexia nervosa 2

Timing of Administration

Initial Injection

• Can be given at any time if reasonably certain woman is not pregnant 1
• If started within first 7 days of menstrual cycle: no backup contraception needed 1
• If started >7 days since menstrual bleeding: need backup contraception for 7 days 1

Postpartum

• Can be given immediately postpartum (breastfeeding: Category 2 if <1 month, Category 1 if ≥1 month) 1
• For non-breastfeeding women: Category 1 at any time postpartum 1

Post-abortion

• Can be given within 7 days of abortion (no backup needed if given at time of surgical abortion) 1

Counseling Points

Effectiveness and Administration

• Highly effective (>99% with perfect use, 94-97% with typical use) 5, 3
• Requires injection every 12 weeks (84 days, with a 5-day grace period) 3
• Independent of intercourse and user's daily memory 3

Side Effects to Discuss

1. Menstrual changes (most common):

   • Irregular bleeding initially
   • Amenorrhea in 57% of women after 1 year 4
   • Potential for breakthrough bleeding 1

2. Weight changes:

   • Potential weight gain 4, 3

3. Other common side effects:

   • Headache
   • Nervousness
   • Abdominal discomfort
   • Dizziness 4

4. Delayed return to fertility:

   • May take several months after discontinuation for ovulation to resume 6
   • MPA can be detected in serum for up to 9 months after injection 6

Long-term Considerations

• Bone mineral density (BMD) decreases with use but partially recovers after discontinuation 2
• BMD should be evaluated for long-term users 2
• No increased risk of ovarian, liver, or cervical cancer 4
• Reduced risk of endometrial cancer 4

Follow-up Recommendations

• Return every 12 weeks (84 days, with 5-day grace period) for injection 3
• Consider calcium and vitamin D supplementation, especially in adolescents 1
• Regular weight-bearing exercise recommended 1
• Discuss alternative methods if used for >2 years 2

DMPA offers a highly effective, convenient contraceptive option that doesn't require daily adherence. The decision to use DMPA should prioritize the woman's health status, lifestyle needs, and understanding of potential side effects, particularly menstrual changes and bone health considerations.