Is the Depo (medroxyprogesterone acetate) shot contraindicated in individuals with hyperbilirubinemia?

Depo Shot Safety with High Bilirubin Levels

The Depo shot (medroxyprogesterone acetate) is contraindicated in patients with significant liver disease, which could include those with high bilirubin levels. 1

Contraindications and Liver Function

• The FDA label for medroxyprogesterone acetate (Depo shot) specifically lists "significant liver disease" as a contraindication 1
• Hyperbilirubinemia is often indicative of liver dysfunction, particularly when it involves conjugated (direct) bilirubin elevation 2
• Medications that are metabolized by the liver may have altered pharmacokinetics in patients with impaired liver function, potentially leading to drug accumulation 3

Evidence on Medroxyprogesterone and Liver Function

• Research has shown that medroxyprogesterone acetate elimination is reduced in subjects with advanced liver disease, particularly alcoholic cirrhosis 3
• In patients with normal liver function, medroxyprogesterone acetate does not appear to interfere with liver function tests, including serum bilirubin levels 4
• However, the safety profile changes significantly in those with existing liver dysfunction 3

Clinical Considerations

• The severity and cause of hyperbilirubinemia are important factors in determining contraceptive eligibility 2
• Unconjugated hyperbilirubinemia (such as Gilbert's syndrome) may be less concerning than conjugated hyperbilirubinemia, which often indicates more significant liver dysfunction 2
• Cotrimoxazole, another medication, lists "risk of the infant developing hyperbilirubinemia" as a contraindication for breastfeeding mothers, highlighting the general concern about medications in the context of hyperbilirubinemia 2

Alternative Contraceptive Options

• For patients with liver disease, non-hormonal contraceptive methods such as copper intrauterine devices (IUDs) may be safer options 2
• If a hormonal method is desired, the levonorgestrel IUD might be considered as it has lower systemic absorption compared to injectable methods 2
• Progestin-only contraceptives generally have fewer metabolic effects than combined hormonal contraceptives, but caution is still warranted with significant liver disease 2

Monitoring Recommendations

• If Depo is used in a patient with mild, stable hyperbilirubinemia (against recommendations), close monitoring of liver function tests before and after administration would be essential 4
• Patients should be educated about symptoms of worsening liver function that would warrant immediate medical attention 2
• Alternative contraceptive methods should be discussed thoroughly with patients who have liver disease 2

Conclusion

The presence of high bilirubin levels, particularly if indicative of significant liver disease, represents a contraindication to the use of the Depo shot. The FDA label explicitly states that significant liver disease is a contraindication for medroxyprogesterone acetate injectable suspension 1. While some research suggests potential benefits of medroxyprogesterone in specific autoimmune liver diseases 5, the general recommendation remains to avoid its use in patients with liver dysfunction as indicated by elevated bilirubin levels.