Can Depo Medroxyprogesterone Acetate (DMPA) be given along with Mirena (levonorgestrel) insertion for the first 3 months to control bleeding?

Using DMPA with Mirena Insertion for Bleeding Control

DMPA can be used along with Mirena insertion for the first 3 months to control bleeding, as this combination may help manage the irregular bleeding commonly experienced during initial levonorgestrel IUD use.

Rationale for Combination Therapy

• Levonorgestrel IUDs (Mirena) commonly cause unscheduled spotting or light bleeding, as well as heavy or prolonged bleeding, especially during the first 3-6 months of use 1
• These bleeding irregularities are generally not harmful but can affect patient satisfaction and continuation rates 1
• Enhanced counseling about expected bleeding patterns and reassurance has been shown to reduce method discontinuation in clinical trials with contraceptives like DMPA 1

Benefits of Adding DMPA During Initial Mirena Use

• DMPA provides high contraceptive efficacy (>99%) while the body adjusts to the Mirena IUD 2
• DMPA use is typically associated with amenorrhea with continued use, which may help counteract initial Mirena-related bleeding 3
• The combination provides redundant contraceptive protection during the adjustment period 1

Administration Considerations

• DMPA can be initiated on the same day as Mirena insertion ("quick start") 1
• The standard DMPA dose is 150 mg intramuscularly every 12 weeks (84 days + 5 days) 4
• Subcutaneous DMPA (DMPA-SC) is also available and equally effective 5, 6

Potential Side Effects and Monitoring

• Weight changes should be monitored, as both methods can potentially cause weight gain 7, 6
• Patients should be counseled that DMPA may delay return to fertility for up to 18 months after discontinuation 2
• After 3 months, DMPA can be discontinued while maintaining the Mirena IUD for ongoing contraception 1

Alternative Approaches for Managing IUD-Related Bleeding

If DMPA is not desired or contraindicated, consider these alternatives:

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 1, 8
• Mefenamic acid 500 mg three times daily for 5 days can be particularly effective 1, 8
• If bleeding persists and is unacceptable to the patient, counseling on alternative contraceptive methods should be provided 1

Special Considerations

• DMPA should be avoided in patients with positive antiphospholipid antibodies due to potential increased thrombosis risk (RR 2.67) 1
• For patients with rheumatic diseases receiving immunosuppressive therapy, both Mirena and DMPA are generally safe options 1
• Patients should be informed that bleeding patterns typically improve over time with continued Mirena use, with many achieving amenorrhea 1

Follow-up Recommendations

• Schedule follow-up at 3 months to assess bleeding patterns and determine whether to continue or discontinue DMPA 7
• Document specific bleeding characteristics including frequency, duration, and amount of flow 7, 8
• Assess for any underlying gynecological problems if bleeding patterns are concerning 1