What are the contraindications for Depo Medroxyprogesterone Acetate (DMPA) use?

Contraindications for DMPA Use

Depo-medroxyprogesterone acetate (DMPA) is absolutely contraindicated in patients with active thrombophlebitis, current or history of thromboembolic disorders, cerebral vascular disease, known or suspected breast malignancy, hypersensitivity to DMPA or its ingredients, significant liver disease, or undiagnosed vaginal bleeding. 1

Absolute Contraindications

DMPA should not be used in patients with:

• Active thrombophlebitis or current/history of thromboembolic disorders or cerebral vascular disease 1
• Known or suspected malignancy of breast 1
• Known hypersensitivity to medroxyprogesterone acetate or any of its ingredients 1
• Significant liver disease 1
• Undiagnosed vaginal bleeding 1

Relative Contraindications and Cautions

Cardiovascular Conditions

• Multiple risk factors for arterial cardiovascular disease (Category 3 - risks usually outweigh benefits) 2
• Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg (Category 3) 2
• Vascular disease (Category 3) 2
• History of DVT/PE with risk factors for recurrence (Category 2 - benefits generally outweigh risks) 2

Reproductive Tract Conditions

• Unexplained vaginal bleeding before evaluation (Category 3) 2
• Cervical cancer awaiting treatment (Category 2) 2
• Current breast cancer (Category 4 - unacceptable health risk) 2
• Past breast cancer with no evidence of current disease for 5 years (Category 3) 2

Metabolic Conditions

• Diabetes with nephropathy/retinopathy/neuropathy (Category 3) 2
• Diabetes with other vascular disease or duration >20 years (Category 3) 2
• Severe (decompensated) cirrhosis (Category 3) 2
• Liver tumors (benign or malignant) (Category 3) 2

Bone Health Considerations

• While the FDA has a black box warning about bone mineral density (BMD) loss with long-term use, ACOG does not recommend limiting DMPA use to 2 years 3
• Special consideration should be given to patients with risk factors for osteoporosis (metabolic bone disease, chronic alcohol/tobacco use, anorexia nervosa, strong family history of osteoporosis, or chronic use of drugs that reduce bone mass) 1
• Adolescents with BMI ≥30 kg/m² (Category 2) 2

Special Populations

Adolescents

• Generally safe for use in adolescents, but bone health considerations are important 2
• Counseling about calcium intake (1300 mg daily), vitamin D (600 IU daily), and weight-bearing exercise is recommended 2
• Weight gain may be a concern, particularly in those who show early weight gain (>5% at 6 months) 3

Post-partum Women

• Safe for use in lactating women 2
• Can be initiated during or after the sixth post-partum week in exclusively breastfeeding mothers 1

Women with Chronic Conditions

• May provide additional benefits in certain conditions (e.g., raising seizure threshold, decreasing sickle cell crises) 2
• Appropriate for women with medical conditions that contraindicate estrogen use 4

Important Clinical Considerations

• DMPA causes menstrual irregularities in nearly all patients initially, which typically improve over time 2
• Return to fertility is delayed after discontinuation, typically 9-18 months, which may be a consideration for women planning pregnancy in the near future 2, 5
• Weight gain is a common side effect, particularly in women who show early weight gain 3
• DMPA reduces serum estrogen levels, which can lead to reversible bone mineral density loss 1

Administration Guidelines

• The recommended dose is 150 mg every 3 months (13 weeks) administered by deep intramuscular injection 1
• Can be given up to 2 weeks late (14 weeks from the last injection) without requiring additional contraceptive protection 6
• If more than 2 weeks late, pregnancy should be ruled out before administration 6

By understanding these contraindications and special considerations, clinicians can appropriately select patients for whom DMPA would be a safe and effective contraceptive option.