Depo Provera Administration and Usage
Administer Depo Provera (medroxyprogesterone acetate) as 150 mg intramuscularly every 3 months (13 weeks), with a grace period allowing injections up to 2 weeks late (15 weeks total) without requiring backup contraception. 1, 2, 3
Administration Schedule and Timing
Give the first injection only during the first 5 days of a normal menstrual period, or within the first 5 days postpartum if not breastfeeding, or at 6 weeks postpartum if exclusively breastfeeding. 3
Repeat injections every 13 weeks, with up to a 2-week grace period (total 15 weeks from last injection) without requiring additional contraceptive protection. 1, 2, 3
If the interval exceeds 15 weeks, perform a pregnancy test before administering the next injection. 3
Route and Technique
Administer 150 mg by deep intramuscular injection into the gluteal or deltoid muscle. 3
Vigorously shake the vial or prefilled syringe immediately before use to ensure uniform suspension. 3
The subcutaneous formulation (DMPA-SC 104 mg) is an alternative that can be provider-administered or self-administered (off-label), offering equivalent efficacy to the intramuscular formulation. 1, 2, 4
Self-Administration Option
Self-administered subcutaneous DMPA-SC is now recommended by the CDC as an additional approach that improves contraceptive access and reproductive autonomy, though this is technically off-label use. 1, 2
Critical implementation elements include: instruction on self-injection technique (in-person or via telemedicine), sharps disposal guidance, access to follow-up care, reinjection reminders, and addressing administrative issues like ordering and billing. 1, 2
Self-administered DMPA-SC has demonstrated higher continuation rates compared to provider-administered formulations. 2
Duration of Use
Do not limit Depo Provera use to 2 years, as the benefits of preventing unintended pregnancy generally outweigh the risks of bone density loss, according to ACOG. 2, 5
For patients using DMPA beyond 2 years, counsel about skeletal health measures: daily calcium intake of 1,300 mg, vitamin D 600 IU, regular weight-bearing exercise, and smoking cessation. 2, 5
Routine bone density monitoring is not recommended after 2 years of use unless other osteoporosis risk factors are present. 5
Mechanism and Efficacy
Depo Provera inhibits gonadotropin secretion, preventing follicular maturation and ovulation while causing endometrial thinning. 3
The contraceptive efficacy is extremely high, with zero pregnancies reported in Phase 3 studies totaling 16,023 woman-cycles of exposure, comparable to modern copper IUDs. 6, 4
Peak plasma concentrations occur at approximately 3 weeks, with levels decreasing exponentially and becoming undetectable between 120-200 days post-injection. 3
Return to Fertility
Counsel patients that return to fertility may be delayed 9-18 months after discontinuation, with median time to ovulation being 30 weeks. 2, 5, 7
Women with lower body weights conceive sooner than those with higher body weights after discontinuing DMPA. 3
If amenorrhea persists beyond 18 months after discontinuation, further evaluation is warranted as this exceeds the expected recovery timeframe. 8
Side Effect Management
The most common side effect is menstrual irregularity, including spotting, irregular bleeding, and amenorrhea (which occurs in most users over time). 6, 9
For spotting or light bleeding, consider NSAIDs for 5-7 days. 2, 8
Weight gain is common; weight gain >5% at 6 months is a strong predictor of future excessive weight gain with ongoing use. 5
Pre-use counseling about menstrual changes is essential to minimize discontinuation due to bleeding patterns. 5, 6
Advantages Over Other Methods
DMPA has no appreciable effects on blood pressure or thrombosis risk, providing an advantage over combined oral contraceptives. 6
It is independent of intercourse timing and user memory (except for remembering quarterly appointments), which is advantageous for women with irregular lifestyles. 6
For breastfeeding women, DMPA causes no adverse effects on lactation, unlike some other hormonal methods. 10
Common Pitfalls to Avoid
Do not discontinue DMPA at 2 years based solely on duration concerns, as this increases risk of unintended pregnancy without clear benefit. 5
Do not routinely order bone density scans after 2 years unless other osteoporosis risk factors are present. 5
Do not assume amenorrhea after discontinuation is solely due to prior DMPA use without ruling out pregnancy and other causes, especially if amenorrhea persists beyond 18 months. 8
Ensure patients understand that DMPA is temporarily irreversible during its 3-month duration, so side effects cannot be immediately withdrawn. 6, 10