What is the recommended dosage and administration of Deprovera (Depot Medroxyprogesterone Acetate, DMPA) for contraceptive purposes?

Depo-Provera (DMPA) Dosing and Administration for Contraception

Recommended Dosage

Depo-Provera is administered as either 150 mg intramuscularly (IM) every 13 weeks OR 104 mg subcutaneously (SC) every 13 weeks, with both formulations providing equivalent contraceptive efficacy and side effect profiles. 1, 2

Intramuscular Formulation (DMPA-IM)

• Dose: 150 mg deep IM injection into gluteal or deltoid muscle 2
• Frequency: Every 3 months (13 weeks), with a grace period allowing administration up to 15 weeks from the last injection without requiring backup contraception 1
• Preparation: Vial must be vigorously shaken immediately before use to ensure uniform suspension 2

Subcutaneous Formulation (DMPA-SC)

• Dose: 104 mg subcutaneous injection 1
• Frequency: Every 13 weeks, with the same 2-week grace period (up to 15 weeks) 1
• Advantage: Can be self-administered by patients after proper training, expanding access and reproductive autonomy 1, 3

Timing of First Injection

The FDA label specifies strict timing requirements to ensure the patient is not pregnant 2:

• During menstrual cycle: MUST be given only during the first 5 days of a normal menstrual period 2
• Postpartum (not breastfeeding): Only within the first 5 days postpartum 2
• Postpartum (exclusively breastfeeding): Only at the sixth postpartum week 2

Alternative "Quick Start" approach: DMPA can be initiated mid-cycle on the same day as the visit if the provider is reasonably certain the patient is not pregnant, though this requires backup contraception (condoms or abstinence) for at least the first week 1

Scheduling Strategy for Adolescents

Many providers schedule visits every 11-12 weeks for adolescents rather than the full 13 weeks to allow buffer time for missed or delayed appointments. 1 This practical approach helps maintain contraceptive coverage in populations with higher rates of missed appointments.

Contraceptive Efficacy

• Typical use: Approximately 6% pregnancy rate in the first year 1
• Perfect use: 0.2% pregnancy rate 1
• Mechanism: Ovulation suppression for at least 14 weeks after a 150 mg dose, with MPA detectable in serum within 30 minutes and maintaining plateau levels around 1.0 ng/mL for approximately 3 months 4, 5

Self-Administration of DMPA-SC

The CDC (2021) recommends that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception, enhancing reproductive autonomy and access. 1

Implementation Requirements

• Patient instruction: In-person or telemedicine training on self-injection technique and sharps disposal 1
• Follow-up access: Patients should be able to contact providers to discuss side effects, switch methods, or address concerns about reinjection 1
• Reinjection reminders: System for reminding patients when next dose is due 1
• Off-label consideration: While FDA labeling states DMPA-SC should only be administered by healthcare professionals, providers may prescribe for self-administration when medically indicated 1

Essential Pre-Use Counseling

Comprehensive counseling about menstrual irregularities before the first injection significantly reduces discontinuation rates. 1

Key Counseling Points

• Menstrual changes: Nearly all patients initially experience irregular spotting and bleeding, which typically improves over time and often progresses to amenorrhea 1, 6
• STI protection: Condoms should be used at all times for STI protection, as DMPA provides no protection against infections 1
• Weight gain: Weight status at 6 months strongly predicts future excessive weight gain, though not all patients experience weight gain 1
• Delayed return to fertility: Median time to return to ovulation is approximately 30 weeks (7.5 months), with typical return to fertility taking 9-18 months after discontinuation 7, 8

Bone Health Considerations

Despite the FDA black-box warning about decreased bone mineral density (BMD), current guidelines do not recommend limiting DMPA use to 2 years or routinely monitoring bone density. 1

Bone Health Management

• BMD effects: DMPA causes reversible reductions in BMD, with substantial recovery after discontinuation 1
• Supplementation: All patients should receive counseling on daily intake of 1300 mg calcium and 600 IU vitamin D, plus regular weight-bearing exercise 1
• Risk assessment: Consider other osteoporosis risk factors and tailor recommendations individually 1
• Duration concerns: If amenorrhea persists beyond 18 months after discontinuation, bone density assessment may be considered, especially if used for more than 2 years 7

Special Populations

HIV-Infected Adolescents

• Safety: DMPA can be administered with all classes of antiretroviral agents without significant drug interactions 1
• Transmission concern: Patients should be informed that progestin-only injectables may or may not increase HIV transmission risk to partners, and condoms should be emphasized 1
• No dose adjustment needed: DMPA levels are not reduced by antiretroviral agents including efavirenz, zidovudine, lamivudine, nevirapine, and nelfinavir 1

Common Pitfalls to Avoid

• Inadequate pre-injection counseling: Failing to thoroughly discuss menstrual irregularities leads to higher discontinuation rates 1, 6
• Missing the injection window: If interval exceeds 15 weeks, pregnancy must be ruled out before next injection 2
• Overlooking bone health: Not counseling about calcium, vitamin D, and weight-bearing exercise 1
• Assuming prolonged amenorrhea is always benign: If amenorrhea persists beyond 18 months after discontinuation, further evaluation is warranted 7
• Inadequate sharps disposal planning: When prescribing for self-administration, must ensure proper disposal access 1