When should a patient start Depo-Provera (medroxyprogesterone acetate)?

When to Start Depo-Provera (DMPA)

Depo-Provera can be started at any time if you are reasonably certain the patient is not pregnant, but the timing determines whether backup contraception is needed for the first 7 days. 1

Optimal Timing for Initiation

During Normal Menstrual Cycles

• Start within the first 5 days of menstrual bleeding: No backup contraception needed 1, 2
• Start after day 5 of menstrual bleeding: Requires backup contraception (condoms or abstinence) for 7 consecutive days 1

The FDA label specifically states the first injection should be given "ONLY during the first 5 days of a normal menstrual period" to ensure the patient is not pregnant at the time of first injection. 2

Quick Start/Same-Day Initiation

• DMPA can be initiated on the same day as the visit ("mid-cycle" or "quick start") as long as you are reasonably certain the patient is not pregnant 1
• This approach requires backup contraception for 7 days 1
• Pregnancy rates do not differ based on timing of contraceptive initiation during the menstrual cycle 3

Special Clinical Situations

Postpartum - Not Breastfeeding

• Can start immediately postpartum (U.S. MEC 1) 1
• If ≥21 days postpartum without return of menses: backup contraception for 7 days 1
• If menstrual cycles have returned and >7 days since bleeding started: backup contraception for 7 days 1

Postpartum - Breastfeeding

• Can start at any time, including immediately postpartum 1
• U.S. MEC 2 if <1 month postpartum; U.S. MEC 1 if ≥1 month postpartum 1
• If <6 months postpartum, amenorrheic, and exclusively/nearly exclusively breastfeeding: No backup contraception needed 1
• The FDA label recommends administering DMPA "during or after the sixth post-partum week" in exclusively breastfeeding mothers 2
• Otherwise, if ≥21 days postpartum: backup contraception for 7 days 1

Postabortion (Spontaneous or Induced)

• Can start within the first 7 days, including immediately postabortion (U.S. MEC 1) 1
• Requires backup contraception for 7 days unless given at the time of surgical abortion 1

Amenorrhea (Not Postpartum)

• Can start at any time if reasonably certain not pregnant 1
• Always requires backup contraception for 7 days 1

Switching from Another Contraceptive Method

• Can start immediately without waiting for next menstrual period 1
• If >7 days since menstrual bleeding started: backup contraception for 7 days 1

Special consideration when switching from an IUD: If the patient has had intercourse since the start of her current cycle and it's been >5 days since menstrual bleeding started, consider one of these options: 1

• Retain the IUD for at least 7 days after DMPA injection, then remove
• Abstain or use barrier contraception for 7 days before removing IUD
• Use emergency contraception at time of IUD removal

Dosing Schedule

• 150 mg intramuscularly every 13 weeks (up to 15 weeks) 1, 2
• Alternative: 104 mg subcutaneously every 13 weeks 1
• Many providers schedule visits every 11-12 weeks for adolescents to allow for missed/delayed visits 1

Late Injections

• <2 weeks late (<15 weeks after previous injection): Proceed with injection, no backup needed 1
• ≥2 weeks late: Treat as new start, backup contraception for 7 days, consider emergency contraception 1

Critical Counseling Points

Backup Contraception

Always counsel patients that backup contraception (condoms or abstinence) should be used for at least the first 7 days unless started within the first 5 days of menstrual bleeding. 1

Duration of Use Limitation

The FDA black-box warning states DMPA is not recommended as long-term (>2 years) birth control unless other options are inadequate due to bone mineral density loss. 2 However, ACOG does not advise limiting DMPA use to 2 years, recognizing the risk of unwanted pregnancy if contraceptive options are limited. 1

Common Pitfalls to Avoid

• Failing to ensure reasonable certainty of non-pregnancy status before initiating DMPA 1, 2
• Not counseling about menstrual irregularities before first injection - this counseling reduces discontinuation rates 1
• Forgetting to advise backup contraception when starting after day 5 of the menstrual cycle 1
• Not scheduling follow-up appropriately - efficacy depends on adherence to the 13-week dosing schedule 2