How is the Depovera (medroxyprogesterone acetate) injection administered and what is the recommended dosing schedule?

Depo-Provera (Medroxyprogesterone Acetate) Administration and Dosing Schedule

Depo-Provera is administered as 150 mg by deep intramuscular injection into the gluteal or deltoid muscle every 13 weeks (3 months), with injections permitted up to 15 weeks from the last dose without requiring backup contraception. 1, 2

Administration Technique

Intramuscular Injection Protocol

• Vigorously shake the 1 mL vial immediately before use to ensure uniform suspension of the medication 2
• Administer 150 mg by deep intramuscular (IM) injection using strict aseptic technique 2
• Inject into either the gluteal or deltoid muscle, rotating injection sites with each administration 2
• Assess body habitus before each injection to determine if a longer needle is necessary, particularly for gluteal injections, to avoid inadvertent subcutaneous administration 2

Subcutaneous Formulation Alternative

• A lower-dose subcutaneous formulation (104 mg/0.65 mL) is available and provides equivalent contraceptive efficacy 1
• Self-administration of subcutaneous DMPA is an acceptable option when patients receive proper instruction on injection technique and sharps disposal 1
• Both formulations have similar effectiveness and side effect profiles 1

Dosing Schedule

Initial Injection Timing

• First injection must be given ONLY during the first 5 days of a normal menstrual period to ensure the patient is not pregnant 2
• Alternatively, administer within the first 5 days postpartum 2
• For exclusively breastfeeding mothers, delay administration until during or after the sixth postpartum week 2

Repeat Injection Intervals

• Standard reinjection interval is every 13 weeks (3 months) 1, 2
• Injections can be given up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 1, 3, 4
• Many providers schedule visits every 11-12 weeks for adolescents to allow buffer time for missed or delayed appointments 1
• If more than 15 weeks have elapsed since the last injection, verify the patient is not pregnant before administering the next dose 2

Backup Contraception Requirements

• When initiating DMPA mid-cycle (quick start), use backup contraception (condoms or abstinence) for at least 7 days 1
• Condoms should be used at all times for STI protection, regardless of contraceptive efficacy 1

Duration of Use Considerations

Long-Term Use Recommendations

• The FDA label states use for longer than 2 years is not recommended unless other birth control methods are inadequate, due to bone mineral density concerns 2
• However, ACOG does not recommend restricting DMPA to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh the risks of bone density loss 1, 3
• No time limit exists for DMPA use in current ACOG guidance, and subsequent research has demonstrated substantial recovery of bone mineral density after discontinuation 3
• Do not routinely monitor bone density after 2 years of use unless other osteoporosis risk factors are present 1, 3

Skeletal Health Counseling for Long-Term Users

• Counsel patients to ensure daily calcium intake of at least 1,300 mg 1, 3
• Recommend daily vitamin D intake of 600 IU 1, 3
• Encourage regular weight-bearing exercise 1, 3
• Advise smoking cessation and alcohol avoidance to maintain skeletal health 1, 3

Common Pitfalls to Avoid

Critical Administration Errors

• Do not administer the first injection without confirming the patient is not pregnant through timing within the first 5 days of menses or appropriate postpartum timing 2
• Do not use inadequate needle length for gluteal injections, as this may result in subcutaneous rather than intramuscular administration and potentially reduced efficacy 2
• Do not forget to shake the vial vigorously before drawing up the medication, as failure to ensure uniform suspension may result in inconsistent dosing 2

Counseling and Follow-Up Mistakes

• Do not fail to counsel patients about menstrual irregularities before the first injection, as pre-counseling significantly improves continuation rates 1
• Menstrual irregularities occur in nearly all patients initially but typically improve over time, with 57% of women experiencing amenorrhea by the end of one year 1
• Do not discontinue DMPA at 2 years based solely on duration concerns, as this increases risk of unintended pregnancy without clear benefit 3
• Weight gain at 6 months (>5% increase) is a strong predictor of future excessive weight gain with ongoing DMPA use, warranting discussion of alternative methods 1, 3

Return to Fertility Considerations

• Counsel patients that return to fertility is typically delayed 9-18 months after discontinuation, which is longer than other hormonal methods 1, 3
• This delay represents the time needed for the endometrial lining to return to its pre-DMPA state and for ovulatory function to resume 1