Should blood tests be performed for patients on Depoprovera (medroxyprogesterone acetate) injections?

Blood Testing for Patients on Depo-Provera Injections

Routine blood tests are not required for patients receiving Depo-Provera (DMPA) injections. 1

Pre-Initiation Requirements

Among healthy women, no examinations or laboratory tests are needed before initiating DMPA, although baseline weight and BMI measurement may be useful for monitoring over time. 1 Women with known medical problems or special conditions might need additional testing before being determined appropriate candidates, but this is based on individual medical conditions, not routine DMPA use. 1

Specifically, the following tests are not required before starting DMPA: 1

• Blood pressure screening (though measurement is reasonable)
• Lipid panels
• Glucose/diabetes screening
• Liver enzyme testing
• Pregnancy testing (unless clinically indicated)

Monitoring During Use

No routine blood work is recommended during ongoing DMPA use. 1 Patients should have an annual visit for blood pressure check and other routine healthcare needs, but this does not mandate laboratory testing. 2

Bone Density Monitoring

Routine bone mineral density (BMD) scans are not recommended, even after prolonged use beyond 2 years. 1 The American College of Obstetricians and Gynecologists explicitly states there is no evidence to support routine dual-energy radiograph absorptiometry (DEXA) scans in adolescent or adult patients using DMPA. 1 Some providers obtain baseline DEXA scans when patients begin DMPA, but there is no evidence to recommend this practice. 1

BMD assessment may be considered only if: 3

• The patient has used DMPA for more than 2 years AND has additional osteoporosis risk factors
• Pre-existing bone disease is present
• Strong family history of osteoporosis exists
• Chronic corticosteroid use is concurrent
• Eating disorders (anorexia nervosa) are present
• Heavy alcohol use or smoking is ongoing 1

Special Populations Requiring Consideration

HIV-Infected Patients

For HIV-infected patients on DMPA, no additional routine blood testing is required specifically for contraceptive monitoring. 1 DMPA levels do not appear to be reduced by antiretroviral agents (including efavirenz, zidovudine, lamivudine, nevirapine, and nelfinavir), and the agent is largely free of antiretroviral interactions. 1 However, these patients require their standard HIV monitoring (CD4 counts, viral loads) as part of HIV care, not contraceptive management. 1

Pregnancy Testing

Pregnancy testing should be performed only when clinically indicated, not routinely: 1

• Missed menses (unless already amenorrheic on DMPA)
• New onset irregular bleeding after prolonged amenorrhea
• New onset pelvic pain
• Before institution of new medications with potential fetal effects
• At patient request

Clinical Counseling Instead of Testing

Rather than laboratory monitoring, counseling is the key intervention for DMPA users: 1

• Age-appropriate calcium supplementation (1,300 mg daily) 1, 4
• Vitamin D supplementation (600 IU daily) 1, 4
• Regular weight-bearing exercise 1, 4
• Smoking cessation 1, 4
• Alcohol avoidance 1
• Expected menstrual changes (amenorrhea in 57% by one year) 2, 5
• Weight monitoring (weight gain at 6 months predicts future excessive gain) 1

Common Pitfalls to Avoid

Do not order routine laboratory panels (CBC, metabolic panel, liver function tests) for DMPA monitoring, as this increases healthcare costs without evidence of benefit. 1

Do not routinely screen for anemia unless the patient has symptoms or risk factors unrelated to DMPA use. 1 Unlike IUDs or combined oral contraceptives, DMPA actually reduces menstrual bleeding over time and protects against iron-deficiency anemia. 1

Do not order DEXA scans at 2 years of use based solely on duration, as this contradicts current guidelines and may lead to unnecessary discontinuation of effective contraception. 1, 4 Initial BMD losses stabilize by 5 years with substantial recovery after discontinuation. 1

Do not check hormone levels (FSH, LH, estradiol) in amenorrheic DMPA users, as amenorrhea is an expected effect of the medication, not a pathologic condition requiring investigation. 3