What should I do about persistent bleeding almost 1 month after receiving a Depo (medroxyprogesterone acetate) injection 2 months ago?

Management of Persistent Bleeding After Depo-Provera Injection

For persistent bleeding one month after Depo-Provera injection, first-line treatment is NSAIDs (such as ibuprofen or mefenamic acid) for 5-7 days during bleeding episodes, and if this fails, consider short-term hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days. 1

Initial Clinical Assessment

Before initiating treatment, you must rule out several underlying conditions that could be causing or contributing to the bleeding:

• Pregnancy - Always exclude this first, even though Depo-Provera is highly effective 1, 2
• Sexually transmitted infections - Screen for STDs that can cause irregular bleeding patterns 1, 2
• Medication interactions - Review for antibiotics, anticonvulsants, or other drugs that may affect contraceptive efficacy 2
• Pathologic uterine conditions - Consider polyps, fibroids, or endometrial abnormalities if bleeding persists beyond initial treatment 1, 2

Treatment Algorithm for DMPA-Related Bleeding

Reassurance and Counseling (First Step)

Unscheduled bleeding is extremely common with Depo-Provera use and is generally not harmful. 1 Enhanced counseling about expected bleeding patterns has been shown to significantly reduce discontinuation rates in clinical trials. 1

For Spotting or Light Bleeding

First-line pharmacologic treatment:

• NSAIDs for 5-7 days during bleeding episodes 1
  • Mefenamic acid 500 mg three times daily for 5 days 3
  • Ibuprofen 600-800 mg every 6-8 hours with food 4
  • Naproxen 440-550 mg every 12 hours 4

Two small studies demonstrated significant cessation of bleeding within 7 days among women taking valdecoxib for 5 days or mefenamic acid for 5 days compared with placebo. 1

For Heavy or Prolonged Bleeding (Your Current Situation)

If NSAIDs alone are insufficient after 5-7 days, escalate to:

Second-line hormonal treatment (if medically eligible):

• Low-dose combined oral contraceptives for 10-20 days 1
• Estrogen therapy for 10-20 days 1

Treatment with ethinyl estradiol was found to stop bleeding better than placebo during the treatment period, though the CDC guidelines note that safety outcomes were not extensively examined in these studies. 1

Critical Pitfalls to Avoid

• Do NOT use aspirin - It may actually increase bleeding in some patients 2, 4
• Do NOT assume functional bleeding - Always exclude structural pathology and other underlying conditions first 1, 2, 4
• Do NOT delay evaluation - One month of persistent bleeding warrants clinical assessment, not just continued observation 1

When to Consider Method Discontinuation

If bleeding persists despite treatment and you find it unacceptable, the CDC recommends counseling on alternative contraceptive methods and offering to switch to another method. 1 This is a legitimate option - persistent bleeding that affects quality of life is a valid reason to discontinue Depo-Provera and transition to an alternative contraceptive.

Expected Timeline

Most bleeding irregularities with DMPA improve over time, and amenorrhea becomes common after ≥1 year of continuous use. 1 However, you should not have to wait months while experiencing unacceptable bleeding - treatment should be initiated now given that bleeding has persisted for one month.