What are the considerations for a 24-year-old female smoker, smoking 5 cigarettes daily for 4 years, using Depo-Provera (medroxyprogesterone acetate) as a contraceptive method?

Depo-Provera Use in a 24-Year-Old Smoker

Depo-Provera (DMPA) is safe and appropriate for this 24-year-old woman who smokes 5 cigarettes daily, as progestin-only contraceptives like DMPA do not carry the cardiovascular risks associated with estrogen-containing methods in smokers. 1

Why DMPA is Safe for Smokers

• Progestin-only methods do not increase cardiovascular risk in smokers, unlike combined hormonal contraceptives (CHCs) that contain estrogen 1, 2
• The cardiovascular concerns with smoking and contraception specifically relate to estrogen-containing products, not progestin-only methods like DMPA 3, 4
• At age 24, this patient is well below the critical age threshold of 35 years where smoking becomes a major contraindication for estrogen-containing contraceptives 1, 2

Key Patient Education Points

Administration and Effectiveness

• DMPA requires an injection every 13 weeks (up to 15 weeks maximum) to maintain contraceptive effectiveness 1
• No examination is required before starting DMPA 1
• If starting more than 7 days after menses began, use backup contraception (condoms) for 7 days 1
• DMPA is highly effective because it works through multiple mechanisms: inhibiting ovulation, thickening cervical mucus, and thinning the endometrial lining 5

Expected Side Effects

Menstrual Changes (Most Important):

• Irregular bleeding and spotting are nearly universal initially and typically the most bothersome side effect 1
• Bleeding patterns generally improve over time, with many women eventually experiencing amenorrhea (no periods) 1
• Counseling about bleeding irregularities before the first injection significantly improves continuation rates 1
• If irregular bleeding occurs, NSAIDs for 5-7 days can be used for treatment 1

Weight and Metabolism:

• Potential weight gain is a common concern and should be discussed upfront 1
• Some women experience increased appetite 1

Bone Health Considerations

• DMPA causes reversible decreases in bone mineral density (BMD) during use, which is partially or fully reversible after discontinuation 6
• This patient should be counseled to:
  • Consume at least 1300 mg calcium daily (through diet or supplements) 1
  • Take 600 IU vitamin D daily 1
  • Engage in regular weight-bearing exercise 1
  • Stop smoking, as smoking independently impairs bone health 1

Return to Fertility

• Expect a delayed return to fertility of 9-18 months after the last injection, even if she only receives one dose 1, 5
• This delay occurs while the endometrium recovers and ovulation resumes 1
• MPA can be detected in serum for up to 9 months after a single 150 mg injection 5

Advantages Specific to Her Situation

• No increased cardiovascular risk from smoking, unlike with combined hormonal contraceptives 1, 3
• Convenient dosing schedule (every 3 months) compared to daily pills 1
• May improve dysmenorrhea (menstrual cramps) 1
• Protection against iron-deficiency anemia 1
• Safe for use while breastfeeding if relevant in the future 1

Smoking Cessation Counseling

• While DMPA is safe for smokers, smoking cessation should still be strongly encouraged for overall cardiovascular and bone health 1
• Smoking at any level increases risks for cardiovascular disease, lung cancer, and impairs bone health 3, 4
• At age 24 with only 5 cigarettes daily for 4 years, she has an excellent opportunity to quit before more significant health consequences develop 7

When to Contact Provider

• Severe or persistent abdominal pain (to rule out ectopic pregnancy, though rare) 6
• Signs of allergic reaction 6
• Severe or prolonged bleeding that is unacceptable to her 1
• Any concerns about side effects that might affect her willingness to continue the method 1

Alternative Considerations

If DMPA is not acceptable due to concerns about irregular bleeding, weight gain, or delayed return to fertility, other excellent progestin-only options include:

• Levonorgestrel IUD: Highly effective, lasts 5-7 years, often reduces menstrual bleeding 8
• Etonogestrel implant: Highly effective, lasts 3 years, requires backup contraception for only 7 days if inserted >5 days after menses 1
• Progestin-only pills: Require daily adherence but no injection 1

All of these progestin-only methods are safe for smokers and do not carry cardiovascular risks 1.