What are the recommendations and considerations for using Depo Provera (medroxyprogesterone acetate) as a form of contraception?

Depo Provera (Medroxyprogesterone Acetate) for Contraception

Depo Provera is a highly effective progestin-only injectable contraceptive that should be offered as part of comprehensive contraceptive counseling, with both provider-administered intramuscular (DMPA-IM) and self-administered subcutaneous (DMPA-SC) formulations now recommended by the CDC, though use beyond 2 years requires careful consideration due to bone mineral density concerns. 1, 2

Administration and Dosing

The standard dosing regimen is 150 mg intramuscularly every 3 months (13 weeks), with a grace period allowing administration up to 2 weeks late (15 weeks from last injection) without requiring backup contraception. 1, 3

Key Administration Details:

• First injection timing: Must be given within the first 5 days of a normal menstrual period, or within the first 5 days postpartum (or after the sixth postpartum week in exclusively breastfeeding mothers) 2
• Injection technique: Deep intramuscular injection in gluteal or deltoid muscle, rotating sites with each injection 2
• Body habitus assessment: Evaluate before each injection to determine if a longer needle is necessary to avoid inadvertent subcutaneous administration 2
• Dosage adjustment: No adjustment needed for body weight 2

Self-Administration Option

Self-administered subcutaneous DMPA-SC is now recommended by the CDC as an additional approach that improves contraceptive access and increases reproductive autonomy, with moderate-certainty evidence showing higher continuation rates and equivalent safety compared to provider administration. 1

Implementation Requirements for Self-Administration:

• Instruction on self-injection technique (in-person or via telemedicine) 1
• Proper sharps disposal guidance 1
• Access to follow-up care for questions or method switching 1
• Reinjection reminders 1
• Same medical eligibility criteria apply as provider-administered DMPA 1

No routine follow-up is required, but patients should contact their provider to discuss side effects, change methods, or address injection concerns. 1

Duration of Use and Bone Health Concerns

The FDA label states that use longer than 2 years is not recommended unless other birth control methods are considered inadequate, due to significant bone mineral density loss that is greater with increasing duration and may not be completely reversible. 2

Critical Bone Health Considerations:

• Adolescent use warning: It is unknown if use during adolescence or early adulthood (critical periods of bone accretion) will reduce peak bone mass and increase osteoporotic fracture risk later in life 2
• ACOG perspective: Does not recommend limiting use to 2 years, as benefits of preventing unwanted pregnancy generally outweigh bone density risks 3
• For use beyond 2 years: Counsel patients about skeletal health measures including 1300 mg calcium daily, 600 IU vitamin D daily, regular weight-bearing exercise, and smoking cessation 3

Contraindications

Depo Provera is contraindicated in patients with active thrombophlebitis, current or history of thromboembolic disorders, or cerebral vascular disease. 2

Side Effects and Management

Menstrual Changes:

Menstrual disturbances occur in most patients, with irregular bleeding common initially and amenorrhea developing in a high percentage of long-term users. 1, 4, 5

• For spotting or light bleeding: Consider NSAIDs for 5-7 days 3
• Pattern over time: Irregular/excessive bleeding diminishes with continued use 5
• Patient counseling: Pre-use counseling about menstrual changes is essential to minimize discontinuation 4

Other Common Side Effects:

• Weight gain: Tendency for weight gain reported in multiple studies 4, 5, 6
• Headaches: Among the most prevalent non-menstrual side effects 6
• Discontinuation rates: 12-month discontinuation rate approximately 49%, primarily due to non-menstrual side effects (35.6%) and menstrual side effects (23.1%) 6

Return to Fertility

Fertility return may be delayed 9-18 months after discontinuation, which is a critical counseling point distinguishing Depo Provera from immediately reversible methods. 3, 7

Advantages Over Other Methods

Depo Provera has significant advantages including independence from daily user compliance, no effect on blood pressure or thrombosis risk (unlike combined oral contraceptives), and no adverse effects on lactation in breastfeeding women. 8, 4

Specific Clinical Scenarios Where Depo Provera Excels:

• Women who cannot tolerate estrogenic side effects of combined contraceptives 8
• Women with focal migraine (contraindicated for combined pills) 4
• Postpartum breastfeeding women 8
• Women with irregular lifestyles or difficulty with daily pill compliance 4
• Women with hypertension or thrombosis concerns 4

Common Pitfalls to Avoid

• Do not wait for menses to return before administering subsequent injections in amenorrheic users—this is expected and not a contraindication 7
• Do not assume continuous coverage without backup when switching from other methods—follow specific transition protocols 7
• Do not dismiss patient concerns about menstrual changes—early intervention with NSAIDs or shorter injection intervals can improve tolerability 4
• Do not forget pregnancy verification if injection interval exceeds 15 weeks 2