What are the guidelines for starting Depo Provera (medroxyprogesterone acetate)?

Starting Depo-Provera (Medroxyprogesterone Acetate)

Administer the first Depo-Provera injection ONLY during the first 5 days of a normal menstrual period to ensure the patient is not pregnant, using either 150 mg intramuscularly or 104 mg subcutaneously, with repeat injections scheduled every 13 weeks. 1

Timing of First Injection

Standard Initiation

• Give the first injection only during the first 5 days of a normal menstrual period 1
• This timing ensures the patient is not pregnant and provides immediate contraceptive protection 1

Postpartum Initiation

• For non-breastfeeding women: administer within the first 5 days postpartum 1
• For exclusively breastfeeding women: delay until the sixth postpartum week 1

Quick-Start/Mid-Cycle Initiation

• Quick-start initiation is acceptable if you are reasonably certain the patient is not pregnant 2
• When using quick-start, require backup contraception (condoms or abstinence) for 7 days after the first injection 2

Dosing and Administration

Two Equivalent Formulations

• Intramuscular (IM): 150 mg by deep intramuscular injection in the gluteal or deltoid muscle 1, 3
• Subcutaneous (SC): 104 mg subcutaneously 2
• Both formulations have equivalent effectiveness and side effects 2

Dosing Schedule

• Schedule repeat injections every 13 weeks (91 days) 4, 2
• Consider scheduling adolescents every 11-12 weeks to allow buffer time for missed appointments 2
• The injection can be given up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 4, 2
• If more than 15 weeks have elapsed, verify the patient is not pregnant before administering the next injection and use backup contraception for 7 days 2

Essential Pre-Injection Counseling

Menstrual Changes (Most Important)

• Nearly all patients experience menstrual irregularities initially with unpredictable spotting and bleeding 2
• Bleeding patterns typically improve over time, with amenorrhea becoming common (57% by end of first year) 3
• Pre-injection counseling about menstrual changes significantly reduces discontinuation rates 2
• Reassure patients that amenorrhea is not harmful and does not require intervention 5

Weight Gain

• Weight gain occurs in some but not all patients 2
• Early weight gain (>5% at 6 months) is a significant predictor of future excessive weight gain 2

Bone Mineral Density

• DMPA causes reversible reductions in bone mineral density, but BMD substantially recovers after discontinuation 2
• Do not limit use to 2 years despite FDA black-box warning, as the benefits of pregnancy prevention outweigh the risks 2
• Counsel all patients on skeletal health promotion: daily calcium and vitamin D intake, regular weight-bearing exercise, and avoidance of smoking and alcohol 2

Return to Fertility

• Ovulation suppression may persist for 9-18 months after the last injection 2
• Time to ovulation after discontinuation varies widely, with the majority ranging from 15 to 49 weeks 2
• DMPA does not permanently affect fertility 6

Contraceptive Efficacy

• Failure rate is less than 1% with perfect use (0-0.7% in clinical studies) 1
• Typical use failure rate is approximately 6% in the first year 2
• Effectiveness depends on the patient returning every 13 weeks for reinjection 1

STI Protection

• Counsel patients to use condoms at all times for STI protection, as DMPA provides no protection against sexually transmitted infections 2

Contraindications to Screen For

• Undiagnosed vaginal bleeding 1
• Known or suspected breast malignancy 1
• Current thromboembolic disorders or cerebrovascular disease 1
• Liver dysfunction 1
• Known or suspected pregnancy 1

Special Populations

HIV-Infected Patients

• Inform HIV-infected women that DMPA may or may not increase HIV transmission risk to partners 2
• Counsel to continue condom use for HIV prevention 2
• DMPA has no significant interactions with antiretroviral agents 2

Self-Administration Option

• The subcutaneous 104 mg formulation can be prescribed for self-administration as an off-label use 4
• Provide instruction (in-person or via telemedicine) on self-injection technique and sharps disposal 4
• Ensure access to follow-up care for questions or to switch methods 4
• Provide reinjection reminders 4

Common Pitfalls to Avoid

• Do not wait for a menstrual period to return before giving subsequent injections, as many users are amenorrheic and waiting increases pregnancy risk 7
• Do not fail to counsel about menstrual irregularities before the first injection, as this significantly reduces discontinuation 2
• Do not assume amenorrhea after DMPA is pathologic without ruling out other causes 2
• Do not routinely monitor bone density or limit use to 2 years based solely on BMD concerns 2
• Do not forget to verify no contraindications before initiating, particularly pregnancy status 1

Monitoring and Follow-Up

• No routine follow-up is required 4
• Encourage patients to contact you at any time to discuss side effects, change methods, or address concerns about reinjection 4
• Be alert for ectopic pregnancy in patients who become pregnant or complain of severe abdominal pain 1