How to manage irregular bleeding in patients on Depo Medroxyprogesterone Acetate (DMPA)?

Management of Irregular Bleeding on DMPA

For irregular bleeding on DMPA, first rule out pregnancy, STIs, medication interactions, and uterine pathology, then treat unscheduled spotting or light bleeding with NSAIDs for 5-7 days during active bleeding episodes as first-line therapy. 1

Initial Evaluation

Before initiating any treatment for irregular bleeding, you must systematically exclude:

• Pregnancy 1
• Sexually transmitted infections 1
• Medication interactions (particularly anticonvulsants that may reduce DMPA effectiveness) 1
• New uterine pathology (polyps, fibroids, or other structural abnormalities) 1, 2

This evaluation is critical because treating bleeding without addressing underlying pathology can delay appropriate diagnosis and worsen patient outcomes. 1

Treatment Algorithm by Bleeding Severity

For Unscheduled Spotting or Light Bleeding

• NSAIDs are first-line treatment and should be used for 5-7 days during active bleeding only 1, 2
• Mefenamic acid specifically has been shown to reduce continued irregular bleeding in progestin-only contraceptive users 3
• Ibuprofen decreases the length of bleeding episodes over time 3

For Heavy or Prolonged Bleeding

First-line: NSAIDs for 5-7 days during active bleeding 1, 2

Second-line (if NSAIDs fail): Combination oral contraceptives or estrogen can be added, but only for short-term treatment (10-20 days) during active bleeding episodes 1, 2

Before prescribing estrogen-containing contraceptives, verify the patient has no contraindications including:

• Severe uncontrolled hypertension 1
• Migraines with aura 1
• History of thromboembolism or thrombophilia 1
• Active liver disease 1
• Complicated valvular heart disease 1

Alternative Pharmacologic Options

Tranexamic acid (250 mg four times daily for 5 days) is highly effective:

• 88% of women stopped bleeding within the first week compared to 8.2% with placebo 4
• 68% achieved a bleeding-free interval >20 days versus 0% with placebo 4
• Mean bleeding days were significantly reduced (5.7 days vs. 17.5 days with placebo) 4

Mifepristone shows promise but is not routinely available for this indication:

• Therapeutic use reduced bleeding days in implant users 3
• Prophylactic monthly use by new users reduced bleeding compared to placebo 3

Counseling and Expectations

Set realistic expectations before initiating DMPA:

• Irregular bleeding and amenorrhea are common and generally not harmful 1, 2
• Bleeding patterns typically improve with continued DMPA use, with amenorrhea becoming increasingly common over time 1, 2
• Enhanced counseling about expected bleeding patterns before DMPA initiation reduces discontinuation rates 1, 2

Reassure patients during bleeding episodes:

• Breakthrough bleeding does not indicate contraceptive failure 5
• Unscheduled bleeding is most common in the first 3-6 months and decreases with continued use 5

When to Consider Method Switching

If bleeding persists despite appropriate treatment and remains unacceptable to the patient, counsel on alternative contraceptive methods such as:

• Long-acting reversible contraceptives (IUDs or implants) 1, 2
• Other hormonal methods if medically eligible 1

Offer another method if the patient desires switching rather than allowing them to discontinue contraception entirely, as discontinuation leads to high repeat pregnancy rates. 6

Important Caveats

Avoid cyclic estrogen regimens: Cyclic transdermal estradiol does not create regular bleeding patterns in DMPA users and does not improve continuation rates 6. Short-term estrogen treatment (10-20 days) during active bleeding is the only recommended estrogen approach. 1

DMPA continuation rates are inherently low: Only 19-24% of women continue DMPA at 12 months post-initiation, with high repeat pregnancy rates among discontinuers 6. This underscores the importance of proactive counseling and effective bleeding management.

Special consideration for thrombocytopenia: DMPA should be initiated with caution in women with severe thrombocytopenia given the increased or erratic bleeding that may occur and the irreversibility of DMPA for 11-13 weeks after administration 7