What are the guidelines for administering Depo (medroxyprogesterone acetate) as a contraceptive method?

Depo-Provera (DMPA) Administration Guidelines

Timing of Administration

DMPA can be initiated at any time if it is reasonably certain the patient is not pregnant, without waiting for the next menstrual period. 1, 2

Standard Initiation Scenarios

• First injection timing: Can be given at any time during the menstrual cycle if pregnancy is reasonably excluded 1
• Immediately post-abortion: No backup contraception needed when given at the time of surgical abortion or within 7 days of any abortion 1, 2
• Postpartum (breastfeeding): Can be given immediately postpartum; if <6 months postpartum, amenorrheic, and fully/nearly fully breastfeeding, no backup needed 1
• Postpartum (not breastfeeding): Can be given immediately postpartum 1

Backup Contraception Requirements

Use backup contraception (abstinence or barrier method) for 7 days after injection in the following situations: 1, 2

• When >7 days have passed since menstrual bleeding started
• When ≥21 days postpartum and menstrual cycles have not returned
• When switching from another method and >7 days since menstrual bleeding started
• Any time you cannot be reasonably certain the patient is not pregnant

No backup contraception needed when: 2

• Given immediately post-abortion (surgical)
• Given within first 7 days of menstrual cycle
• Once established on DMPA between properly timed injections

Ongoing Administration Schedule

Administer DMPA every 13 weeks (3 months), with a grace period allowing injections up to 15 weeks from the last injection without requiring additional contraceptive protection. 3, 4

• Many providers schedule visits every 11-12 weeks for adolescents to allow for missed appointments 1
• Dosing options: 150 mg intramuscularly OR 104 mg subcutaneously 1, 4
• No dose adjustment needed for body weight 4

Self-Administration Option

Self-administered subcutaneous DMPA-SC should be made available as an additional approach to deliver injectable contraception, as it has higher continuation rates compared with provider-administered DMPA. 1, 3

Requirements for Self-Administration 3

• Instruction on self-injection technique
• Proper sharps disposal guidance
• Access to follow-up care
• Reinjection reminders
• Patients should be encouraged to contact provider for side effects or concerns

Special Considerations When Switching from IUD

When switching from an IUD to DMPA and the patient has had intercourse since current menstrual cycle started AND >5 days since bleeding started, consider one of these options: 1, 2

• Retain IUD for at least 7 days after DMPA injection, then remove
• Abstain or use barrier contraception for 7 days before IUD removal
• Use emergency contraception at time of IUD removal

Efficacy and STI Protection

• Failure rate: <1% with perfect use, 3% with typical use 1, 4
• Critical caveat: DMPA does NOT protect against sexually transmitted infections; condoms should be used for STI prevention regardless of DMPA use 1, 2

Side Effect Management

For spotting or light bleeding: Consider NSAIDs for 5-7 days 3

Menstrual changes: Nearly all patients experience menstrual irregularities initially, which typically improve over time with continued use; amenorrhea becomes common with long-term use 1, 5

Long-Term Use Considerations

Duration of use: ACOG does not recommend limiting DMPA to 2 years, as benefits of preventing unwanted pregnancy generally outweigh risks of bone density loss 1, 3

For patients using DMPA beyond 2 years, counsel about skeletal health measures: 3

• Daily intake of 1300 mg calcium and 600 IU vitamin D
• Regular weight-bearing exercise
• Smoking cessation

Return to fertility: May be delayed 9-18 months after discontinuation 3, 6