When is DMPA (Depot Medroxyprogesterone Acetate) use not recommended based on the U.S. Medical Eligibility Criteria for category 3 and 4 conditions?

DMPA Contraindications: Category 3 and 4 Conditions

DMPA should not be used (Category 4) in women with active thrombophlebitis, current or history of thromboembolic disorders, cerebral vascular disease, known or suspected breast malignancy, significant liver disease, or undiagnosed vaginal bleeding. 1

Category 4 Conditions (Unacceptable Health Risk - Do Not Use)

Cardiovascular Contraindications

• Active thrombophlebitis or current thromboembolic disorders 1
• History of thromboembolic disorders or cerebral vascular disease 1
• Peripartum cardiomyopathy with normal or mildly impaired cardiac function (NYHA Class I or II) if less than 6 months postpartum 2
• Complicated solid organ transplantation (graft failure, rejection, cardiac allograft vasculopathy) 2

Oncologic Contraindications

• Known or suspected malignancy of breast 1

Hepatic Contraindications

• Significant liver disease 1

Other Category 4 Conditions

• Undiagnosed vaginal bleeding 1

Category 3 Conditions (Risks Usually Outweigh Benefits - Generally Avoid)

Thrombotic Risk Conditions

• History of DVT/PE not on anticoagulant therapy with lower risk for recurrence (no additional risk factors) 2
• Women with positive antiphospholipid antibodies should avoid DMPA due to significantly elevated VTE risk (RR 2.67,95% CI 1.29-5.53) 3
• History of stroke or chronic coronary disease - DMPA carries elevated thrombotic risk in these populations 3

Cardiovascular Conditions

• Peripartum cardiomyopathy with normal or mildly impaired cardiac function (NYHA Class I or II) if 6 months or more postpartum 2

Rheumatologic Conditions

• Rheumatoid arthritis on immunosuppressive therapy - classified as Category 2/3 requiring clinical judgment 2
• Systemic lupus erythematosus with positive antiphospholipid antibodies should use DMPA with extreme caution 3

Bone Health Concerns

• Women with osteoporosis risk factors (metabolic bone disease, chronic alcohol/tobacco use, anorexia nervosa, strong family history of osteoporosis, chronic anticonvulsant or corticosteroid use) - DMPA causes BMD loss up to 7.5% over 2 years 3, 1
• Use longer than 2 years is not recommended unless other options are inadequate due to bone mineral density loss 1

Clinical Assessment Algorithm

Step 1: Screen for Absolute Contraindications (Category 4)

• Current or history of thromboembolism/stroke 1
• Active breast cancer or undiagnosed breast mass 1
• Significant liver disease 1
• Undiagnosed vaginal bleeding 1
• Recent peripartum cardiomyopathy (<6 months) 2
• Complicated solid organ transplant 2

If any present: Do not prescribe DMPA

Step 2: Evaluate Category 3 Conditions

• History of DVT/PE without ongoing anticoagulation 2
• Antiphospholipid antibodies or thrombophilia 3
• Osteoporosis risk factors 3, 1
• Rheumatoid arthritis on immunosuppression 2
• Peripartum cardiomyopathy ≥6 months with good function 2

If present: Consider alternative contraception (LNG-IUS preferred) unless patient has no acceptable alternatives 3

Step 3: Special Population Considerations

• Adolescents: Particular concern for BMD loss during critical bone accretion period; mean BMD loss at hip and femoral neck did not fully recover by 5 years post-treatment in those treated >2 years 1
• Cyanotic congenital heart disease: High-risk population that should avoid DMPA 3
• Severe thrombocytopenia: Use with caution 3
• Moderate to severe cardiac impairment (NYHA Class III-IV): Use with extreme caution 3

Monitoring Requirements for Ongoing Use

Immediate Discontinuation Indicators

• Development of thrombosis - discontinue unless no other acceptable birth control options exist 1
• Sudden partial or complete vision loss 1
• Sudden onset of proptosis, diplopia, or migraine 1
• Papilledema or retinal vascular lesions on examination 1

Long-Term Monitoring (If Use Exceeds 2 Years)

• BMD evaluation required when continuation beyond 2 years is necessary 1
• Monitor for signs of thrombosis in all users 3
• Assess bone health particularly in those with additional osteoporosis risk factors 3, 1

Common Pitfalls to Avoid

• Failing to reassess at each injection visit: The 13-week interval provides opportunity to screen for new conditions that would contraindicate continued use 1
• Overlooking thrombotic risk factors: DMPA has significantly higher VTE risk (RR 2.67) compared to other progestin-only methods 3
• Ignoring bone health in young users: Adolescents show incomplete BMD recovery even 5 years after discontinuation if used >2 years 1
• Not considering alternative progestin-only methods: LNG-IUS is first-line for most women due to superior safety profile 3