What are the contraindications to Depo-Provera (medroxyprogesterone acetate)?

Contraindications to Depo-Provera (DMPA)

Depo-Provera is absolutely contraindicated in patients with active or history of thromboembolic disorders, known or suspected breast malignancy, significant liver disease, undiagnosed vaginal bleeding, or known hypersensitivity to medroxyprogesterone acetate. 1

Absolute Contraindications

The FDA label clearly defines the following as absolute contraindications:

• Active thrombophlebitis, current or history of thromboembolic disorders, or cerebral vascular disease - This includes deep vein thrombosis, pulmonary embolism, stroke, or myocardial infarction 1, 2

• Known or suspected malignancy of breast - Any current or suspected breast cancer is an absolute contraindication 1, 2

• Significant liver disease - Active or severe hepatic dysfunction precludes use 1

• Undiagnosed vaginal bleeding - Must be evaluated and diagnosed before initiating DMPA 1

• Known hypersensitivity to medroxyprogesterone acetate or any ingredient - Any documented allergic reaction to the medication 1

Additional High-Risk Conditions

Beyond the FDA-labeled absolute contraindications, certain conditions warrant extreme caution or avoidance:

• History of neurofibromas or meningiomas - Evidence suggests DMPA may stimulate tumor growth, particularly with high-dose depot injections 2

• Active smoking combined with other cardiovascular risk factors - While not an absolute contraindication like with combined hormonal contraceptives, smoking increases cardiovascular risk 2

Important Clinical Considerations

Pregnancy Status

• The first injection must be given ONLY during the first 5 days of a normal menstrual period or within the first 5 days postpartum to ensure the patient is not pregnant 1
• In exclusively breastfeeding mothers, administer during or after the sixth postpartum week 1
• If the interval between injections exceeds 13 weeks, pregnancy must be ruled out before re-administration 1

Not Contraindications (Common Misconceptions)

The following are NOT contraindications to DMPA use:

• Past history of pelvic inflammatory disease (PID) - Only current PID is a contraindication 3
• HIV infection or immunosuppression - These do not preclude DMPA use 3
• Adolescent age - DMPA can be used in adolescents, though bone density concerns require counseling 3

Long-Term Use Caution

• Use beyond 2 years is not recommended unless other methods are inadequate due to bone mineral density loss, though this is not an absolute contraindication 1, 3
• The American College of Obstetricians and Gynecologists does not recommend restricting use to 2 years if it is the patient's best contraceptive option, as unintended pregnancy poses greater risks 4

Clinical Pitfalls to Avoid

• Do not confuse relative and absolute contraindications - The FDA-labeled contraindications are absolute and must be respected 1
• Do not administer if thrombosis develops during treatment - Discontinue immediately unless no other acceptable birth control options exist 1
• Do not re-administer if sudden vision changes, proptosis, diplopia, migraine, papilledema, or retinal vascular lesions develop - These suggest serious vascular events 1