Medroxyprogesterone: Proper Usage and Dosage
Contraceptive Use
For contraception, depot medroxyprogesterone acetate (DMPA) should be administered as either intramuscular (DMPA-IM) or subcutaneous (DMPA-SC) injection every 3 months (13 weeks), with self-administered DMPA-SC now recommended as a preferred option that improves continuation rates and reproductive autonomy. 1
Administration Protocol for Contraception
Dosing interval: Administer DMPA every 13 weeks, with a grace period allowing injections up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 2, 3
Self-administration option: The CDC now recommends self-administered DMPA-SC as an additional delivery approach based on moderate-certainty evidence showing it is safe, effective, and associated with higher continuation rates compared to provider-administered formulations 1
Patient counseling requirements: Self-administration requires instruction on injection technique, proper sharps disposal, access to follow-up care, reinjection reminders, and encouragement to contact providers for side effects or method changes 2
Duration and Safety Considerations
No arbitrary time limits: ACOG does not recommend limiting DMPA use to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh risks of bone density loss 2
Bone health counseling: For patients using DMPA beyond 2 years, counsel on skeletal health measures including 1300 mg calcium daily, 600 IU vitamin D, weight-bearing exercise, and smoking cessation 2
Return to fertility: Inform patients that fertility may be delayed 9-18 months after discontinuation 2, 3
Side Effect Management
Bleeding irregularities: For spotting or light bleeding, consider NSAIDs for 5-7 days 2
Common patterns: Amenorrhea occurs in approximately 75% of users, with breakthrough bleeding in 20% and persistent cyclic bleeding in 10% 4
Endometriosis Treatment
For endometriosis, oral medroxyprogesterone acetate (MPA) at 50 mg daily for 3-4 months effectively reduces symptoms and disease severity, though evidence suggests it may not be superior to expectant management for fertility outcomes.
Dosing for Endometriosis
Standard regimen: Administer oral MPA 50 mg daily for 3-4 months for symptomatic endometriosis 4, 5
Alternative dosing: Historical studies used 30 mg daily for 90 days with similar efficacy 6, 7
Subcutaneous depot option: DMPA-SC 104 mg every 3 months for 6 months is equivalent to leuprolide acetate for pain reduction, with less bone mineral density loss and fewer hypoestrogenic symptoms but more irregular bleeding 8
Expected Outcomes
Symptom improvement: Approximately 80% of patients experience improvement in pain, pelvic nodularity, and tenderness 4
Disease regression: Mean American Fertility Society stage scores decrease significantly (from 18.2 to 5.9 in one study) 4
Mechanism: MPA induces pseudodecidualized reaction and atrophic changes in both eutopic endometrium and ectopic implants, while suppressing ovulation and reducing LH and estradiol levels 4
Critical Evidence Limitation
A major caveat: A randomized, placebo-controlled trial found that both MPA 50 mg daily and placebo achieved similar significant reductions in endometriosis stages and scores at second-look laparoscopy, questioning whether medical therapy should be instituted at all for mild to moderate disease. 5
This 2000 study of 100 infertile women showed no difference in disease regression between MPA and placebo groups 5
Pregnancy rates were actually higher in the placebo group (6 pregnancies) versus MPA group (1 pregnancy) during the 6-month follow-up 5
For stage I and II endometriosis with infertility, expectant management with correction of other fertility factors may be warranted before initiating medical therapy, as cumulative pregnancy rates at 30 months were 71% with MPA versus 55% with no treatment (not statistically significant) 7
Other Indications (Non-Contraceptive, Non-Endometriosis)
Secondary Amenorrhea
Dosing: 5-10 mg daily for 5-10 days, with 10 mg daily for 10 days optimal for inducing secretory transformation of adequately primed endometrium 9
Timing: May be started at any time 9
Expected response: Progestin withdrawal bleeding usually occurs within 3-7 days after discontinuing therapy 9
Abnormal Uterine Bleeding
Dosing: 5-10 mg daily for 5-10 days, beginning on calculated day 16 or 21 of menstrual cycle 9
Optimal regimen: 10 mg daily for 10 days beginning on day 16 of cycle for adequately primed endometrium 9
Planned cycling: Patients with recurrent episodes may benefit from planned menstrual cycling with MPA 9
Endometrial Hyperplasia Prevention
Dosing: 5-10 mg daily for 12-14 consecutive days per month in postmenopausal women receiving daily 0.625 mg conjugated estrogens 9
Timing options: Begin on day 1 or day 16 of cycle 9
Duration: Use lowest effective dose for shortest duration consistent with treatment goals, with re-evaluation every 3-6 months 9
Hormone Replacement in Premature Ovarian Insufficiency
Dosing: When oral/vaginal progestin is added to transdermal estradiol, use MPA 10 mg daily for 12-14 days every 28 days 1
Alternative: Micronized progesterone 200 mg daily is preferred over MPA in this population due to better cardiovascular profile 1
Important Contraindications
Micronized progesterone (not MPA) is contraindicated in patients with severe peanut allergies due to peanut oil excipients, and in patients with hormone receptor-positive cancers 10
Before prescribing estrogen-containing contraceptives in combination scenarios, verify no contraindications exist such as thromboembolism history, migraine with aura, uncontrolled hypertension, or smoking over age 35 3