What are the management options for vaginal bleeding in patients using depot medroxyprogesterone acetate (DMPA) for family planning?

Management of Vaginal Bleeding with Depot Medroxyprogesterone Acetate (DMPA)

For patients experiencing vaginal bleeding on DMPA, first rule out underlying pathology, then treat unscheduled spotting or light bleeding with NSAIDs for 5-7 days, and treat heavy or prolonged bleeding with NSAIDs first-line or add low-dose combined oral contraceptives or estrogen for 10-20 days if NSAIDs fail. 1, 2, 3

Initial Assessment

Before treating bleeding irregularities, evaluate for:

• Pregnancy 1, 3, 4
• Sexually transmitted infections 1, 3, 4
• Medication interactions 1, 3, 4
• New pathologic uterine conditions (polyps, fibroids) 1, 3, 4

If any underlying gynecological problem is identified, treat the condition or refer for care before addressing the bleeding pattern. 1, 3

Treatment Algorithm by Bleeding Pattern

Unscheduled Spotting or Light Bleeding

First-line treatment:

• NSAIDs for 5-7 days during active bleeding episodes only 1, 2, 3, 4
• Specific NSAIDs studied include mefenamic acid and valdecoxib, both showing significant cessation of bleeding within 7 days compared to placebo 1

If bleeding persists and is unacceptable:

• Counsel on alternative contraceptive methods (long-acting reversible contraceptives such as IUDs or implants) 1, 2, 4
• Offer method switching if desired 1, 2, 4

Heavy or Prolonged Bleeding

First-line treatment:

• NSAIDs for 5-7 days during active bleeding episodes 1, 2, 3, 4

Second-line treatment (if NSAIDs fail):

• Low-dose combined oral contraceptives OR estrogen for 10-20 days during active bleeding 1, 2, 3, 4
• Patient must be medically eligible for estrogen-containing contraceptives with no contraindications including severe uncontrolled hypertension, migraines with aura, history of thromboembolism or thrombophilia, active liver disease, or complicated valvular heart disease 4
• Treatment with ethinyl estradiol stops bleeding better than placebo during the treatment period, though discontinuation rates were high in studies 1
• One study in adolescents showed 94% continuation rates when vaginal bleeding was successfully treated with monophasic oral contraceptive pills 5

If bleeding persists despite treatment:

• Counsel on alternative contraceptive methods 1, 2, 4
• Offer method switching if the patient finds bleeding unacceptable 1, 2, 4

Amenorrhea

• Amenorrhea requires no medical treatment—provide reassurance only 1, 3
• Amenorrhea becomes increasingly common with continued use: 55% by month 12 and 68% by month 24 6
• If regular bleeding pattern changes abruptly to amenorrhea, rule out pregnancy if clinically indicated 1, 3
• If amenorrhea persists and the patient finds it unacceptable, counsel on alternative methods 1

Critical Counseling Points

Before initiating DMPA:

• Counsel that irregular bleeding and amenorrhea are common and generally not harmful 1, 2, 3
• Explain that bleeding patterns typically improve with continued use 1, 2, 3
• Enhanced counseling about expected bleeding patterns has been shown to reduce DMPA discontinuation rates in clinical trials 1, 3, 4

Expected timeline:

• Unscheduled bleeding or spotting is common, especially during the first 3-6 months 3
• Amenorrhea becomes increasingly common over time 2
• Irregular bleeding generally decreases with continued use 1, 6

Important Caveats

• Most women using DMPA experience disruption of menstrual bleeding patterns—this is expected and generally not harmful 1, 6
• If abnormal bleeding persists or is severe, appropriate investigation should be instituted to rule out organic pathology 6
• One study found chronic endometritis in 25% of DMPA users (35% in those with breakthrough bleeding versus 15% in those with amenorrhea), suggesting underlying infectious or anatomic causes should be considered 7
• Breakthrough bleeding can occur even after more than 12 months of use—45% of women with breakthrough bleeding in one study had received DMPA for more than 12 months 7
• DMPA does not protect against sexually transmitted diseases, and patients should be counseled accordingly 6