How to administer Depo-Trust (medroxyprogesterone)?

How to Administer Depo-Trust (Medroxyprogesterone Acetate)

Administer 150 mg of medroxyprogesterone acetate by deep intramuscular injection into the gluteal or deltoid muscle every 13 weeks, after vigorously shaking the vial to ensure uniform suspension. 1

Preparation and Injection Technique

Pre-Injection Steps

• Vigorously shake the 1 mL vial immediately before use to ensure the dose represents a uniform suspension 1
• Assess body habitus prior to each injection to determine if a longer needle is necessary, particularly for gluteal injections, to avoid inadvertent subcutaneous administration 1
• Use strict aseptic technique 1

Injection Site and Method

• Administer by deep intramuscular (IM) injection into either:
  • Gluteal muscle (preferred), or
  • Deltoid muscle 1
• Rotate injection sites with every administration 1
• The dose is 150 mg administered every 3 months (13 weeks) 1

Timing of First Injection

Give the first injection ONLY during the first 5 days of a normal menstrual period to ensure the patient is not pregnant at the time of administration 1

Alternative Timing for Postpartum Patients

• Non-breastfeeding mothers: Within the first 5 days postpartum 1
• Exclusively breastfeeding mothers: During or after the sixth postpartum week 1

Quick-Start Method

• Mid-cycle or "quick start" initiation is acceptable if you are reasonably certain the patient is not pregnant 2
• Require backup contraception (condoms or abstinence) for the first 7 days after initial injection 2

Repeat Injection Schedule

Schedule repeat injections every 13 weeks (91 days) 2, 1

Grace Period for Late Injections

• The injection can be given up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 3, 2
• If more than 2 weeks late (>15 weeks), determine the patient is not pregnant before administering, and instruct the patient to use backup contraception for 7 days 3, 1
• No time limits exist on early injections—they can be given when necessary (e.g., when a patient cannot return at the routine interval) 2

Practical Scheduling Tip

• Many providers schedule adolescents every 11-12 weeks to allow buffer time for missed appointments 2

Subcutaneous Formulation Alternative

A 104 mg subcutaneous formulation is available and has equivalent effectiveness and side effects to the 150 mg intramuscular injection 2, 4

Self-Administration Option

• Subcutaneous DMPA (104 mg) can be self-administered as an additional approach to deliver injectable contraception 3
• Self-administration should be offered through shared decision-making, with a focus on patient preferences and equitable access 3
• Critical implementation elements include instruction on self-injection technique and sharps disposal education 2
• Self-administration has higher continuation rates compared with provider-administered DMPA 3

Essential Patient Counseling Before First Injection

Menstrual Changes (Critical to Prevent Discontinuation)

• Counsel that nearly all patients experience menstrual irregularities initially with unpredictable spotting and bleeding 2
• Bleeding patterns typically improve over time, with amenorrhea becoming common (57% by end of first year) 2, 5
• Pre-injection counseling about menstrual changes reduces discontinuation rates 2

Backup Contraception

• Use backup contraception for the first 7 days after initial injection 2
• Typical use failure rate is approximately 6% in the first year 2

STI Protection

• Counsel to use condoms at all times for STI protection, as DMPA provides no protection against sexually transmitted infections 2

Weight Gain

• Weight gain occurs in some but not all patients 2, 6
• Weight gain at 6 months (>5% increase) is a strong predictor of future excessive weight gain with ongoing use 2, 7

Bone Health

• DMPA causes reversible reductions in bone mineral density, but BMD substantially recovers after discontinuation 2
• Counsel all patients on skeletal health promotion: daily calcium intake of 1,300 mg, vitamin D 600 IU, regular weight-bearing exercise, and avoidance of smoking and alcohol 2, 7

Duration of Use

• Use for longer than 2 years is not recommended unless other birth control methods are considered inadequate, due to bone mineral density concerns 1
• However, the American College of Obstetricians and Gynecologists does not recommend restricting use to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh the risks 7

Common Pitfalls to Avoid

• Do not fail to shake the vial vigorously before drawing up the dose—this is critical for uniform suspension 1
• Do not administer subcutaneously when intramuscular injection is intended—assess body habitus and use appropriate needle length 1
• Do not skip counseling about menstrual irregularities before first injection—this significantly reduces discontinuation 2
• Do not assume amenorrhea after DMPA is pathologic without ruling out other causes 2
• Do not routinely monitor bone density or limit use to 2 years based solely on BMD concerns 2, 7

Switching from Other Contraceptive Methods

When switching from oral contraceptives, give the first DMPA injection on the day after the last active tablet, or at the latest, on the day following the final inactive tablet to ensure continuous contraceptive coverage 1