Switching from Combined Oral Contraceptive to Depot Medroxyprogesterone Acetate
You can start DMPA immediately without waiting for a menstrual period—simply begin the injection at any time during the pill pack, finish the current pack of COCs, and use backup contraception (condoms or abstinence) for 7 days after the DMPA injection. 1
Timing of the Switch
Start DMPA at any point during your current COC pack—there is no need to wait for withdrawal bleeding or complete the pack before initiating the depot shot. 1
Continue taking the COC until the pack is finished to maintain contraceptive coverage during the transition, as this prevents any gap in protection. 2
Administer the first DMPA injection (150 mg intramuscularly or 104 mg subcutaneously) while still on the COC, ensuring overlap between methods rather than creating a gap. 3, 4
Backup Contraception Requirements
Use backup contraception (condoms or abstinence) for 7 days after the DMPA injection, regardless of when during the COC pack you receive the shot. 1
This 7-day window is necessary because while DMPA begins working immediately to suppress ovulation, the standard recommendation ensures full contraceptive efficacy is established. 1
Formulation Options
Two equivalent DMPA formulations are available: 150 mg intramuscularly every 13 weeks (Depo-Provera) or 104 mg subcutaneously every 13 weeks (DMPA-SC). 3, 5
Self-administered subcutaneous DMPA-SC is now recommended as an additional option that can improve contraceptive access and increase reproductive autonomy, though this is considered off-label use. 6, 3
Key Clinical Considerations Before Switching
Screen for new contraindications to progestin-only contraception, including history of stroke, myocardial infarction, pulmonary embolism, deep vein thrombosis, current breast cancer, and history of meningiomas. 3
Counsel about return to fertility differences: DMPA can delay return to fertility for 9-18 months after discontinuation, whereas COCs allow immediate return to fertility once stopped. 1, 5
Discuss expected menstrual changes: Most DMPA users experience irregular bleeding initially, with 57% developing amenorrhea by one year of use—a significant change from the predictable withdrawal bleeding with COCs. 7
Counsel about bone health: Recommend daily intake of 1300 mg calcium and 600 IU vitamin D, regular weight-bearing exercise, and smoking cessation, particularly for long-term use beyond 2 years. 3, 5
Follow-Up and Reinjection Schedule
No routine follow-up visit is required between injections, but patients should contact you to discuss side effects, method changes, or injection concerns. 6, 3, 5
Schedule repeat injections every 3 months (13 weeks), with a grace period allowing injections up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection. 6, 3, 5
If more than 15 weeks have elapsed since the last injection, verify the patient is not pregnant before administering the next dose and require backup contraception for 7 days. 3
Common Pitfalls to Avoid
Do not wait for a menstrual period before starting DMPA—this creates an unnecessary gap in contraceptive coverage and increases pregnancy risk. 1
Do not assume continuous contraceptive coverage without the 7-day backup period—even though there is overlap with the COC, the standard 7-day backup recommendation applies when initiating DMPA. 1
Do not forget to counsel about weight changes—patients should be informed that weight gain is a common side effect, and those with higher body weights may experience longer delays in return to fertility after discontinuation. 3, 4
Do not limit DMPA use to 2 years based solely on bone density concerns—the benefits of preventing unwanted pregnancy generally outweigh the risks of bone density loss. 5