What is the protocol for a female wanting Depo-Provera (Medroxyprogesterone Acetate) for contraception?

Protocol for Initiating Depo-Provera (DMPA) for Contraception

Start Depo-Provera at any time if you are reasonably certain the patient is not pregnant, with backup contraception (condoms or abstinence) for 7 days if initiated more than 7 days after menses started. 1

Pre-Initiation Requirements

No Examination or Testing Required

• No physical examination, pelvic exam, or laboratory tests are needed before starting DMPA 1
• Blood pressure measurement is not required (unlike combined hormonal contraceptives) 1
• Weight/BMI measurement is optional but may be helpful for baseline documentation to address future weight concerns 1

Timing of First Injection

The FDA-approved approach requires first injection during the first 5 days of normal menses or within first 5 days postpartum 2. However, CDC guidelines allow more flexible "Quick Start" at any time if reasonably certain patient is not pregnant 1:

• If within 7 days of menses starting: No backup contraception needed 1
• If >7 days after menses started: Use backup contraception (condoms/abstinence) for 7 days 1
• For exclusively breastfeeding postpartum mothers: Administer during or after the sixth postpartum week 2

Assessing Pregnancy Status ("Reasonably Certain Not Pregnant")

If uncertain about pregnancy status, the benefits of starting DMPA likely exceed any risk; start the method with follow-up pregnancy test in 2-4 weeks 1

Contraindications to Screen For

Absolute Contraindications

• Current pregnancy 2
• History of stroke or myocardial infarction 3
• Pulmonary embolism or deep vein thrombosis 3
• Active smoking combined with other cardiovascular risk factors 3
• History of neurofibromas or meningiomas (DMPA may stimulate tumor growth) 3

Conditions That Are NOT Contraindications

• Past history of pelvic inflammatory disease (only current PID is contraindicated) 3
• HIV infection or immunosuppression 3
• Adolescent age (though bone density counseling is needed) 3
• Nulliparity 1

Administration Protocol

Dosing

• 150 mg intramuscular injection every 3 months (13 weeks) 2
• Inject deep IM in gluteal or deltoid muscle, rotating sites 2
• Vigorously shake vial before use to ensure uniform suspension 2
• Assess body habitus to determine if longer needle needed to avoid inadvertent subcutaneous injection 2

Alternative: Self-Administered Subcutaneous Formulation

• DMPA-SC 104 mg subcutaneously is now recommended as an option that can improve access and increase reproductive autonomy 4
• Self-administration requires instruction on injection technique, sharps disposal, access to follow-up, and reinjection reminders 4
• Self-administered DMPA-SC shows higher continuation rates than provider-administered DMPA 4

Reinjection Schedule and Grace Period

• Standard reinjection interval: Every 13 weeks 4, 2
• Grace period: Up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 4
• If >15 weeks from last injection: Verify patient is not pregnant before administering next dose 2

Essential Counseling Points

Menstrual Changes (Most Important)

• Irregular bleeding/spotting is common initially; amenorrhea typically develops with long-term use 5, 6
• For spotting or light bleeding: NSAIDs for 5-7 days may help 1, 4
• Menstrual disturbances rarely require operative intervention 5
• Counsel patients to seek advice early rather than waiting for next appointment 5

Return to Fertility

• Fertility may be delayed 9-18 months after discontinuation 4, 6
• MPA can be detected in serum for up to 9 months after single injection 7
• Not appropriate for women who may wish to conceive within next 2 years 6

Weight Changes

• Weight gain is a potential side effect 5
• Consider assessing weight at baseline for future comparison 1

Bone Mineral Density

• FDA recommends use for longer than 2 years is not recommended unless other methods are inadequate 2
• However, ACOG states benefits of preventing unwanted pregnancy generally outweigh risks of bone density loss, and does not recommend limiting use to 2 years 4
• For use beyond 2 years: Counsel on skeletal health measures including 1300 mg calcium daily, 600 IU vitamin D daily, regular weight-bearing exercise, and smoking cessation 4

Common Pitfalls to Avoid

• Do not delay initiation waiting for menses if reasonably certain patient is not pregnant—use Quick Start approach 1
• Do not require unnecessary examinations (pelvic exam, labs) that create barriers to access 1
• Do not forget the 7-day backup contraception rule when starting >7 days after menses 1
• Do not assume continuous contraceptive coverage if patient presents >15 weeks from last injection—verify not pregnant first 2
• Do not discourage long-term use solely based on 2-year FDA limitation—individualize based on patient preference and other contraceptive options 4