What are the recommendations for a 52-year-old woman who wants to continue using Depo-Provera (medroxyprogesterone acetate) for pregnancy prevention after years of use and amenorrhea?

Continuing Depo-Provera at Age 52

A 52-year-old woman who has been on Depo-Provera for years can continue the medication for pregnancy prevention, but she should be counseled that she may already be menopausal and contraception may no longer be necessary—the key is determining if she has reached menopause, which is challenging given Depo-induced amenorrhea. 1

Age-Related Considerations for DMPA Use

Women over age 45 are classified as U.S. MEC Category 2 for DMPA use, meaning the advantages generally outweigh theoretical risks. 1 This is a higher category than for younger women (18-45 years: Category 1), reflecting increased concerns but not prohibiting use. 1

The primary concern at this age is bone mineral density loss, as DMPA use beyond 2 years increases risk of osteopenia and osteoporosis. 2 The FDA specifically warns that DMPA should not be used for more than 2 years unless other birth control methods are inadequate. 2 However, this woman has already been using it for years, so the bone loss concern is already present.

Determining Need for Continued Contraception

Assessing Menopausal Status

The critical clinical question is whether this patient still needs contraception at all. Women are considered menopausal after 12 months of amenorrhea in the absence of other causes, but Depo-Provera itself causes amenorrhea in 55% of users by 12 months and 68% by 24 months, making natural menopause impossible to diagnose clinically while on the medication. 1

For women over age 50, fertility is significantly reduced but not absent until confirmed menopause. The average age of menopause in the United States is 51 years, making this patient likely perimenopausal or postmenopausal. 1

Practical Approach

• If she wishes to determine menopausal status: She would need to discontinue Depo-Provera and use an alternative contraceptive method (such as barrier methods or a copper IUD) for 12 months to see if menses return. 1 If no menses occur for 12 months after stopping DMPA, she can be considered menopausal and contraception can be discontinued.

• If she wishes to continue DMPA: She can continue receiving injections every 12 weeks (with a 2-week grace period, so up to 14 weeks from last injection without requiring backup contraception). 1 The injection can be given early when necessary. 1

Ongoing Management Recommendations

Bone Health Monitoring

Given her prolonged DMPA use beyond 2 years, bone health is paramount:

• Ensure adequate calcium intake of at least 1300 mg daily plus 600 IU vitamin D 1
• Encourage regular weight-bearing exercise 1
• Smoking cessation if applicable 1
• Consider baseline bone density measurement given prolonged use, though this is not explicitly required by guidelines 1

Injection Timing

• Continue injections every 12 weeks (84 days) 1
• Grace period extends to 2 weeks late (14 weeks total from last injection) without requiring backup contraception 1
• If more than 14 weeks from last injection, ensure she is not pregnant before administering, and advise abstinence or backup contraception for 7 days 1

Amenorrhea Management

Her amenorrhea requires no medical treatment and is expected with long-term DMPA use—provide reassurance that this is normal. 1 If her bleeding pattern changes abruptly (such as sudden return of bleeding), rule out pregnancy or other gynecologic pathology. 1

Alternative Contraceptive Options

Given her age and prolonged DMPA exposure, consider discussing alternatives:

• Copper IUD (Paragard): No hormonal effects, highly effective (0.8% failure rate), lasts 10 years, and would allow assessment of natural menstrual cycles to determine menopausal status 1, 3
• Levonorgestrel IUD (Mirena): Highly effective (0.2% failure rate), may provide endometrial protection, though also causes amenorrhea 1, 3
• Barrier methods alone may be sufficient given her likely reduced fertility at age 52

Common Pitfalls to Avoid

• Do not assume she needs contraception indefinitely—at 52, she may be menopausal and continuing unnecessary medication with bone health risks
• Do not perform pelvic examination before continuing DMPA—no examination is needed for continuation 1
• Do not wait for return of menses to determine if DMPA is still working—amenorrhea is the expected outcome, not a sign of failure 1
• Do not forget to counsel about the 2-year limitation recommendation—while she can continue beyond 2 years, she should understand the increased osteoporosis risk 2