What are the uses and dosages of Provera (medroxyprogesterone acetate)?

Provera (Medroxyprogesterone Acetate): Uses and Dosages

Primary Contraceptive Use

Provera (depot medroxyprogesterone acetate, DMPA) is administered as 150 mg intramuscularly every 13 weeks or 104 mg subcutaneously every 13 weeks for highly effective contraception, with the subcutaneous formulation now recommended for self-administration to improve access and continuation rates. 1, 2, 3

Dosing Schedule and Administration

• Standard dosing: Administer every 3 months (13 weeks), with a grace period allowing injections up to 2 weeks late (15 weeks from last injection) without requiring backup contraception 1, 2, 3
• Two equivalent formulations available:
  • 150 mg intramuscular (DMPA-IM) every 13 weeks 2
  • 104 mg subcutaneous (DMPA-SC) every 13 weeks 2

Self-Administration Option

• The CDC now recommends self-administered DMPA-SC as an additional delivery approach based on moderate-certainty evidence showing it is safe, effective, and achieves higher continuation rates than provider-administered formulations 1, 2
• Self-administration is considered off-label use since FDA labeling specifies healthcare professional administration, but providers can prescribe it when medically indicated 1, 2
• Critical implementation elements include instruction on self-injection technique, sharps disposal guidance, access to follow-up care, and reinjection reminders 1, 2

Follow-Up Requirements

• No routine follow-up visits are required between injections 2, 3
• Patients should contact their provider to discuss side effects, change methods, or address injection concerns 1, 2
• At each visit (if patient presents), assess satisfaction, screen for new contraindications (stroke, MI, PE, DVT, meningiomas), evaluate new medical conditions, and monitor weight changes 2

Late Injection Protocol

• If on time or up to 2 weeks late: Administer injection without backup contraception 2
• If more than 2 weeks late: Administer only if reasonably certain patient is not pregnant; require abstinence or backup contraception for 7 days 2

Oncologic Uses

For endometrial or renal carcinoma, DMPA is dosed at 400-1000 mg intramuscularly per week initially as adjunctive and palliative treatment in advanced inoperable cases. 4

• If improvement occurs within weeks to months and disease stabilizes, maintenance doses as low as 400 mg per month may suffice 4
• This is not recommended as primary therapy but for recurrent or metastatic disease 4

Endometriosis Treatment

Oral medroxyprogesterone acetate at 50 mg daily for 4 months effectively treats moderate to severe endometriosis, improving symptoms in 80% of patients. 5

• This dosing regimen significantly reduces disease staging scores and induces atrophic changes in both endometrium and ectopic implants 5
• Ovulation is suppressed in all patients, with amenorrhea occurring in 75% 5

Key Clinical Considerations

Duration of Use

• Do not limit DMPA use to 2 years based solely on bone density concerns—the benefits of pregnancy prevention outweigh risks 2, 3
• For use beyond 2 years, counsel patients on skeletal health measures: 1300 mg calcium and 600 IU vitamin D daily, regular weight-bearing exercise, and smoking cessation 3

Return to Fertility

• Fertility may be delayed 9-18 months after discontinuation 3
• MPA can be detected in serum for up to 9 months after a single 150 mg injection 6

Side Effect Management

• For spotting or light bleeding: Consider NSAIDs for 5-7 days 3
• Menstrual disturbances are common but rarely require operative intervention and can be improved with short courses of estrogen or shorter injection intervals 7
• Weight gain is a potential disadvantage that should be monitored 2, 7

Contraindications

• Screen for history of stroke, MI, PE, DVT, and meningiomas 2
• Note that micronized progesterone formulations (not DMPA) are contraindicated in severe peanut allergies and hormone receptor-positive cancers 8

Patient Counseling

• Counsel on STI protection: DMPA provides no protection against sexually transmitted infections; recommend condoms 2
• Pre-use counseling is essential to minimize impact of menstrual changes, which occur in most patients 7
• Offer through shared decision-making in a noncoercive manner with focus on patient preferences and access to full range of contraceptive methods 1, 2