What back-up contraceptive method is recommended after the first dose of the Depo (medroxyprogesterone acetate) shot?

Backup Contraception After First Depo-Provera Injection

Use backup contraception (condoms or abstinence) for 7 consecutive days after the first Depo-Provera injection if given more than 7 days after menstrual bleeding started. 1, 2

Timing-Based Algorithm for Backup Contraception

No Backup Needed

• If injection given within first 5-7 days of menstrual cycle: No backup contraception required 1, 2, 3
• The woman is immediately protected against pregnancy when started in this window 3
• Approximately 90% of women develop poor quality cervical mucus within 24 hours of injection, providing rapid contraceptive effect 3

Backup Required for 7 Days

• If injection given more than 7 days after menses started: Use backup contraception for 7 consecutive days after the injection 1, 2
• This applies to "quick start" or "mid-cycle" initiation, which is acceptable if reasonably certain the patient is not pregnant 1
• The 7-day period allows sufficient time for the injection to establish contraceptive levels 1

Preferred Backup Method

Condoms are the preferred backup method because they provide dual protection against both pregnancy and sexually transmitted infections 1

• Complete abstinence from sexual intercourse for 7 days is an alternative to barrier methods 1
• DMPA provides no protection against STIs, so condom use should be counseled at all times regardless of injection timing 1

Emergency Contraception Considerations

Consider emergency contraception if unprotected intercourse occurred within 5 days before receiving the injection, especially if given outside the first week of the cycle 2

• Ulipristal (Ella) may be more effective than levonorgestrel, particularly after 72 hours and in overweight/obese women 1
• Copper IUD insertion within 5 days is the most effective emergency contraception option 1

Evidence Supporting the 7-Day Window

Research demonstrates that DMPA injections given between days 8-13 of the menstrual cycle failed to prevent ovulation in 30% of women, with all ovulations occurring within 3 days after injection 4

• This supports the recommendation for 7 days of backup contraception when starting outside the optimal window 4
• Injections given on days 8-9 were more effective at preventing ovulation than those given on days 10-13 4

Critical Pitfall to Avoid

Do not assume patients need backup contraception if the injection was given within the first 7 days of menses 1, 3

• This is a common source of confusion and unnecessary anxiety 3
• Document clearly whether the injection was given within or outside the 7-day window to guide counseling 3