What is the proper way to write a prescription for Depo-Provera (medroxyprogesterone) for birth control?

How to Write a Prescription for Depo-Provera for Birth Control

Prescribe Depo-Provera (medroxyprogesterone acetate) 150 mg intramuscularly every 13 weeks, administered by deep IM injection into the gluteal or deltoid muscle, with the first injection given only during the first 5 days of a normal menstrual period. 1

Prescription Components

Formulation Options

• Intramuscular (IM) formulation: Write for medroxyprogesterone acetate injectable suspension 150 mg/mL, administered every 3 months (13 weeks) by deep IM injection into the gluteal or deltoid muscle 1
• Subcutaneous (SC) formulation: Write for medroxyprogesterone acetate subcutaneous injection 104 mg/0.65 mL every 13 weeks, which can be prescribed for self-administration (off-label use) 2

Dosing Schedule

• The standard reinjection interval is every 13 weeks 2, 3, 1
• Injections can be given up to 2 weeks late (15 weeks from the last injection) without requiring additional contraceptive protection 2, 3
• If the interval exceeds 15 weeks, verify the patient is not pregnant before administering the next injection 1

Initial Injection Timing

For Non-Postpartum Patients

• Administer the first injection ONLY during the first 5 days of a normal menstrual period to ensure the patient is not pregnant 1

For Postpartum Patients

• Give the first injection within the first 5 days postpartum if not exclusively breastfeeding 1
• For exclusively breastfeeding mothers, administer during or after the sixth postpartum week 1

Administration Instructions

IM Injection Technique

• Shake the 1 mL vial vigorously just before use to ensure uniform suspension 1
• Use strict aseptic technique for deep IM injection 1
• Rotate injection sites between gluteal and deltoid muscles with every injection 1
• Assess body habitus prior to each injection to determine if a longer needle is necessary, particularly for gluteal IM injection, to avoid inadvertent subcutaneous administration 1

Self-Administration Option (Off-Label)

• The CDC recommends self-administration of DMPA-SC as an additional approach that can improve contraceptive access and increase reproductive autonomy 2, 3
• Provide instruction (in-person or through telemedicine) on self-injection technique and sharps disposal 2
• Ensure access to follow-up care for questions or to switch methods 2
• Set up reinjection reminders 2

Duration of Use Counseling

Long-Term Use Recommendations

• The FDA label states that use for longer than 2 years is not recommended unless other birth control methods are considered inadequate, due to bone mineral density (BMD) loss 1
• However, ACOG does not recommend limiting use to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh the risks of bone density loss 3, 4
• No time limit exists for DMPA use according to ACOG, despite the FDA black box warning 4

Bone Health Counseling for Long-Term Users

• For patients continuing beyond 2 years, counsel about skeletal health measures including daily calcium intake of 1,300 mg 3, 4
• Recommend daily vitamin D intake of 600 IU 3, 4
• Advise regular weight-bearing exercise 3, 4
• Encourage smoking cessation 3, 4
• Routine bone density monitoring is not recommended, even after prolonged use beyond 2 years 4

Pre-Prescription Considerations

No Required Testing

• No examinations or laboratory tests are needed before initiating DMPA 4
• Baseline weight and BMI measurement may be useful for monitoring over time 4

Contraindications to Screen For

• Active thrombophlebitis, current or history of thromboembolic disorders, or cerebral vascular disease 1
• Known or suspected malignancy of breast 1
• Known hypersensitivity to medroxyprogesterone acetate or any ingredients 1
• Significant liver disease 1
• Undiagnosed vaginal bleeding 1

Patient Counseling Points

Expected Side Effects

• Menstrual irregularities are common, with amenorrhea occurring in 57% of women by the end of one year 5
• For spotting or light bleeding, NSAIDs for 5-7 days may be considered 3
• Weight gain at 6 months (>5% increase) is a strong predictor of future excessive weight gain 4

Return to Fertility

• Return to fertility may be delayed 9-18 months after discontinuation 3, 4
• Median time for return to ovulation is 30 weeks, with a 97.4% cumulative rate of return to ovulation at 12 months 6

Common Pitfalls to Avoid

• Do not require a pelvic exam or laboratory testing before prescribing, as this creates unnecessary barriers to contraceptive access 4
• Do not discontinue DMPA at 2 years based solely on duration concerns, as this increases risk of unintended pregnancy without clear benefit per ACOG guidelines 4
• Do not routinely order bone density scans after 2 years of use unless other osteoporosis risk factors are present 4
• Do not wait for a menstrual period to return before giving subsequent injections, as many users are amenorrheic 7
• Do not adjust dosage for body weight, as efficacy is not affected 1