What knowledge and skills are required to administer Depo-Provera (medroxyprogesterone acetate) safely and effectively?

Knowledge and Skills Required for Depo-Provera Administration

Healthcare providers administering Depo-Provera must be trained in proper injection technique (intramuscular or subcutaneous), pregnancy assessment, contraceptive counseling, and management of common side effects, while patients receiving self-administered subcutaneous formulations require instruction in self-injection technique, sharps disposal, and access to follow-up care. 1, 2

Pre-Administration Knowledge Requirements

Medical Eligibility Assessment

• Screen for absolute contraindications including active thrombophlebitis, current or past thromboembolic disorders, cerebral vascular disease, known or suspected breast malignancy, significant liver disease, undiagnosed vaginal bleeding, and known hypersensitivity to medroxyprogesterone acetate 3
• Assess for history of stroke, myocardial infarction, pulmonary embolism, deep vein thrombosis, and meningiomas 2
• Evaluate patients with strong family history of breast cancer carefully, as they require closer monitoring 3
• No laboratory tests or physical examinations are required before initiating DMPA, though baseline weight and BMI measurement may be useful for monitoring 4

Pregnancy Exclusion

• Ensure the patient is not pregnant before administration, as fetal exposure may lead to low birth weight and other problems 3, 5
• Use clinical judgment and pregnancy testing when indicated to establish reasonable certainty that the patient is not pregnant 2

Contraceptive Counseling Skills

• Provide comprehensive counseling about menstrual irregularities, which occur in 57% of users at 12 months and 32% at 24 months, with amenorrhea becoming common (57% by end of first year) 3, 5
• Counsel about weight gain, which occurs in 38% of users (>10 lb at 24 months), and that weight gain at 6 months (>5% increase) predicts future excessive weight gain 3, 4
• Discuss bone mineral density concerns: inform patients that bone loss is greater with increasing duration of use and may not be completely reversible, though use should not be limited to 2 years as benefits of pregnancy prevention generally outweigh risks 3, 4
• Explain that return to fertility may be delayed 9-18 months after discontinuation 1, 4
• Emphasize that DMPA provides no protection against sexually transmitted infections and condoms should be used for STI protection 2

Administration Skills

Provider-Administered Intramuscular (IM) Formulation

• Administer 150 mg by deep intramuscular injection in the gluteal or deltoid muscle every 3 months (13 weeks) 3, 1
• Master proper IM injection technique to ensure deep muscle penetration 3
• Understand that injections can be given up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 1, 2

Provider-Administered Subcutaneous (SC) Formulation

• Administer 104 mg subcutaneously every 3 months (13 weeks) 2
• Demonstrate proper subcutaneous injection technique 6

Self-Administration Training (for SC formulation)

Critical implementation elements for patient self-administration include: 1, 2

• Instruction on proper self-injection technique for subcutaneous administration 1, 2
• Guidance on proper sharps disposal 1, 2
• Ensuring access to follow-up care 1, 2
• Providing reinjection reminders 1, 2
• Addressing administrative issues including prescription access and insurance coverage 1

Self-administered DMPA-SC should be offered through shared decision-making in a noncoercive manner with focus on patient preferences, and provider-administered options must remain available 2, 6

Post-Administration Management Skills

Timing and Follow-Up

• No routine follow-up visits are required between injections 2, 4
• Schedule repeat injections every 13 weeks, with grace period up to 15 weeks from last injection 1, 2
• If more than 2 weeks late (>15 weeks), administer injection only if reasonably certain patient is not pregnant, and require abstinence or backup contraception for 7 days 2

Ongoing Assessment at Reinjection Visits

• Assess patient satisfaction with the method 2
• Evaluate for new medical conditions that would change appropriateness of DMPA based on U.S. Medical Eligibility Criteria 2
• Monitor weight changes and counsel patients concerned about weight 2
• Screen for new contraindications 2

Side Effect Management

• For spotting or light bleeding, consider NSAIDs for 5-7 days 1
• Encourage patients to contact provider to discuss side effects, change methods, or address injection concerns 1, 2
• Understand that menstrual disturbances rarely require operative intervention and can often be improved with short courses of estrogen or shorter injection intervals 7

Long-Term Use Counseling

• For patients continuing DMPA beyond 2 years, counsel about skeletal health measures including daily calcium intake of 1,300 mg, vitamin D intake of 600 IU, regular weight-bearing exercise, and smoking cessation 4, 1
• Do not routinely order bone density scans unless patient has additional osteoporosis risk factors 4
• Monitor diabetic patients carefully as DMPA may affect carbohydrate metabolism 3

Common Pitfalls to Avoid

• Do not limit use to 2 years based solely on duration concerns, as this increases risk of unintended pregnancy without clear benefit 4, 2
• Do not require routine laboratory panels (CBC, metabolic panel, liver function tests) for DMPA monitoring, as this increases costs without evidence of benefit 4
• Do not require routine follow-up visits between injections 2, 4
• Do not order DEXA scans at 2 years based solely on duration, as this contradicts current guidelines 4
• Ensure patients receive injections on schedule to prevent pregnancy, as the method's effectiveness depends on timely administration 5

Special Populations

HIV-Infected Patients

• HIV infection is not a contraindication to DMPA use (CDC category 2) 6
• DMPA levels are not reduced by antiretroviral agents and the agent is largely free of antiretroviral interactions 6, 4
• No additional routine blood testing is required specifically for contraceptive monitoring in HIV-infected patients 4
• Inform patients that progestin-only injectables may or may not increase risk of HIV transmission to partners 6

Adolescents

• Self-administered DMPA-SC is an option for adolescents eligible to use provider-administered DMPA 6
• Counsel about age-appropriate calcium and vitamin D supplementation and regular weight-bearing exercise 6