Is depot injection a safe treatment option for heavy menstrual bleeding in a patient with a history of stroke?

Depot Medroxyprogesterone Acetate (DMPA) is Contraindicated for Heavy Menstrual Bleeding in Patients with Prior Stroke

Depot medroxyprogesterone acetate (DMPA) should NOT be used for heavy menstrual bleeding in a patient with a history of stroke, as hormonal therapies containing progestogens carry thrombotic risks that are unacceptable in this high-risk population.

Why DMPA is Contraindicated

Stroke History as an Absolute Concern

• Postmenopausal hormone therapy (estrogen with or without progestin) is explicitly not recommended for women who have had ischemic stroke or TIA 1
• While the guideline specifically addresses postmenopausal hormone therapy, the underlying concern about thrombotic risk from exogenous hormones applies to all hormonal contraceptives in stroke survivors 1
• Women with prior stroke are at elevated risk for recurrent cerebrovascular events, and any intervention that could increase thrombotic risk must be avoided 1

Progestogen-Only Methods and Thrombotic Risk

• Although progestogen-only methods are generally considered lower risk than combined hormonal contraceptives, women on anticoagulation (which many stroke survivors require) experience abnormal uterine bleeding in approximately 70% of cases 2
• The interaction between hormonal therapies and the prothrombotic state in stroke survivors creates an unacceptable risk profile 1

Recommended Alternatives for Heavy Menstrual Bleeding After Stroke

First-Line: Levonorgestrel Intrauterine System (LNG-IUS)

• The LNG-IUS (20 μg/day) is the most effective first-line treatment for heavy menstrual bleeding, reducing menstrual blood loss by 71-95% 3, 4, 5, 6
• The LNG-IUS delivers progestogen locally to the endometrium with minimal systemic absorption, substantially reducing thrombotic risk compared to systemic hormonal therapies 5, 6
• LNG-IUS results in large reduction of menstrual blood loss and high satisfaction rates 5

Second-Line: Non-Hormonal Options

• Tranexamic acid is a highly effective non-hormonal option that reduces menstrual blood loss by approximately 50% 4, 7
• However, tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis 4, 7
• Given her stroke history, tranexamic acid should be avoided unless she is on therapeutic anticoagulation and the thrombotic event was remote 7

Third-Line: NSAIDs (with caution)

• NSAIDs can reduce heavy menstrual bleeding when used short-term (5-7 days during menses) 3, 4, 5
• NSAIDs are less effective than LNG-IUS or tranexamic acid but may be sufficient for moderate bleeding 6
• NSAIDs should be avoided in patients with history of spontaneous coronary artery dissection 3

Surgical Options if Medical Management Fails

• Endometrial ablation techniques are effective when medical treatment fails 3, 2
• Hysterectomy is definitive treatment reserved for refractory cases after less invasive procedures have been attempted 3, 2

Critical Clinical Pitfalls to Avoid

Do Not Use Systemic Hormonal Contraceptives

• Avoid all depot progestogen injections (DMPA), combined oral contraceptives, and systemic progestogen therapy in stroke survivors 1
• The thrombotic risk outweighs any benefit for menstrual control 1

Assess Anticoagulation Status

• If the patient is on antiplatelet therapy, reassess the indication for ongoing antiplatelet therapy, as this may worsen menstrual bleeding 2
• Many stroke survivors require long-term anticoagulation, which itself causes or exacerbates heavy menstrual bleeding 1, 2

Evaluate for Hemodynamic Instability

• Bleeding that saturates a large pad or tampon hourly for at least 4 hours requires urgent evaluation 3, 2
• Check for signs of hemodynamic instability (tachycardia, hypotension) indicating significant blood loss 3

Recommended Treatment Algorithm

1. Rule out pregnancy in all reproductive-age women with abnormal uterine bleeding 3, 2
2. Assess severity and hemodynamic stability 3, 2
3. First choice: LNG-IUS for local hormonal effect with minimal systemic absorption 3, 5, 6
4. If LNG-IUS is declined or contraindicated: Consider NSAIDs (5-7 days during menses) if no cardiovascular contraindications 3, 4
5. Avoid tranexamic acid given stroke history unless on therapeutic anticoagulation with remote thrombotic event 4, 7
6. Refer for endometrial ablation or hysterectomy if medical management fails 3, 2