Menstrual Bleeding on Depo-Provera: Normal Side Effect and Management
Menstrual bleeding while on Depo-Provera (DMPA) is a normal and expected side effect, not a withdrawal bleed, and represents disruption of menstrual patterns that occurs in nearly all patients initially. 1, 2
Understanding the Bleeding Pattern
Irregular bleeding is the most common side effect of DMPA, with most women experiencing disruption of menstrual bleeding patterns including irregular or unpredictable bleeding, spotting, or rarely heavy/continuous bleeding. 2
This bleeding typically improves over time with continued use—by 12 months, 55% of women achieve amenorrhea, and by 24 months, 68% become amenorrheic. 1, 2
The bleeding irregularities are poorly understood pathophysiologically but are well-documented across multiple studies and represent altered endometrial response to progestin-only contraception. 3
Initial Management Approach
The most critical intervention is thorough counseling before and after injection, as women counseled about expected bleeding patterns are less likely to discontinue the method. 1, 3
When to Treat Medically
If bleeding persists or the patient requests treatment, the CDC recommends the following evidence-based options: 1
NSAIDs for 5-7 days for unscheduled spotting, light bleeding, or heavy/prolonged bleeding 1
Hormonal treatment (if medically eligible) with combined oral contraceptives (COCs) or estrogen for 10-20 days for heavy or prolonged bleeding 1
Vaginal estrogen supplementation may decrease bleeding days (median 16 vs 28 days in one randomized trial) and is highly acceptable to patients, though this approach requires further validation. 4
Important Clinical Caveats
Rule out organic pathology if abnormal bleeding is severe or persistent—appropriate investigation should be instituted before assuming the bleeding is solely DMPA-related. 2
Heavy or "severe" bleeding is uncommon (reported in only 1-2% of users), so if present, maintain a higher index of suspicion for other causes. 3
Dilatation and curettage is almost never necessary to stop bleeding but may occasionally be needed for diagnostic purposes. 3
What NOT to Do
Do not give an early second injection (at 6 weeks instead of 12 weeks) to manage bleeding—this does not reduce bleeding episodes or duration and actually increases weight gain. 5
Do not routinely induce withdrawal bleeding in women who develop amenorrhea, as amenorrhea is an expected and acceptable outcome for most DMPA users. 3
When to Switch Methods
If bleeding persists and the woman finds it unacceptable despite medical management, counsel on alternative contraceptive methods and offer another method if desired. 1
- Each additional day of bleeding/spotting decreases the likelihood of continuing DMPA by 3% (OR 0.97,95% CI 0.94-0.99), so persistent bleeding is a legitimate reason to consider method change. 4
Special Strategy: Transitioning from Combined Oral Contraceptives
Starting DMPA after discontinuing COCs (rather than starting DMPA de novo) significantly reduces bleeding duration during the first 6 months (5.7 vs 17.1 total days, p<0.003), though this benefit does not persist beyond 6 months. 5
This approach may be considered for women particularly concerned about irregular bleeding during DMPA initiation. 5