What are the recommendations for using Provera (medroxyprogesterone) in a female patient of reproductive age with an unspecified medical history?

Provera (Medroxyprogesterone Acetate) Recommendations

For reproductive-age women, oral medroxyprogesterone acetate (Provera) is indicated for secondary amenorrhea (5-10 mg daily for 5-10 days) and abnormal uterine bleeding (5-10 mg daily for 5-10 days starting on cycle day 16 or 21), while injectable DMPA (Depo-Provera) is reserved exclusively for long-term contraception (≥3 months) and should not be used for menstrual cycle planning. 1, 2

Oral Medroxyprogesterone Acetate (Provera Tablets)

Indications and Dosing

Secondary Amenorrhea:

• Dose: 5-10 mg daily for 5-10 days (10 mg for 10 days is optimal for adequate secretory transformation) 2
• Timing: May be started at any time 2
• Expected outcome: Withdrawal bleeding occurs within 3-7 days after discontinuing therapy 2
• If no bleeding occurs: Further evaluation is warranted for thyroid dysfunction, hyperprolactinemia, or PCOS 1

Abnormal Uterine Bleeding (hormonal imbalance without organic pathology):

• Dose: 5-10 mg daily for 5-10 days (10 mg for 10 days preferred) 2
• Timing: Begin on calculated day 16 or 21 of menstrual cycle 2
• Expected outcome: Withdrawal bleeding within 3-7 days after stopping 2
• Recurrent episodes: Planned menstrual cycling with medroxyprogesterone may benefit patients with recurrent abnormal bleeding 2

Endometrial Protection in Postmenopausal Women:

• Dose: 5-10 mg daily for 12-14 consecutive days per month 2
• Use: In women with intact uterus receiving 0.625 mg conjugated estrogens daily 2
• Timing: Start on cycle day 1 or day 16 2

Pre-Treatment Requirements

Mandatory screening before initiation:

• Pregnancy test: Must rule out pregnancy before starting treatment 1, 2
• Blood pressure measurement: NOT required for oral medroxyprogesterone 3
• Pelvic examination: NOT required for oral formulation 3
• Endometrial sampling: Required only for undiagnosed persistent or recurring abnormal vaginal bleeding to rule out malignancy 2

Screening NOT necessary before initiation:

• Weight/BMI measurement 3
• Glucose testing 3
• Lipid testing 3
• Liver enzyme testing 3
• Clinical breast examination 3

Absolute Contraindications

Do not prescribe oral medroxyprogesterone if patient has: 2

• Undiagnosed abnormal genital bleeding
• Known, suspected, or history of breast cancer
• Known or suspected estrogen- or progesterone-dependent neoplasia
• Active DVT, PE, or history of these conditions
• Active arterial thromboembolic disease (stroke, MI) or history
• Known anaphylactic reaction or angioedema to medroxyprogesterone
• Known liver impairment or disease
• Known or suspected pregnancy

Injectable Medroxyprogesterone (Depo-Provera/DMPA)

Appropriate Use

DMPA should only be used when long-term contraception (≥3 months) is the primary goal, NOT for menstrual cycle planning. 1

Contraceptive efficacy:

• Failure rate <1% per year with typical use 1, 4
• Highly effective, comparable to modern copper IUDs 5

Dosing and Administration

• Dose: 150 mg by deep intramuscular injection (gluteal or deltoid muscle) 4
• Frequency: Every 3 months (every 12 calendar weeks = 84 days + 5-day grace period) 5
• Timing of first injection: Can start anytime if reasonably certain patient is not pregnant 3
• Back-up contraception: If started >7 days after menses, use barrier methods or abstain for 7 days 3

Pre-Treatment Requirements

Before DMPA initiation:

• Pregnancy test: Must rule out pregnancy 4
• Blood pressure measurement: NOT required 3
• Pelvic examination: NOT required 3

Expected Side Effects and Counseling

Menstrual changes (nearly universal): 6

• Initial irregular bleeding/spotting is normal and expected
• 55% achieve amenorrhea by 12 months 6
• 68% achieve amenorrhea by 24 months 6
• Critical: Pre-injection counseling about bleeding patterns reduces discontinuation rates 6

Management of unscheduled bleeding on DMPA: 6

• First-line: NSAIDs for 5-7 days for spotting, light bleeding, or heavy/prolonged bleeding
• Second-line: Combined oral contraceptives or estrogen for 10-20 days for heavy or prolonged bleeding
• If bleeding persists and unacceptable: Counsel on alternative contraceptive methods

Other common side effects: 4, 5

• Weight gain
• Headache
• Nervousness
• Abdominal pain or discomfort
• Dizziness
• Asthenia (weakness)

Important Warnings

Bone health concerns:

• Long-term use may contribute to osteoporosis 4
• Consider this risk, especially in adolescents and women with other osteoporosis risk factors

Return to fertility:

• Method is temporarily irreversible during 3-month duration 5
• Ovulation suppression may persist beyond injection interval

Follow-Up

Routine follow-up after DMPA initiation: 3

• No routine follow-up visit required
• Advise patient to return anytime for side effects, method change concerns, or when reinjection is due
• At subsequent visits: assess satisfaction, changes in health status/medications, and consider monitoring weight changes

Special Populations

Women with Hypertension

• Hypertension is NOT a contraindication to oral medroxyprogesterone use 3
• For hormone replacement in premature ovarian insufficiency with hypertension, transdermal estradiol is preferred over oral formulations 3

Women with Endometriosis

• Oral medroxyprogesterone 30-50 mg daily for 90-120 days is effective for endometriosis treatment 7, 8
• Improvement or remission occurs in most cases 8
• Induces pseudodecidualized reaction and atrophic changes in endometrial implants 7

Women Receiving Radiation Therapy

• Caution: Medroxyprogesterone may act as a radiosensitizing agent and potentially enhance ovarian injury when given with radiotherapy 9
• This is a critical consideration for young women with cancer receiving pelvic radiation

Drug Interactions

Medications that reduce contraceptive efficacy of DMPA: 3

• Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine)
• Rifampin or rifabutin
• St. John's wort

HIV medications: 3

• Most antiretroviral medications can be used with DMPA, though some interactions exist
• Consult specific drug interaction tables for individual ARV agents