What is the management approach for a 17-year-old female experiencing vaginal bleeding after one dose of Depo-Provera (medroxyprogesterone acetate)?

Management of Vaginal Bleeding After First Depo-Provera Injection in a 17-Year-Old

Reassure the patient that irregular bleeding after the first Depo-Provera injection is extremely common, generally not harmful, and does not indicate contraceptive failure—this is the expected side effect that typically improves with continued use. 1

Initial Assessment

Before initiating any treatment, rule out the following conditions if clinically indicated: 1

• Pregnancy - particularly important given the irregular bleeding pattern 1
• Sexually transmitted infections (STIs) - test for chlamydia and gonorrhea 1, 2
• Pathologic uterine conditions - such as polyps or fibroids, though less likely in this age group 1
• Medication interactions - specifically enzyme-inducing drugs that could affect contraceptive efficacy 2

Understanding the Bleeding Pattern

The bleeding this patient is experiencing falls into the category of either unscheduled spotting/light bleeding or heavy/prolonged bleeding, which determines the treatment approach: 1

• Unscheduled spotting or light bleeding is extremely common with DMPA use, particularly in the first few months 1, 3
• Approximately 35.7% of DMPA users experience irregular bleeding in the first 3-6 months of use 4
• These bleeding irregularities generally decrease with continued use, and amenorrhea becomes increasingly common (57% by one year) 5, 3

Treatment Algorithm

If Spotting or Light Bleeding:

First-line management: 1, 2

• Provide reassurance and counseling that this is a normal, expected side effect
• No medical treatment is required unless the patient requests it

If patient desires treatment: 1, 2

• NSAIDs during bleeding days only - mefenamic acid 500 mg three times daily for 5-7 days OR ibuprofen for 5-7 days 1, 2
• Studies show significant cessation of bleeding within 7 days with mefenamic acid compared to placebo 1

If Heavy or Prolonged Bleeding:

First-line treatment: 1, 2

• NSAIDs - mefenamic acid 500 mg three times daily for 5-7 days 1, 2

Second-line treatment (if NSAIDs fail and patient is medically eligible): 1, 2

• Low-dose combined oral contraceptives for 10-20 days OR
• Estrogen therapy for 10-20 days 1, 2
• Note: Ethinyl estradiol has been shown to stop bleeding better than placebo during the treatment period 1

Critical Counseling Points

Enhanced counseling about expected bleeding patterns has been shown to reduce DMPA discontinuation rates in clinical trials: 1

• Irregular bleeding is not harmful and does not indicate contraceptive failure 1, 2
• Bleeding patterns typically improve with continued use 1, 4
• Amenorrhea becomes increasingly common and is also not harmful 1
• Contraceptive efficacy remains intact provided injections are given on schedule 2, 5

When to Consider Method Discontinuation

If bleeding persists despite treatment and the patient finds it unacceptable: 1

• Counsel on alternative contraceptive methods
• Offer another method if desired 1

Important Caveats for This Age Group

Given the patient's age (17 years), special consideration must be given to: 6

• Bone mineral density concerns - DMPA use during adolescence (a critical period of bone accretion) may reduce peak bone mass 6
• DMPA is not recommended as a long-term method (>2 years) unless other options are inadequate 6
• However, for short-term use, the benefits of highly effective contraception typically outweigh these concerns in most adolescents 6

What NOT to Do

• Do not perform unscheduled cervical cancer screening outside the regular screening program for this bleeding alone 7
• Do not assume the bleeding indicates contraceptive failure or reduced efficacy 1, 2
• Do not discontinue the method prematurely without adequate counseling about expected bleeding patterns 1