Can a female patient of reproductive age with a history of thromboembolic events, breast cancer, or other conditions take the depot injection (medroxyprogesterone acetate) with Provera (progesterone)?

Can a Patient Take Depot Medroxyprogesterone Acetate (Depo-Provera)?

Depot medroxyprogesterone acetate (DMPA, Depo-Provera) is contraindicated in patients with current or past history of thromboembolic events (including deep vein thrombosis, pulmonary embolism, stroke, or myocardial infarction), active or history of breast cancer, undiagnosed vaginal bleeding, significant liver disease, or known hypersensitivity to the medication. 1, 2

Absolute Contraindications (Do Not Use)

The FDA drug label explicitly lists the following as contraindications 1:

• Current or past history of thromboembolic disorders (thrombophlebitis, deep vein thrombosis, pulmonary embolism, cerebrovascular disease, stroke, or myocardial infarction) 1, 3
• Known or suspected breast malignancy 1, 3
• Undiagnosed vaginal bleeding 1
• Significant liver dysfunction or disease 1
• Known or suspected pregnancy 1
• Known hypersensitivity to medroxyprogesterone acetate or any ingredients 1

Special Populations Requiring Caution

Patients with Antiphospholipid Antibodies or Active SLE

• For patients with positive antiphospholipid antibodies, DMPA should be avoided in favor of intrauterine devices (IUDs) or progestin-only pills 4
• For patients with moderate-to-high disease activity SLE, IUDs or progestin implants are preferred over DMPA 4

Patients at Risk for Osteoporosis

• DMPA should be avoided in patients at high risk for osteoporosis 4
• The FDA warns that long-term use (beyond 2 years) may contribute to bone mineral density loss, particularly in adolescents 1
• For use beyond 2 years, patients require counseling on calcium/vitamin D supplementation, weight-bearing exercise, and smoking cessation 5

Cardiovascular Risk Factors

• Active smoking combined with other cardiovascular risk factors is a contraindication 3
• The method has no appreciable effects on blood pressure or thrombosis risk in otherwise healthy patients, providing an advantage over combined hormonal contraceptives 6

Conditions That Are NOT Contraindications

It is critical to understand that the following conditions do not preclude DMPA use 3, 7:

• Past history of pelvic inflammatory disease (only current PID is a contraindication) 3
• HIV infection or immunosuppression 3, 7
• Adolescent age (though bone density counseling is required) 3

Clinical Decision Algorithm

Step 1: Screen for absolute contraindications 1

• History of stroke, MI, DVT/PE, or other thromboembolic events → Do not use
• Current or history of breast cancer → Do not use
• Undiagnosed vaginal bleeding → Do not use
• Significant liver disease → Do not use
• Known pregnancy → Do not use

Step 2: Assess special populations 4, 5

• Positive antiphospholipid antibodies → Recommend IUD instead
• Active/moderate-high SLE → Recommend IUD or implant instead
• High risk for osteoporosis → Avoid DMPA
• Active smoking + other CV risk factors → Do not use

Step 3: If no contraindications present 5, 7

• DMPA is highly effective (failure rate <1% with perfect use, 6% typical use) 7, 8
• Administer 150 mg IM every 13 weeks (grace period up to 15 weeks) 5, 7
• Counsel on menstrual irregularities (55% amenorrhea by 12 months, 68% by 24 months) 1
• No physical exam, pelvic exam, or laboratory tests required before initiation 5

Common Pitfalls to Avoid

• Do not confuse past history of PID with current PID – only current PID is a contraindication 3
• Do not withhold from HIV-positive patients – HIV is not a contraindication 3, 7
• Do not assume all progestins are contraindicated in thromboembolic history – DMPA specifically is contraindicated, but this differs from progestin-only pills in some guidelines 1
• Do not use DMPA and oral Provera (progesterone) interchangeably – they have overlapping but distinct contraindication profiles, with both listing thromboembolic history as absolute contraindications 1, 2