QuickStart Depo-Provera Injection Initiation
Depo-Provera (DMPA) can be initiated immediately at the office visit ("QuickStart") without waiting for menses, provided you are reasonably certain the patient is not pregnant, and this approach is explicitly recommended by CDC guidelines to reduce barriers to contraceptive access. 1
Determining Reasonable Certainty of Non-Pregnancy
You can be reasonably certain a patient is not pregnant if she has no symptoms or signs of pregnancy AND meets any ONE of these criteria: 1
- ≤7 days after the start of normal menses
- Has not had sexual intercourse since the start of last normal menses
- Has been using a reliable contraceptive method correctly and consistently
- ≤7 days after spontaneous or induced abortion
- Within 4 weeks postpartum
- Fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum
Required Pre-Administration Assessments
No physical examination, pelvic exam, or laboratory testing is required before initiating DMPA in a healthy patient. 1
Specifically, the following are NOT needed: 1
- Pelvic examination
- Cervical cytology (Pap smear)
- Clinical breast examination
- Blood pressure measurement (Class C - not essential for injectable contraception)
- Laboratory tests (glucose, lipids, liver enzymes, hemoglobin, thrombogenic mutations)
- HIV screening
- Routine pregnancy testing
Weight/BMI measurement is optional but may be helpful for monitoring changes over time, particularly given weight gain concerns. 1
Dosing Options
Two equivalent formulations are available: 2
- 150 mg intramuscularly every 13 weeks, OR
- 104 mg subcutaneously every 13 weeks
Both have equivalent effectiveness and side effects. 2
Backup Contraception Requirements
If DMPA is started within the first 5 days of menstrual bleeding, no backup contraception is needed. 3
If started after day 5 of menses or using QuickStart criteria above, the patient must use backup contraception (condoms or abstinence) for 7 consecutive days after the injection. 1, 2, 3
Critical Pre-Injection Counseling
Menstrual Changes (Most Important for Continuation)
Counsel that nearly all patients experience unpredictable spotting and bleeding initially, but this typically improves over time with amenorrhea becoming common (55% at 12 months, 68% at 24 months). 1, 4 Pre-injection counseling about these menstrual changes significantly reduces discontinuation rates. 1, 2
Weight Gain
Weight gain occurs in some but not all patients. 1, 2 Weight gain status at 6 months is a strong predictor of future excessive weight gain—if a patient gains >5% body weight in the first 6 months, she is at higher risk for continued weight gain. 1, 2
Bone Mineral Density
DMPA causes reversible reductions in BMD, with mean decreases of 5-6% over 5 years, most pronounced in the first 2 years. 4 However, BMD substantially recovers after discontinuation. 1, 2, 4
Despite the FDA black-box warning, ACOG does not recommend limiting use to 2 years, as the benefits of preventing unwanted pregnancy outweigh the BMD risks. 1, 2, 3
All patients should be counseled on skeletal health promotion: 1, 2
- Daily calcium intake of 1300 mg
- Daily vitamin D intake of 600 IU
- Regular weight-bearing exercise
- Avoid smoking and excessive alcohol
STI Protection
Counsel that DMPA provides NO protection against sexually transmitted infections, and condoms should be used at all times for STI prevention. 1, 2
Return to Fertility
Ovulation may be delayed for several months after discontinuation, with most women resuming ovulation 15-49 weeks after the last injection. 2, 5
Follow-Up Injection Timing
Schedule repeat injections every 13 weeks (91 days). 2 Many providers schedule adolescents every 11-12 weeks to allow buffer time for missed appointments. 2
If a patient presents >2 weeks late (>14 weeks from last injection), she can still receive the injection if reasonably certain she is not pregnant, but must use backup contraception for 7 days. 2
Common Pitfall to Avoid
Do not delay initiating DMPA to wait for the next menstrual period—this creates unnecessary barriers to contraceptive access and increases unintended pregnancy risk, particularly in adolescents and low-income women. 1 The QuickStart approach is safe and recommended when reasonable certainty of non-pregnancy is established using the criteria above.