What is the management approach for a female patient of reproductive age experiencing spotting after initiating medroxyprogesterone (Depo-Provera) for contraceptive purposes?

Management of Spotting After Starting Medroxyprogesterone (DMPA)

Reassure the patient that spotting is a common, benign side effect of DMPA that typically improves with continued use, and if treatment is desired, offer NSAIDs for 5-7 days during active bleeding episodes. 1

Initial Assessment

Before initiating any treatment, evaluate for underlying gynecological problems that could be contributing to the bleeding: 1, 2, 3

• Rule out pregnancy with urine or serum testing, especially if bleeding pattern changed abruptly 4
• Screen for sexually transmitted infections (STDs) that could cause pelvic inflammatory disease 1, 4
• Assess for medication interactions that might affect hormonal function 1, 3
• Evaluate for pathologic uterine conditions such as polyps or fibroids through history and physical examination 1, 2, 4

If an underlying gynecological problem is identified, treat the condition or refer for appropriate care. 1, 2

Treatment Algorithm for Spotting/Light Bleeding

First-Line: Reassurance and Observation

• Provide counseling that unscheduled spotting is common with DMPA use and generally not harmful 1, 2
• Explain that bleeding irregularities typically decrease with continued DMPA use 1
• Enhanced counseling about expected bleeding patterns has been shown to reduce DMPA discontinuation in clinical trials 1, 2

Second-Line: NSAIDs (If Patient Desires Treatment)

If no underlying gynecological problem is found and the patient wants treatment: 1

• Prescribe NSAIDs for 5-7 days during active bleeding episodes 1, 2, 3, 4
• Examples include ibuprofen, mefenamic acid, or celecoxib 4
• Treatment can be repeated as needed when bleeding episodes recur 4

Third-Line: Consider Method Switching

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

• Counsel on alternative contraceptive methods such as long-acting reversible contraceptives (IUD, implant) 3, 4
• Offer another method if desired 1, 2

Important Distinctions: Spotting vs. Heavy Bleeding

The management differs based on bleeding severity: 1, 2, 3

• For spotting/light bleeding: NSAIDs alone are recommended 1, 3
• For heavy or prolonged bleeding: NSAIDs remain first-line, but hormonal treatment (low-dose combined oral contraceptives or estrogen for 10-20 days) can be added as second-line if NSAIDs fail 1, 2, 3, 4

Common Pitfalls to Avoid

• Do not assume all bleeding is benign without ruling out pregnancy, infection, or structural pathology first 4
• Do not delay treatment waiting for the next scheduled injection—address bleeding concerns promptly to prevent discontinuation 4
• Do not prescribe estrogen without checking for contraindications to combined hormonal contraceptives (severe uncontrolled hypertension, migraines with aura, history of thromboembolism, active liver disease, complicated valvular heart disease) 3, 4

Follow-Up Considerations

No routine follow-up visit is required for bleeding management, but advise the patient to return if: 4

• Bleeding worsens or becomes unacceptable
• New symptoms develop suggesting underlying pathology
• They wish to discuss method discontinuation
• They want to try different treatment options