NSAID Dosing for Depo-Provera-Related Prolonged Bleeding
For a woman with prolonged bleeding on Depo-Provera, NSAIDs should be taken for 5-7 days during the days of active bleeding. 1
Treatment Algorithm
Step 1: Rule Out Underlying Pathology
Before initiating NSAID therapy, clinically assess for:
- Medication interactions 1
- Sexually transmitted infections 1
- Pregnancy 1
- New uterine pathology such as fibroids or polyps 1
If any underlying gynecologic problem is identified, treat the condition or refer for specialized care rather than proceeding with symptomatic NSAID treatment. 1
Step 2: NSAID Treatment Protocol
If no underlying pathology is found and the patient desires treatment:
- Administer NSAIDs for 5-7 days during bleeding episodes 1, 2
- Treatment should be given only on days when bleeding is occurring 1
- This represents short-term symptomatic management 1
Evidence supporting specific NSAIDs:
- Mefenamic acid for 5 days has demonstrated significant cessation of bleeding within 7 days compared to placebo in DMPA users 1
- Valdecoxib for 5 days also showed significant bleeding cessation within 7 days 1
Step 3: Alternative or Adjunctive Hormonal Treatment
If NSAIDs alone are insufficient for heavy or prolonged bleeding (not just spotting), consider adding:
- Low-dose combined oral contraceptives for 10-20 days (if medically eligible) 1
- Estrogen therapy for 10-20 days (if medically eligible) 1
Note: Hormonal treatments are reserved for heavy or prolonged bleeding patterns, not for simple spotting or light bleeding, where NSAIDs alone are the recommended first-line approach. 1
Important Clinical Considerations
Counseling Before Treatment
Enhanced pre-treatment counseling about expected bleeding irregularities with DMPA reduces discontinuation rates. 1 Patients should understand that:
- Unscheduled bleeding and spotting are common with DMPA use 1
- These bleeding irregularities are generally not harmful 1
- Amenorrhea becomes common after ≥1 year of continuous use 1, 2
When to Consider Method Change
If bleeding persists despite NSAID treatment and the patient finds it unacceptable, counsel about alternative contraceptive methods and offer to switch if desired. 1
Common Pitfall to Avoid
Do not prescribe continuous or prophylactic NSAIDs throughout the entire injection cycle. The CDC guidelines specifically recommend NSAIDs only for 5-7 days during active bleeding episodes, not as ongoing therapy. 1 This approach balances symptom control with minimizing NSAID exposure and potential gastrointestinal or cardiovascular risks.