In a 42-year-old woman requesting Depo‑Provera (medroxyprogesterone acetate) injection, what are the absolute contraindications and what patient education regarding side effects should be provided?

Depo-Provera for a 42-Year-Old Woman: Contraindications and Patient Education

For a 42-year-old woman requesting Depo-Provera, you must screen for absolute contraindications including pregnancy, undiagnosed vaginal bleeding, breast malignancy, active or history of thromboembolic disease, significant liver disease, and hypersensitivity to medroxyprogesterone acetate, and counsel extensively about menstrual changes (especially initial irregular bleeding progressing to amenorrhea), potential weight gain, and reversible bone mineral density loss. 1

Absolute Contraindications to Screen For

Before administering Depo-Provera, you must rule out the following conditions:

• Known or suspected pregnancy – Perform a pregnancy test if there is any uncertainty about pregnancy status 1
• Undiagnosed vaginal bleeding – Any unexplained vaginal bleeding requires evaluation before initiating Depo-Provera 1
• Known or suspected breast malignancy – Current or suspected breast cancer is an absolute contraindication 1
• Active thrombophlebitis or current/past history of thromboembolic disorders – This includes deep vein thrombosis, pulmonary embolism, or cerebrovascular disease 1
• Significant liver disease – Active or severe hepatic dysfunction precludes use 1
• Known hypersensitivity to medroxyprogesterone acetate – Previous allergic reaction to the medication or its components 1

Critical Patient Education on Side Effects

Menstrual Changes (Most Common and Important to Discuss)

• Nearly all patients experience menstrual irregularities initially with unpredictable spotting and bleeding – This is the most common side effect and the primary reason for discontinuation if not properly counseled 2
• Bleeding patterns typically improve over time, with amenorrhea becoming common – By one year of use, approximately 57% of women experience amenorrhea 3
• Pre-injection counseling about menstrual changes significantly reduces discontinuation rates – Patients who understand this is expected are more likely to continue the method 2

Weight Gain

• Weight gain occurs in some but not all patients – This is highly variable between individuals 2, 4
• Weight gain at 6 months predicts future excessive weight gain – If a patient gains more than 5% of body weight in the first 6 months, she is at higher risk for significant weight gain with continued use 2, 5

Bone Mineral Density

• Depo-Provera causes reversible reductions in bone mineral density – This effect prompted an FDA black-box warning 5
• BMD substantially recovers after discontinuation – The bone loss is not permanent 2, 5
• The American College of Obstetricians and Gynecologists does not recommend limiting use to 2 years – Despite the FDA warning, ACOG states that the benefits of pregnancy prevention outweigh the risks of bone density loss 2, 5
• All patients should receive counseling on skeletal health promotion – Recommend daily intake of 1300 mg calcium and 600 IU vitamin D, regular weight-bearing exercise, and avoidance of smoking and alcohol 2, 5

Delayed Return to Fertility

• Return to fertility typically takes 9-18 months after discontinuation – This is significantly longer than other hormonal methods 5, 6
• This delay is expected and not a sign of permanent infertility – Fertility does return, but patients planning pregnancy in the near future should consider alternative methods 5

Other Side Effects to Discuss

• Headache, breast tenderness, nervousness, abdominal discomfort, and dizziness may occur 1, 4
• Changes in libido, mood changes, and fatigue have been reported 1
• Rare but serious: anaphylaxis and anaphylactoid reactions – Patients should seek emergency care if they develop signs of severe allergic reaction 1

Administration and Effectiveness Counseling

• Use backup contraception (condoms or abstinence) for the first 7 days after initial injection – The method is not immediately effective 2
• Typical use failure rate is approximately 6% in the first year – This is higher than perfect use (less than 1%) due to missed appointments 2, 3
• Injections must be repeated every 13 weeks (91 days) – Many providers schedule appointments every 11-12 weeks to allow buffer time for missed appointments 2
• Depo-Provera provides no protection against sexually transmitted infections – Counsel patients to use condoms at all times for STI protection 2

Special Considerations for Age 42

At age 42, this patient is approaching perimenopause, which creates additional considerations:

• Bone health is particularly important – Women in their 40s are approaching the age of accelerated bone loss, so the skeletal health counseling is especially critical 5
• Evaluate for other osteoporosis risk factors – If she has additional risk factors (family history, smoking, low body weight, previous fractures), alternative contraceptive methods may be preferable 5
• Amenorrhea may mask perimenopausal transition – It will be difficult to determine when she reaches menopause while using Depo-Provera, as amenorrhea is expected with the method 2

Common Pitfalls to Avoid

• Failing to counsel about menstrual irregularities before first injection – This significantly increases discontinuation rates 2
• Assuming amenorrhea after Depo-Provera is pathologic – Amenorrhea is expected and not harmful, though other causes should be ruled out if it persists beyond 18 months after discontinuation 2, 6
• Routinely monitoring bone density or limiting use to 2 years based solely on BMD concerns – This is not recommended by ACOG 2, 5
• Not screening for thromboembolic history – Active or past thromboembolic disease is an absolute contraindication 1