What alternative contraceptive method would best control heavy irregular menstrual bleeding in a young female with normal hemoglobin, low‑normal ferritin, painful cramping while on depot medroxyprogesterone (Depo‑Provera) and no prior ultrasound evaluation?

Recommended Alternative Contraceptive Method

Switch from depot medroxyprogesterone acetate (Depo-Provera) to a combined oral contraceptive (COC) containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate as first-line treatment for controlling heavy irregular menstrual bleeding in this patient. 1, 2

Rationale for Switching from Depo-Provera

• This patient demonstrates a clear pattern of treatment failure with DMPA—experiencing only brief periods of amenorrhea followed by prolonged heavy bleeding (currently 3 weeks of saturating 6-7 extra-large pads daily), which is unacceptable and warrants method change 3
• The CDC explicitly recommends counseling on alternative contraceptive methods and offering another method when heavy or prolonged bleeding persists and the patient finds it unacceptable 3, 4
• While DMPA can improve hemoglobin levels over time 5, this patient's ongoing heavy bleeding pattern (despite two injections) indicates she is among those who experience problematic bleeding irregularities that typically do not resolve with continued use 3

Why Combined Oral Contraceptives Are the Best Alternative

• COCs with 30-35 μg ethinyl estradiol are the first-line treatment for heavy menstrual bleeding in adolescents, providing both menstrual regulation and effective contraception by inducing regular shedding of a thinner endometrium, which decreases menstrual blood loss and cramping 1, 2
• Monophasic formulations containing levonorgestrel or norgestimate are specifically recommended as initial therapy 1, 2
• COCs provide additional benefits including improvement in acne and reduced risk of endometrial and ovarian cancers 1, 2
• Unlike DMPA, COCs offer predictable bleeding patterns after the initial 3-month adjustment period, which is critical for this patient who has experienced chaotic bleeding for months 4

Addressing the Low-Normal Ferritin (26)

• COCs will help prevent further iron depletion by reducing menstrual blood loss, whereas continuing DMPA with persistent heavy bleeding risks progression to iron deficiency anemia 5
• Studies demonstrate that hormonal contraceptives (including COCs and DMPA) generally increase hemoglobin and ferritin levels compared to non-users, with differences in ferritin levels of 2-18 μg/L 5
• However, DMPA's benefit only materializes if bleeding is controlled—this patient's ongoing heavy bleeding negates any protective effect 5
• Continue dietary iron optimization as already recommended, pairing iron-rich foods with vitamin C sources 5

Practical Implementation Strategy

• Start COCs using the "quick start" method (same day as visit) after confirming she is not pregnant, with backup contraception (condoms) for the first 7 days 1
• No pelvic examination is required before initiating COCs 3
• Counsel extensively before initiation that breakthrough bleeding is common during the first 3-6 months but generally decreases with continued use and is not harmful 1, 4
• For any breakthrough bleeding during the adjustment period, NSAIDs (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours) for 5-7 days can reduce blood flow acutely 2, 4

Alternative Option: Levonorgestrel IUD

• The levonorgestrel-releasing IUD is an excellent alternative if the patient prefers long-acting reversible contraception, resulting in 71-95% reduction in menstrual blood loss 2
• The American Academy of Pediatrics strongly supports IUD use in adolescents, with studies showing high continuation rates that exceed other hormonal methods 3
• IUDs can be inserted the same day after screening for gonorrhea and chlamydia, with treatment provided afterward if needed without IUD removal 3
• Backup contraception is needed for 7 days only if inserted more than 7 days after menses starts 1
• Common pitfall: More than half of young nulliparous women report moderate to severe pain with insertion, so consider premedication with NSAIDs and local anesthesia 3

Critical Safety Considerations

• Before prescribing COCs, assess for contraindications: personal or family history of venous thromboembolism, migraine with aura, uncontrolled hypertension, or smoking in women ≥35 years (smoking is NOT a contraindication in teenagers) 3, 2
• COCs increase the risk of venous thromboembolism three to fourfold (up to 4 per 10,000 woman-years), though absolute risk remains low in adolescents 1, 2
• Monitor blood pressure at follow-up visits 1, 2
• Emphasize consistent condom use for STI protection regardless of contraceptive method chosen 1

Evaluation Before Switching

• Rule out underlying pathology before initiating new hormonal therapy: pregnancy test, screening for sexually transmitted infections (gonorrhea and chlamydia), and consider evaluation for structural lesions (polyps or fibroids) given the severity and duration of bleeding 3, 2, 4
• The patient reports no prior transvaginal ultrasound or fibroid evaluation—this should be performed given the prolonged heavy bleeding pattern, particularly before attributing symptoms solely to contraceptive side effects 3, 2

Follow-Up and Monitoring

• No routine follow-up visit is required, but the patient should return if she experiences side effects or concerns 1
• Assess satisfaction with the method and any health status changes at follow-up visits 1
• Recheck hemoglobin and ferritin in 3-6 months to ensure improvement with reduced menstrual blood loss 5, 6
• If breakthrough bleeding persists beyond 3-4 months despite NSAIDs and proper pill adherence, consider switching to an extended/continuous COC regimen (taking active pills for 3-4 months continuously) or transitioning to the levonorgestrel IUD 1, 2