In a reproductive‑age woman using depot medroxyprogesterone acetate (Depo‑Provera) who reports irregular menstrual bleeding, abdominal pain, and headache, how should I evaluate and manage her symptoms?

Evaluation and Management of Symptoms in a Woman Using Depo-Provera

Reassure the patient that irregular menstrual bleeding is an expected pharmacologic effect of DMPA, not a pathologic condition, but systematically rule out pregnancy, sexually transmitted infections, and new uterine pathology before attributing all symptoms to the contraceptive. 1

Initial Evaluation: Rule Out Serious Causes

The irregular bleeding, abdominal pain, and headache require targeted evaluation to exclude conditions that DMPA can mask:

Pregnancy Testing

• Perform a pregnancy test immediately, as DMPA is not 100% effective and pregnancy must be excluded before proceeding with any management. 1, 2
• DMPA's irregular bleeding patterns can obscure early pregnancy symptoms. 1

Screen for Sexually Transmitted Infections

• Test for STIs (gonorrhea, chlamydia, and consider trichomonas) as these can cause both irregular bleeding and abdominal pain. 1, 3
• STIs are a common cause of breakthrough bleeding in contraceptive users. 1

Assess for Uterine Pathology

• Evaluate for new uterine conditions (fibroids, polyps, endometrial pathology) if bleeding is unusually heavy or prolonged. 1, 3
• The CDC assigns DMPA a Category 3 rating (caution advised) when unexplained vaginal bleeding suspicious for serious conditions exists before initiating the method. 1

Review Medication Interactions

• Check for drug interactions that may contribute to irregular bleeding. 1, 3

Understanding Expected DMPA Side Effects

Once serious pathology is excluded, recognize that the patient's symptoms align with known DMPA effects:

Menstrual Irregularities (Expected and Common)

• Irregular bleeding and spotting are direct pharmacologic effects caused by endometrial atrophy, decreased vascular density, and disrupted menstrual cycling from sustained progestin exposure. 1
• Unscheduled bleeding is particularly common in the first months of use. 1, 2
• By month 12,55% of women experience amenorrhea; by month 24,68% do—bleeding typically decreases over time. 1, 2
• These irregularities are generally not harmful. 1

Headache and Abdominal Pain

• Headache is a recognized adverse effect of DMPA, along with mastalgia, hair loss, and changes in libido. 4
• Abdominal pain/discomfort is a documented side effect in clinical studies. 2, 5
• However, severe or persistent abdominal pain warrants evaluation for other causes (ectopic pregnancy if pregnant, PID, ovarian cysts). 1

Management of Irregular Bleeding

For Light Spotting or Irregular Bleeding

• Prescribe NSAIDs (ibuprofen or naproxen) for 5-7 days during active bleeding as first-line treatment. 3
• NSAIDs reduce prostaglandin-mediated bleeding and are effective for unscheduled spotting. 3

For Heavy or Prolonged Bleeding

• Start with NSAIDs for 5-7 days; if this fails, add short-term hormonal treatment. 3
• Consider combination oral contraceptives (COCs) for 10-20 days during the bleeding episode only. 3
• Before prescribing COCs, confirm the patient has no contraindications: no severe uncontrolled hypertension, migraines with aura, history of thromboembolism or thrombophilia, active liver disease, or complicated valvular heart disease. 3

Counseling and Setting Expectations

Provide Realistic Expectations

• Enhanced pre-treatment counseling about expected bleeding patterns significantly reduces discontinuation rates. 4, 1, 3
• Explain that menstrual irregularities typically improve with continued use and that amenorrhea often develops, which is not harmful. 1, 3

Address Weight Gain Concerns

• Weight gain occurs in some but not all patients. 4
• Weight status at 6 months predicts future excessive weight gain—counsel on diet and exercise. 4

Discuss Headache Management

• If headaches are severe or persistent, consider standard headache evaluation and treatment.
• If headaches develop focal neurologic features (migraine with aura), reassess contraceptive choice. 4

When to Consider Switching Methods

If bleeding persists despite treatment and remains unacceptable to the patient, counsel on alternative contraceptive methods such as long-acting reversible contraceptives (IUDs or implants) or combined hormonal methods. 3

Common Pitfalls to Avoid

• Do not dismiss symptoms without ruling out pregnancy and STIs first—DMPA's bleeding patterns can mask serious conditions. 1
• Do not prescribe estrogen-containing treatments without screening for contraindications—thrombotic risk must be assessed. 3
• Do not fail to counsel patients before initiating DMPA—inadequate counseling is the primary driver of discontinuation due to bleeding irregularities. 4, 1