How should a patient on medroxyprogesterone acetate (Provera) 10 mg twice daily be weaned and transitioned to an intrauterine device (IUD)?

Transitioning from Provera 10 mg BID to IUD

You do not need to wean medroxyprogesterone acetate (Provera) before IUD insertion—simply stop the oral medication on the day of IUD placement and use backup contraception for 7 days afterward if the IUD is inserted more than 7 days after menses started. 1

Key Principle: No Tapering Required

• Oral medroxyprogesterone acetate does not require gradual dose reduction or tapering when discontinuing for contraceptive purposes 1
• The medication can be stopped abruptly without adverse effects related to withdrawal 2
• The primary concern is ensuring contraceptive coverage during the transition, not managing withdrawal symptoms 1

Step-by-Step Transition Protocol

1. Timing of IUD Insertion

• The IUD can be inserted at any time if you are reasonably certain the patient is not pregnant 1
• Ideally, insert within 7 days of menstrual bleeding onset to avoid need for backup contraception 1
• If inserting >7 days after menses started, backup contraception is required for 7 days post-insertion 1

2. Managing the Oral Provera

• Continue Provera 10 mg BID until the day of IUD insertion to maintain contraceptive coverage 1
• Stop Provera completely on the day of IUD placement—no tapering needed 1
• If the patient has been sexually active and it's >5 days since menses started, consider that residual sperm may be present 1

3. Backup Contraception Requirements

For Copper IUD:

• No backup contraception needed at any time 1
• Provides immediate contraceptive protection 1

For Levonorgestrel IUD:

• Backup contraception for 7 days if inserted >7 days after menses started 1
• Use barrier methods or abstinence during this period 1
• If residual sperm may be present (sexual activity within past 5 days and >5 days since menses), consider emergency contraceptive pills at time of IUD placement 1

4. Special Consideration for Residual Sperm

When switching from oral Provera to an IUD, if the patient has had intercourse since her last menses and it's been >5 days since bleeding started, you have three options 1:

1. Continue Provera for 7 additional days after IUD insertion, then stop (provides overlap coverage) 1
2. Advise abstinence or barrier methods for 7 days before IUD insertion 1
3. Administer emergency contraceptive pills at time of IUD insertion 1

Common Pitfalls to Avoid

• Don't delay IUD insertion waiting for "withdrawal bleeding" from stopping Provera—this is unnecessary and increases pregnancy risk 1
• Don't assume the patient needs hormonal "washout"—oral medroxyprogesterone clears relatively quickly (detectable for weeks to months after depot injection, but oral formulations have much shorter half-lives) 2
• Don't forget to verify pregnancy status before IUD insertion using CDC criteria for reasonable certainty 1
• Don't confuse oral Provera dosing with depot medroxyprogesterone acetate (DMPA)—the 10 mg BID dose is unusually high for typical contraceptive use and may indicate treatment for endometriosis or other conditions 3, 4

Important Clinical Note

The 10 mg twice daily dosing of oral medroxyprogesterone acetate is not a standard contraceptive regimen—typical contraceptive dosing is depot injection (150 mg IM every 13 weeks), not oral administration 3, 5. This high oral dose (20 mg/day total) suggests the patient may be using it for endometriosis suppression, abnormal uterine bleeding, or endometrial protection rather than primary contraception 3, 4. Clarify the original indication with the prescriber, as this may affect your choice of IUD type (levonorgestrel IUD may provide therapeutic benefits for endometriosis or menorrhagia that copper IUD would not) 1, 6.

Expected Menstrual Changes

• After stopping oral Provera, the patient may experience withdrawal bleeding within 3-7 days, though this is not required before IUD insertion 4
• Levonorgestrel IUD users should expect irregular spotting for 3-6 months, with eventual amenorrhea in many cases 1
• Copper IUD users may experience heavier menses and more cramping 6