Duration of Depo-Provera Treatment
There is no time limit on how long Depo-Provera can be used safely for contraception or therapy. The American College of Obstetricians and Gynecologists (ACOG) explicitly does not recommend limiting use to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh the risks of bone density loss 1, 2.
Key Guideline Recommendations
No Duration Restrictions
- ACOG does not advise limiting Depo-Provera use to 2 years or routinely monitoring bone density after this timeframe, despite the FDA's 2004 black box warning about bone mineral density (BMD) reductions 1.
- The benefits of pregnancy prevention outweigh the risks of BMD loss, particularly when contraceptive options are limited 1.
- Subsequent research has demonstrated substantial recovery of BMD after discontinuation of Depo-Provera 1.
Standard Dosing Schedule
- Administer 150 mg intramuscularly every 13 weeks (91 days) or 104 mg subcutaneously every 13 weeks 3, 2.
- Injections can be given up to 2 weeks late (15 weeks from last injection) without requiring backup contraception 3, 2.
- If more than 2 weeks late, the injection can still be given if reasonably certain the patient is not pregnant, but backup contraception is needed for 7 days 3.
Mandatory Counseling for Long-Term Users
All patients using DMPA beyond 2 years must receive counseling on skeletal health promotion 1, 3:
- Daily calcium intake of 1,300 mg 1, 2
- Daily vitamin D intake of 600 IU 1, 2
- Regular weight-bearing exercise 1, 3
- Smoking cessation 1, 2
- Alcohol avoidance 2
Special Populations Requiring Caution
While there is no absolute duration limit, alternatives to DMPA may be preferable for long-term contraception in patients with 4, 1:
- Positive antiphospholipid antibodies 4
- Pre-existing high risk for osteoporosis 4, 1
- Other osteoporosis risk factors 1
For these patients, consider highly effective long-acting reversible contraceptives (copper or progestin IUDs, subdermal implants) which have failure rates <1% per year 4.
Expected Side Effects with Continued Use
Menstrual Changes
- Nearly all patients experience menstrual irregularities initially, which typically improve over time 1, 3.
- Amenorrhea becomes common with continued use and is not harmful 1.
Weight Gain
- Weight gain status at 6 months is a strong predictor of future excessive weight gain 1.
- Patients showing >5% weight gain at 6 months may experience significant BMI increases with continued use 1.
Return to Fertility
- Delayed return to fertility typically occurs 9 to 18 months after discontinuation 1.
- This delay is consistent for both subcutaneous and intramuscular formulations 1.
Common Pitfalls to Avoid
- Do not limit use to 2 years based solely on BMD concerns 2.
- Do not require routine follow-up visits between injections 2.
- Do not routinely monitor bone density in patients without additional risk factors 1.
- Do counsel about menstrual irregularities before first injection, as this significantly reduces discontinuation rates 3.