Can a medically healthy woman of reproductive age who wants a highly effective reversible hormonal contraceptive and has no contraindications to progestin‑only methods start depot medroxyprogesterone acetate (Depo‑Provera)?

Starting Depo-Provera in a Medically Healthy Woman

Yes, a medically healthy woman of reproductive age seeking highly effective reversible contraception with no contraindications to progestin-only methods can and should start depot medroxyprogesterone acetate (Depo-Provera), as it provides highly effective contraception with a failure rate of less than 1% per year with perfect use and approximately 3-6% with typical use. 1, 2, 3

Timing of Initial Administration

Depo-Provera can be started at any time if the provider is reasonably certain the patient is not pregnant. 1, 2

The provider can be reasonably certain a woman is not pregnant if she meets any one of the following criteria: 2

• Is ≤7 days after the start of normal menses
• Has not had sexual intercourse since the start of last normal menses
• Has been using a reliable contraceptive method correctly and consistently
• Is ≤7 days after spontaneous or induced abortion
• Is within 4 weeks postpartum
• Is fully or nearly fully breastfeeding (≥85% of feeds), amenorrheic, and <6 months postpartum

Backup Contraception Requirements

• If started within 7 days of menses onset: No backup contraception needed 1, 2
• If started more than 7 days after menses: Use backup contraception (condoms or abstinence) for 7 consecutive days after injection 1, 2

Pre-Administration Requirements

Minimal testing is required before starting Depo-Provera, which facilitates same-day initiation. 2

No examination or testing needed: 1, 2, 4

• No pelvic examination required
• No cervical cytology (Pap smear) required
• No bimanual examination required
• No clinical breast examination required
• No blood pressure measurement required
• No laboratory tests for glucose, lipids, liver enzymes, hemoglobin, or thrombogenic mutations required
• No HIV screening required

Absolute Contraindications

Do not prescribe Depo-Provera if any of the following are present: 2

• Known or suspected breast cancer or history of breast cancer
• Active thrombophlebitis, current or history of thromboembolic disorders, or cerebrovascular disease
• Significant liver disease or known liver impairment
• Undiagnosed vaginal bleeding
• Known hypersensitivity to medroxyprogesterone acetate or any ingredients
• History of stroke or myocardial infarction

Additional contraindications in specific populations: 1

• Positive antiphospholipid antibody (aPL) testing
• High risk for osteoporosis (metabolic bone disease, chronic alcohol/tobacco use, anorexia nervosa, strong family history of osteoporosis, chronic use of anticonvulsants or corticosteroids)

Essential Pre-Injection Counseling

Delayed Return to Fertility

Patients must understand that return to fertility is delayed after discontinuation, with time to ovulation ranging from 15 to 49 weeks (approximately 9-18 months) after the last injection. 2, 5 This is not permanent infertility, but a prolonged delay that distinguishes Depo-Provera from other reversible methods. 3, 6

Menstrual Changes

Almost all users experience menstrual changes, particularly during the first year: 3, 7

• Episodes of unpredictable irregular spotting and bleeding are common initially
• With continued use, spotting and bleeding decrease
• Amenorrhea becomes common with prolonged use
• These changes rarely require operative intervention and can often be improved with short courses of estrogen or shorter injection intervals 7

Bone Mineral Density Loss

Depo-Provera causes reversible bone mineral density (BMD) loss that is greater with increasing duration of use. 8 The FDA boxed warning states that Depo-Provera should be used as a long-term birth control method (longer than 2 years) only if other birth control methods are inadequate. 8 However, the American College of Obstetricians and Gynecologists does not recommend limiting use to 2 years, recognizing that BMD recovery occurs after discontinuation. 5

All patients should have adequate calcium (1300 mg daily) and vitamin D (600 IU daily) intake. 5, 8

STI Protection

Patients must be counseled to use condoms at all times for STI protection, as Depo-Provera provides no protection against sexually transmitted infections. 2

Weight Gain

Weight gain is a potential side effect that should be discussed, as it is a common reason for discontinuation. 7, 9

Formulation Options and Administration

Two formulations are available with equivalent effectiveness: 2

• 150 mg intramuscularly (IM) every 13 weeks (91 days) - traditional formulation
• 104 mg subcutaneously (SC) every 13 weeks (91 days) - can be self-administered 1

Self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception, as it improves contraceptive continuation rates with equivalent safety and efficacy. 1

Repeat Injection Schedule

Schedule repeat injections every 13 weeks (91 days). 2

• Injections can be given up to 2 weeks late (14 weeks from last injection) without requiring additional contraceptive protection 2
• If more than 2 weeks late (>14 weeks): Patient can still receive injection if reasonably certain she is not pregnant, but must use backup contraception for 7 days 2

Advantages in Specific Populations

Depo-Provera has particular advantages for certain women: 1, 3, 10

• Women who cannot tolerate estrogenic side effects of combined oral contraceptives
• Women with contraindications to estrogen (e.g., history of thromboembolism, migraine with aura)
• Women with rheumatic and musculoskeletal diseases (safe in most RMD patients except those with positive aPL or high osteoporosis risk) 1
• Postpartum women who wish to breastfeed (no adverse effect on lactation) 10
• Women who lead irregular lifestyles or have difficulty with daily pill-taking 7

Additional health benefits include: 3

• Reduced menstrual blood loss
• Decreased incidence of pelvic inflammatory disease
• Dramatically lower risk of endometrial cancer

Common Pitfalls to Avoid

• Do not require unnecessary pre-administration testing that delays same-day initiation 1, 2
• Do not automatically limit use to 2 years based solely on FDA boxed warning; assess individual osteoporosis risk factors and BMD when needed for long-term use 5, 8
• Do not fail to counsel about delayed return to fertility - this is the most important distinguishing feature from other reversible methods 2, 5
• Do not dismiss menstrual irregularities - provide early intervention options rather than having patients wait until next appointment 7
• Do not use Depo-Provera in patients with positive aPL antibodies - these patients should use IUDs or progestin-only pills instead 1