How do I write a prescription for Depo‑Provera (medroxyprogesterone acetate) for a non‑pregnant woman of reproductive age without contraindications?

How to Write a Prescription for Depo-Provera

Write a prescription for either medroxyprogesterone acetate 150 mg intramuscularly every 13 weeks OR 104 mg subcutaneously every 13 weeks, with the first injection given within the first 5 days of menses (or immediately if reasonably certain the patient is not pregnant), and instruct the patient to use backup contraception for 7 days after the first injection. 1, 2, 3

Prescription Components

Formulation Selection

• Intramuscular (IM) formulation: Medroxyprogesterone acetate 150 mg/mL, administered as a deep IM injection in the gluteal or deltoid muscle every 13 weeks 2, 3
• Subcutaneous (SC) formulation: Medroxyprogesterone acetate 104 mg/0.65 mL, administered subcutaneously every 13 weeks 1, 2
• Both formulations have equivalent contraceptive effectiveness and side effect profiles 2

Dosing Schedule

• Standard reinjection interval is every 13 weeks (91 days) 1, 2
• The injection can be given up to 2 weeks late (15 weeks from last injection) without requiring additional contraceptive protection 1
• Many providers schedule appointments every 11-12 weeks to provide a buffer for missed appointments 2

Timing of First Injection

Standard Timing (FDA-Approved)

• The first injection must be given only during the first 5 days of a normal menstrual period 3
• Alternatively, within the first 5 days postpartum if not breastfeeding 3
• If exclusively breastfeeding, at the sixth postpartum week 3

Quick-Start/Mid-Cycle Initiation (Off-Label)

• The first injection can be given at any time if it is reasonably certain the patient is not pregnant 1, 2
• This approach is supported by CDC guidelines and increases contraceptive access 1
• Requires backup contraception for 7 days after injection 1, 2

Backup Contraception Requirements

• If started within the first 5 days of menses, no additional contraceptive protection is needed 1
• If started more than 5 days after menses began, the patient must abstain from intercourse or use additional contraceptive protection (condoms) for 7 days 1, 2
• Condoms are the preferred backup method as they provide dual protection against pregnancy and sexually transmitted infections 2

Sample Prescription Format

Prescription Example (IM formulation):

• Medroxyprogesterone acetate injectable suspension 150 mg/mL
• Dispense: 1 vial (or prefilled syringe)
• Sig: Administer 150 mg (1 mL) by deep intramuscular injection in gluteal or deltoid muscle every 13 weeks
• Refills: 3 (for one year of coverage)

Prescription Example (SC formulation):

• Medroxyprogesterone acetate injectable suspension 104 mg/0.65 mL
• Dispense: 1 prefilled syringe
• Sig: Administer 104 mg (0.65 mL) by subcutaneous injection every 13 weeks
• Refills: 3 (for one year of coverage)

Self-Administration Option (Off-Label)

• The subcutaneous formulation can be prescribed for patient self-administration, though this is off-label use 1
• Critical implementation elements include in-person or telemedicine instruction on self-injection technique, sharps disposal education, and access to follow-up care 1
• Self-administration expands contraceptive access and enhances reproductive autonomy 1

Essential Patient Counseling

Menstrual Changes

• Nearly all patients experience menstrual irregularities initially with unpredictable spotting and bleeding 2
• Bleeding patterns typically improve over time, with amenorrhea becoming common (57% by end of first year) 2, 4
• Pre-injection counseling about menstrual changes significantly reduces discontinuation rates 2

Weight Gain

• Weight gain occurs in some but not all patients 2
• Weight gain status at 6 months (>5% increase) is a strong predictor of future excessive weight gain with continued use 2

Bone Mineral Density

• DMPA causes reversible reductions in bone mineral density, but BMD substantially recovers after discontinuation 2
• The American College of Obstetricians and Gynecologists does not recommend limiting use to 2 years despite FDA black-box warning, as benefits of pregnancy prevention outweigh risks 2, 5
• All patients should receive counseling on skeletal health promotion: daily intake of 1300 mg calcium and 600 IU vitamin D, regular weight-bearing exercise, and avoidance of smoking and alcohol 2, 5

Return to Fertility

• Delayed return to fertility is typical, ranging from 9-18 months after discontinuation 2, 5
• Median time to return to ovulation is approximately 30 weeks after last injection 6

STI Protection

• DMPA provides no protection against sexually transmitted infections 2
• Patients should be counseled to use condoms at all times for STI protection 2

Contraindications to Screen For

Before prescribing, verify the patient does not have:

• Undiagnosed vaginal bleeding 4
• Known or suspected breast malignancy 4
• Active thromboembolic disorders or cerebral vascular disease 4
• Liver dysfunction 4
• Positive antiphospholipid antibodies (consider alternative contraception) 1, 5
• High risk for osteoporosis (low baseline BMD, chronic glucocorticoid use, family history of fractures) 5

Late Injection Management

• If less than 2 weeks late (≤15 weeks from last injection): Proceed with injection immediately, no backup contraception needed 2
• If 2 weeks or more late (>15 weeks from last injection): Verify patient is not pregnant, give injection, and use backup contraception for 7 days 1, 2
• Consider emergency contraception if unprotected intercourse occurred within 5 days before a late injection 2

Common Pitfalls to Avoid

• Do not wait for menstrual period to return before giving subsequent injections, as many users are amenorrheic and waiting increases pregnancy risk 7
• Do not fail to counsel about menstrual irregularities before first injection, as this significantly reduces discontinuation 2
• Do not routinely monitor bone density or limit use to 2 years based solely on BMD concerns 2, 5
• Do not assume amenorrhea after DMPA is pathologic without ruling out other causes (including pregnancy or STIs) 2, 5
• Vigorously shake the vial or prefilled syringe just before administration to ensure uniform suspension 3