Provera and Golf Ball-Size Clots: Immediate Action Required
You should stop Provera immediately and seek urgent medical evaluation for golf ball-size clots, as this represents abnormal heavy bleeding that requires exclusion of serious underlying pathology before any treatment decisions. 1, 2
Why This Is Urgent
- Golf ball-size clots indicate heavy menstrual bleeding that exceeds normal breakthrough bleeding patterns associated with progestin therapy and warrants immediate clinical assessment 1, 2
- The FDA drug label for medroxyprogesterone acetate explicitly states: "In cases of breakthrough bleeding, as in all cases of irregular bleeding per vaginum, nonfunctional causes should be borne in mind and adequate diagnostic measures undertaken" 2
- Passing large clots can indicate significant blood loss that may lead to anemia and hemodynamic instability, requiring urgent evaluation 3
What Must Be Ruled Out First
Before attributing this bleeding to Provera, your clinician must systematically exclude:
- Pregnancy complications (including miscarriage or ectopic pregnancy) - obtain serum hCG immediately 1, 4
- Sexually transmitted infections (chlamydia and gonorrhea can cause abnormal bleeding) 1
- New uterine pathology such as fibroids, polyps, cervical lesions, or endometrial abnormalities 1, 4, 2
- Coagulation disorders or other systemic causes of heavy bleeding 2
Why Stopping Is the Right Decision
- Provera can cause breakthrough bleeding, but golf ball-size clots represent excessive bleeding that is not a typical or acceptable side effect 1, 2
- The CDC guidelines emphasize that unscheduled bleeding requiring intervention should prompt consideration of method change or discontinuation 1
- Continuing Provera while passing large clots delays proper diagnosis and treatment of potentially serious underlying conditions 1, 4
What Happens Next
Your evaluation should include:
- Complete blood count to assess for anemia from blood loss 3
- Pelvic examination and likely transvaginal ultrasound to evaluate for structural abnormalities 1, 2
- Pregnancy test and STI screening as baseline assessments 1, 4
- Assessment of hemodynamic stability - large clot passage can indicate significant blood volume loss 3
Important Context About Provera and Bleeding
- While breakthrough bleeding is common with medroxyprogesterone acetate, particularly in the first 3-6 months, it typically manifests as spotting or light irregular bleeding, not heavy bleeding with large clots 1, 5
- High-dose oral medroxyprogesterone (60-120 mg) is actually used to treat excessive dysfunctional uterine bleeding, with bleeding cessation typically occurring within 1-4 days 3
- The fact that you're experiencing heavy bleeding with large clots while on Provera suggests either an inadequate dose for your bleeding pattern or an underlying pathology that requires different management 3
Critical Safety Point
Do not attempt to manage this bleeding at home or wait to see if it improves. The combination of progestin therapy and heavy bleeding with large clots requires immediate medical assessment to prevent complications and identify treatable causes 1, 2, 3