For how long can a woman safely remain on Depo‑Provera (medroxyprogesterone acetate) for contraception?

Duration of Depo-Provera Use

A woman can safely remain on Depo-Provera indefinitely without a mandatory time limit, though the FDA black-box warning recommends using it as a long-term method (beyond 2 years) only if other contraceptive options are inadequate. 1

Primary Guideline Position

ACOG explicitly does not advise limiting Depo-Provera use to 2 years, as the benefits of preventing unwanted pregnancy generally outweigh the risks of bone density loss. 2 This represents the most current expert consensus despite the FDA's cautionary language from 2004. 2

The Bone Density Concern

The 2-year threshold stems from bone mineral density (BMD) concerns:

• Depo-Provera causes BMD reductions of 5-6% at the spine and hip over 5 years, with the most pronounced decline occurring in the first 2 years. 1
• After year 2, BMD continues to decline but at a slower rate (approximately 1% additional loss from years 2-5). 1
• Crucially, BMD substantially recovers after discontinuation, though longer duration of use is associated with less complete recovery during the 2-year post-therapy period. 2, 1

Clinical Decision Algorithm

For Most Women:

• Continue Depo-Provera beyond 2 years if it is the preferred or most appropriate contraceptive method. 2
• No routine BMD monitoring is required. 2
• Mandatory bone-health counseling includes: 1300 mg daily calcium, 600 IU vitamin D, weight-bearing exercise, and smoking cessation. 2, 3

For Women with Osteoporosis Risk Factors:

• Consider alternative long-acting reversible contraceptives (copper IUD, levonorgestrel IUD, or implant) as first-line options. 2
• Risk factors include: chronic glucocorticoid use, metabolic bone disease, chronic smoking/alcohol use, anorexia nervosa, strong family history of osteoporosis, or anticonvulsant use. 1
• If Depo-Provera is still chosen despite risk factors, BMD should be evaluated when contemplating long-term use. 3, 1

For Adolescents (12-18 years):

• The same principles apply—no mandatory 2-year limit—but heightened attention to bone health is warranted since adolescence is a critical period for bone accretion. 1
• The unknown long-term impact on peak bone mass and future fracture risk requires more careful risk-benefit assessment. 1
• BMD interpretation must account for patient age and skeletal maturity. 1

Other Long-Term Considerations

Menstrual Changes:

• Nearly all patients experience irregular bleeding initially, but amenorrhea rates increase with duration (often by 1 year of use), which many women find desirable. 2, 4

Weight Gain:

• Weight gain >5% at 6 months strongly predicts continued significant weight increase with ongoing use. 2, 3
• This is a key counseling point for continuation decisions. 2

Return to Fertility:

• Expect 9-18 months delay in return to fertility after discontinuation, regardless of duration of use. 2

Common Pitfall to Avoid

Do not automatically discontinue Depo-Provera at 2 years based solely on the FDA warning. 2 The warning reflects theoretical concerns about peak bone mass that must be balanced against the very real risk of unintended pregnancy if contraceptive options are limited. 2 The guideline consensus prioritizes pregnancy prevention while managing bone health through supplementation and lifestyle measures. 2, 3