DMPA Injection Dosing and Administration

Dosing and Route of Administration

• The American Academy of Pediatrics recommends two formulations of DMPA with equivalent effectiveness and side effects: 150 mg intramuscularly or 104 mg subcutaneously every 13 weeks 1, 2
• The 104 mg subcutaneous injection is a viable option for patients, with equivalent effectiveness and side effects to the 150 mg intramuscular injection 1, 2

Timing of First Injection

• The "quick start" or "mid-cycle" initiation of DMPA is acceptable if the provider is reasonably certain the patient is not pregnant, as recommended by the American Academy of Pediatrics 1, 2

Repeat Injection Schedule

• The American Academy of Pediatrics recommends scheduling repeat injections every 13 weeks (91 days) 1, 2
• Many providers schedule adolescents every 11-12 weeks to allow buffer time for missed appointments, as suggested by the American Academy of Pediatrics 1, 2

Side Effects to Counsel About

Menstrual Changes

• Nearly all patients experience menstrual irregularities initially with unpredictable spotting and bleeding, according to the American Academy of Pediatrics 1, 2
• Bleeding patterns typically improve over time, with amenorrhea becoming common with continued use, as reported by the American Academy of Pediatrics 1, 2
• Pre-injection counseling about menstrual changes reduces discontinuation rates, as recommended by the American Academy of Pediatrics 1, 2

Weight Gain

• Weight gain occurs in some but not all patients, with a significant predictor of future excessive weight gain being weight gain status at 6 months, according to the American Academy of Pediatrics 1, 2

Bone Mineral Density

• DMPA causes reversible reductions in bone mineral density (BMD), but BMD substantially recovers after discontinuation, as reported by the American Academy of Pediatrics 1, 2
• The American College of Obstetricians and Gynecologists (ACOG) does not recommend limiting use to 2 years despite FDA black-box warning, as the benefits of pregnancy prevention outweigh the risks 1, 2

Patient Counseling Points

Contraceptive Efficacy

• Patients should use backup contraception (condoms or abstinence) for the first 7 days after initial injection, as recommended by the American Academy of Pediatrics 1, 2
• The typical use failure rate is approximately 6% in the first year, according to the American Academy of Pediatrics 1, 2

STI Protection

• Patients should be counseled to use condoms at all times for STI protection, as DMPA provides no protection against sexually transmitted infections, as recommended by the American Academy of Pediatrics 1, 2

Bone Health Measures

• All patients should receive counseling on skeletal health promotion, including daily intake of calcium and vitamin D, regular weight-bearing exercise, and avoidance of smoking and alcohol, as recommended by the American Academy of Pediatrics 1, 2, 3

Special Considerations for HIV-Infected Patients

• HIV-infected women should be informed that DMPA may or may not increase HIV transmission risk to partners, and should be counseled to continue condom use for HIV prevention, as recommended by the American Academy of Pediatrics 3
• DMPA has no significant interactions with antiretroviral agents, including efavirenz, zidovudine, lamivudine, nevirapine, and nelfinavir, according to the American Academy of Pediatrics 3

Self-Administration Option

• Subcutaneous DMPA (104 mg) can be self-administered as an off-label use when prescribed by a provider, with critical implementation elements including instruction on self-injection technique and sharps disposal education, as recommended by the Centers for Disease Control and Prevention 4

Common Pitfalls to Avoid

• Providers should not assume amenorrhea after DMPA is pathologic without ruling out other causes, and should not routinely monitor bone density or limit use to 2 years based solely on BMD concerns, as recommended by the American Academy of Pediatrics 1, 2
• Providers should not fail to counsel about menstrual irregularities before first injection, as this significantly reduces discontinuation, according to the American Academy of Pediatrics 1, 2

Depo-Provera Injection Duration of Effectiveness and Administration

Administration Schedule and Timing

• The Centers for Disease Control and Prevention, as reported in MMWR Recommendations and Reports, recommends that the repeat Depo-Provera injection can be given up to 2 weeks late (14 weeks from the last injection) without requiring additional contraceptive protection 5
• If a woman is more than 2 weeks late (>14 weeks from the last injection), she can still receive the injection if it's reasonably certain she is not pregnant, but will need to use backup contraception for 7 days, as suggested by MMWR Recommendations and Reports 5, 6
• MMWR Recommendations and Reports indicates that there are no time limits on early injections; they can be given when necessary (e.g., when a woman cannot return at the routine interval) 5

Return to Fertility After Discontinuation

• Studies reported in MMWR Recommendations and Reports indicate a wide variation in time to ovulation after the last injection, with the majority ranging from 15 to 49 weeks 5

Common Side Effects with Long-Term Use

• Weight gain is a common side effect, particularly in women who show early weight gain (>5% at 6 months), according to MMWR Recommendations and Reports 5

Special Considerations

• The American College of Obstetricians and Gynecologists does not recommend limiting use to 2 years despite bone density concerns, as the benefits of preventing unwanted pregnancy generally outweigh the risks, as noted in guidelines from other sources, but for our purposes, MMWR Recommendations and Reports is the guiding reference 5

Backup Birth Control After Missed Depo-Provera Injection

Timing-Based Recommendations

• The American Academy of Family Physicians recommends proceeding with the Depo-Provera injection immediately if less than 2 weeks late, with no backup contraception needed, as the patient remains protected against pregnancy 7
• If 2 weeks or more late, the Centers for Disease Control and Prevention (CDC) recommends receiving the injection if reasonably certain the patient is not pregnant, and using backup contraception for 7 consecutive days after the injection 8, 7, 9

Backup Contraception Options

• The American Academy of Pediatrics recommends condoms as the preferred backup method because they provide dual protection against both pregnancy and sexually transmitted infections 10, 8
• The CDC recommends using condoms consistently for the full 7-day period after a late injection 8, 9
• Complete abstinence from sexual intercourse for 7 days after the injection is an alternative to barrier methods, as recommended by the CDC 8, 9

Emergency Contraception

• The American Academy of Family Physicians recommends considering emergency contraception if unprotected intercourse occurred within 5 days before receiving a late injection 7
• Ulipristal (Ella) may be more effective than levonorgestrel, especially after 72 hours and in women who are overweight or obese, according to the American Academy of Family Physicians 7
• Copper IUD insertion within 5 days is the most effective emergency contraception option, as recommended by the American Academy of Family Physicians 7

Critical Timing Considerations

• The CDC recommends allowing a 7-day backup period after a late injection, which allows sufficient time for the new injection to re-establish contraceptive levels 8, 9

Common Pitfalls to Avoid

• The CDC recommends not delaying receiving a late injection, as it can be received at any time if reasonably certain the patient is not pregnant, though backup contraception will be needed 8, 9
• The American Academy of Pediatrics recommends using condoms consistently regardless of injection timing for STI prevention, as Depo-Provera provides no STI protection 10

Pregnancy Testing Considerations

• The CDC recommends proceeding with the injection and arranging follow-up pregnancy testing in 2-4 weeks if uncertain whether the patient might be pregnant when presenting for a late injection 9
• The CDC also recommends using backup contraception for 7 days after the injection in such cases 9

Alternative Long-Acting Options

• The American Academy of Pediatrics recommends considering alternative contraceptive methods, such as IUDs or contraceptive implants (Nexplanon), which provide longer-acting protection without requiring regular appointments 10
• These methods have higher continuation rates than injectable contraception, according to the American Academy of Pediatrics 10