Depo-Provera Prescription Guidelines

Primary Indications for Prescribing

The American College of Obstetricians and Gynecologists recommends Depo-Provera as a first-line contraceptive option for women seeking highly effective pregnancy prevention, with a failure rate of less than 1% per year with perfect use and approximately 6% with typical use 1

The Centers for Disease Control and Prevention recommends that the first injection should be given during the first 5 days of a normal menstrual period to ensure the patient is not pregnant at the time of administration, or alternatively, the "quick start" or "mid-cycle" initiation is acceptable if the provider can be reasonably certain the patient is not pregnant using established criteria 1, 2
The provider can be reasonably certain a woman is not pregnant if she meets any one of the following: 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, or is fully or nearly fully breastfeeding (≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum 2

If Depo-Provera is started within the first 7 days of menses, no backup contraception is needed 4
If started more than 7 days after menses, patients must use backup contraception (condoms or abstinence) for 7 consecutive days after the injection 1, 4

The Centers for Disease Control and Prevention states that minimal pre-administration testing is required, which facilitates same-day initiation, including no requirement for pelvic examination, cervical cytology (Pap smear), clinical breast examination, laboratory tests for glucose, lipids, liver enzymes, hemoglobin, or thrombogenic mutations, or HIV screening 2, 4

The American College of Obstetricians and Gynecologists recommends not prescribing Depo-Provera in the following circumstances: 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, or history of stroke or myocardial infarction 4, 5

The American College of Obstetricians and Gynecologists recommends that patients must understand that return to fertility is delayed after discontinuation, with time to ovulation ranging from 15 to 49 weeks after the last injection 1
Patients must be counseled to use condoms at all times for STI protection, as Depo-Provera provides no protection against sexually transmitted infections 1

Two formulations are available with equivalent effectiveness: 150 mg intramuscularly every 13 weeks (91 days) and 104 mg subcutaneously every 13 weeks (91 days) 1

Schedule repeat injections every 13 weeks (91 days), and injections can be given up to 2 weeks late (14 weeks from last injection) without requiring additional contraceptive protection 1
If more than 2 weeks late (>14 weeks), the patient can still receive the injection if reasonably certain she is not pregnant, but must use backup contraception for 7 days 1