Menstrual Suppression with Medroxyprogesterone Acetate

Introduction to Menstrual Suppression

The American Academy of Pediatrics recommends that depot medroxyprogesterone acetate (DMPA/Depo-Provera) injections be used for menstrual suppression and amenorrhea in most patients with continued use, as oral medroxyprogesterone acetate is not effective for this purpose 1, 2, 3

DMPA 150 mg intramuscularly every 13 weeks (or 104 mg subcutaneously) is highly effective for menstrual suppression, with amenorrhea occurring in nearly all patients after ≥1 year of continuous use 4
Initial menstrual irregularities are present in nearly all patients, but these typically improve over time with progression toward amenorrhea 1, 2, 3

DMPA is particularly useful for disabled, nonambulatory adolescents where menstrual suppression is needed while avoiding exogenous estrogen and bone density concerns 2, 3
DMPA is also useful for patients with dysmenorrhea seeking relief from painful menses 2, 3
The Centers for Disease Control and Prevention recommends considering alternative contraceptive methods, such as the levonorgestrel IUD, for menstrual suppression when estrogen is contraindicated, avoiding DMPA's bone density effects 2, 3

Patients must understand that irregular bleeding and spotting are common initially and generally not harmful, and that amenorrhea develops gradually, typically after several injections 4
Enhanced counseling about expected bleeding patterns reduces discontinuation rates 4
Weight gain occurs in some but not all patients; weight status at 6 months predicts future excessive weight gain 1
Bone mineral density decreases with use, requiring calcium (1300 mg daily), vitamin D (600 IU), weight-bearing exercise, and smoking cessation 2

If heavy or prolonged bleeding persists despite DMPA use and is unacceptable to the patient, NSAIDs for 5-7 days during bleeding episodes, low-dose combined oral contraceptives or estrogen for 10-20 days (if medically eligible), or alternative contraceptive methods may be considered 4

The American College of Obstetricians and Gynecologists recommends that patients on DMPA receive calcium (1300mg daily), vitamin D (600 IU), and regular weight-bearing exercise to manage bone density concerns 5

DMPA causes reductions in bone mineral density, and all patients require calcium, vitamin D, and regular weight-bearing exercise 5
The American College of Obstetricians and Gynecologists does not advise limiting DMPA use to 2 years or routinely monitoring bone density, recognizing that unwanted pregnancy risks outweigh bone density concerns 5

The CDC recommends considering the levonorgestrel IUD for menstrual suppression when estrogen is contraindicated, as this avoids DMPA's bone density effects, with effective menstrual suppression in adolescent patients with complex medical conditions 5