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Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration

Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration
Literature review current through: Jan 2024.
This topic last updated: Jan 19, 2023.

INTRODUCTION — Depot medroxyprogesterone acetate (DMPA, also known as DepoProvera) is an injectable progestin-only contraceptive that provides highly effective, private, three-month-long reversible contraception. Use of DMPA eliminates the need for daily user action, action near the time of sexual intercourse, and need for partner cooperation.

This topic will review DMPA formulation, patient selection, and use. Related information on counseling about side effects, risks, and benefits is presented separately. This topic will not discuss norethisterone enanthate injections. Related information on other progestin-only contraceptives and contraceptive counseling and selection is presented separately.

(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits".)

(See "Contraception: Etonogestrel implant".)

(See "Intrauterine contraception: Background and device types", section on 'Levonorgestrel IUD'.)

(See "Contraception: Progestin-only pills (POPs)".)

(See "Contraception: Counseling and selection".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

FORMULATIONS AND PHARMACOLOGY — DMPA is available in two formulations: 150 mg/1 mL for intramuscular injection (available as a generic) and 104 mg/0.65 mL for subcutaneous injection. Either formulation can be given every 3 months (13 weeks) because low solubility of the microcrystals at the injection site allows pharmacologically active drug levels to persist and remain effective for several months [1].

Intramuscular (IM) – Following a single IM dose of DMPA, the drug level increases for approximately three weeks, reaching a peak blood concentration of up to 7 ng/mL for a few days [2,3]. The level then declines until it becomes undetectable between 120 and 200 days following injection [3], but there is considerable inter-individual variability in serum levels. Ovulation resumes at DMPA levels <0.1 ng/mL [1].

Subcutaneous (SC) – The formulation for subcutaneous injection provides slower and more sustained absorption of the progestin than conventional intramuscular DMPA. This enables a 30 percent lower dose of progestin (104 versus 150 mg) and reduces peak blood levels by half [4] but with the same duration of effect as conventional DMPA. A study of the pharmacokinetic profile of subcutaneous DMPA over one cycle after injection in the upper arm reported injection at this site provided sufficient medroxyprogesterone levels for contraceptive protection [5]. The study included 24 women with body mass index from 18 to 40 kg/m2. Compared with intramuscular dosing, subcutaneous injections are associated with more injection site reactions (8.0 versus 0.4 percent) [6]. These reactions have been described as skin dimpling and may represent lipoatrophy; it is uncertain to what degree these skin changes are reversible [7]. SC DMPA is a user-controlled method, which likely contributes to its higher continuation rates compared with the IM formulation [8] (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Local'.)

Serum progesterone levels are low (<0.4 ng/mL) for several months following an injection of DMPA [1]. Estradiol levels vary, but most women have lower levels than normally cycling women [1,9]. Women who have used DMPA for several years have serum estradiol levels between 10 and 92 pg/mL (mean approximately 40 pg/mL) [1]. Although the endometrium becomes atrophic, vasomotor symptoms are uncommon and the vaginal epithelium remains moist and well rugated.

DMPA is an effective contraceptive method (figure 1). The unintended pregnancy rate in the first year of use is 6 percent [10]. Efficacy data are discussed in detail in the related counseling topic (see "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits"). Progestins can prevent pregnancy via several mechanisms. DMPA primarily acts by inhibition of gonadotropin secretion, thereby inhibiting follicular maturation and ovulation [11]. Progestins also cause changes in cervical mucus (thicker and less permeable to sperm) and tubal motility (reduced ciliary action) that are unfavorable to sperm migration, thus inhibiting fertilization. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Efficacy'.)

PATIENT SELECTION

Women with contraindications to estrogen therapy — Although clinicians should familiarize themselves with the contraindications listed on package labeling for all medications they prescribe, progestin-only hormonal methods appear to be appropriate contraceptive choices for many women with relative contraindications to estrogen-containing contraceptives [12]. Many of the contraindications listed in the package insert were established for combined estrogen-progestin oral contraceptives and then extrapolated to progestin-only methods because clinical trials have not evaluated the safety of the latter in women with contraindications to estrogen. (See "Combined estrogen-progestin contraception: Side effects and health concerns".)

Other candidates — Most adolescent and adult women can use DMPA. The Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use and the World Health Organization Medical Eligibility Criteria for Contraceptive Use list individual (eg, breastfeeding) and medical conditions that may impact use of nonbarrier contraceptives [12]. The advantages and disadvantages of DMPA use are summarized in the table (table 1).

DMPA is a particularly good contraceptive option for adolescent and adult women who meet any of the following criteria:

Desire a highly effective reversible contraceptive that does not require daily use

Have a contraindication to, or wish to avoid, an estrogen-containing contraceptive

Desire or medical indication for eliminating menstrual bleeding

Wish to take advantage of DMPA's noncontraceptive benefits (eg, reduction in dysmenorrhea as well as pelvic pain from endometriosis)

Prefer a private/discreet method of contraception

May not consistently remember to use types of contraception that require frequent or pericoital administration

Have difficulty using other forms of contraception

Have physical or intellectual differences that make other methods difficult to use or remember

A comparison of attributes of the various progestin contraceptive methods is presented separately. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Comparison with other progestin-only contraceptives'.)

Contraindications — DMPA should not be used by women with known breast cancer or who are pregnant [12,13]. In addition, DMPA (both doses) is generally avoided in the following adolescent and adult women, as other contraceptive options are available [12,13]:

Women with severe cirrhosis, hepatocellular adenoma, diabetes with nephrosis or vascular complications, hypertension, ischemic heart disease or multiple risk factors for atherosclerotic disease, and some forms of lupus [12].

Unexplained vaginal bleeding [12].

Pregnancy planned within the next year, because a delay in return in fertility may occur with DMPA. (See 'Return to fertility after discontinuation' below.)

Long-term use of corticosteroid therapy in women with a history of, or risk factors for, nontraumatic (frailty) fractures. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

Current use of aminoglutethimide (usually for the treatment of Cushing's syndrome) because aminoglutethimide may increase metabolism of progestins [14].

ADMINISTRATION

Screening — Routine pelvic and breast examinations, blood pressure measurement, and laboratory tests are not required before initiating DMPA [15].

Injection techniques — Administration via the subcutaneous (SC) route is less painful than intramuscular (IM) injection and may facilitate off-label patient self-administration [16-19]. Otherwise, the benefits and risks are similar for IM and SC administration.

Intramuscular – Both the 1 mL vial and the 1 mL prefilled syringe of DMPA should be shaken vigorously just before use to ensure that the dose being administered represents a uniform suspension; 150 mg of DMPA is administered by deep IM injection in the gluteal or deltoid muscle [3].

Subcutaneous – The prefilled syringe (0.65 mL) of DMPA should be shaken vigorously just before use to create a uniform suspension; 104 mg of DMPA is administered by SC injection into the anterior thigh or abdomen. Although off-label use, SC DMPA can be administered in the upper arm for women who prefer this injection site or decline injection into the anterior thigh or abdomen.

Self-administration – Although self-administration is off-label, this approach can enhance access and facilitate timely continuation. Several reports have documented preliminary experience with DMPA IM and DMPA SC self-administration [16,17,20,21]. A trial that randomly assigned 401 women to either self- or clinic administration of DMPA SC reported significantly higher one-year continuation rates for women who self-administered the drug (69 versus 54 percent for self- versus clinic administered) [22].

Timing of injections — The first DMPA injection can be given at any time once pregnancy has reasonably been excluded (table 2).

Initial injection — Although pregnancy should be excluded before initiating contraception (table 2), there is no evidence that inadvertent administration of DMPA during pregnancy increases the risk of congenital anomalies [23,24]. In the United States Planned Parenthood National Database for 1994 to 1998, 402 DMPA users became pregnant, and many of these women received more than one dose of DMPA while pregnant [23]. No fetal anomalies were reported; however, birth outcome data were incomplete.

First day of menses – In cycling women, the ideal time to initiate DMPA is within seven days of the onset of menses. This approach increases the certainty that the patient is not pregnant at the time of injection and prevents ovulation during the first month of use so that back-up contraception is unnecessary [25]. Most women have pharmacologically active drug levels and relatively impermeable cervical mucus within 24 hours after injection.

Quick start – Several studies have initiated DMPA on the day the patient is first seen for contraception, rather than waiting until her next menses begins [26-29], as long as pregnancy can be excluded with reasonable certainty by history or pregnancy testing (table 2). This "same day," "quick start," or "Depo-now" approach facilitates DMPA initiation for many users [30].

If DMPA is initiated more than seven days after the first day of the woman's menstrual period and she has had unprotected intercourse during the cycle, clinicians and patients must recognize that there is a small chance of preimplantation or early pregnancy despite a negative pregnancy test prior to the injection. We suggest these women receive emergency contraception if intercourse occurred within the previous 120 hours, and we advise them to use back-up contraception for seven days after DMPA injection [31] since ovulation may occur within 24 hours of the initial injection, and we counsel them to have a repeat pregnancy test in two to three weeks. (See 'Need for back-up contraception' below.)

Switching from another method – Begin DMPA while the woman is still using hormonal contraception (pill, patch, ring) and discontinue the other method seven days after the injection (table 3). Otherwise, a condom or abstinence should be used as a back-up if the first injection is not given within seven days of menses onset.

If switching from intrauterine contraception, the injection should be given seven days before removal of the intrauterine device (IUD). Otherwise, switching from an IUD requires consideration of fertilization and implantation from residual sperm in the reproductive tract. Options to prevent these pregnancies include advising the woman to [15]:

Abstain from sex or use barrier contraception for seven days before removing the IUD and receiving the first DMPA injection.

Use emergency contraception at the time of IUD removal.

Repeat injections — DMPA users should be encouraged to return every 3 months (13 weeks) for repeat injections.

Women who return late for a repeat injection – Women using injectable birth control who present late for follow-up injections should not be denied repeat injection solely because they are not on time. After a 150 mg injection, ovulation does not occur for at least 14 weeks. In women more than two weeks late for their injection (>15 weeks from the last injection), we suggest a pregnancy test before administering DMPA and back-up contraception (or abstinence) for seven days [11]. In the United States, Centers for Disease Control and Prevention guidelines support this approach [15]; however, the package labeling is more conservative and recommends excluding pregnancy prior to reinjection in women more than one week late for their injection or >14 weeks from their last injection.

As a result of a study showing that contraceptive efficacy is maintained with a grace period as long as four weeks [32], the World Health Organization adopted a longer grace period in its updated guideline [33]. In this study of 2290 women in developing countries who underwent 13,608 DMPA cycles, the pregnancy risk per 100 women-years was statistically similar for users who were "on time" for their injection (0.6, 95% CI 0.33-0.92, 12,508 cycles), users who were two weeks late for their injection (0.0, 95% CI 0.0-1.88, 739 cycles), and users who were four weeks late for their injection (0.4, 95% CI 0.01-2.29, 893 cycles) [32]. A limitation of these data is that more than one-third of the women in the study were lactating, placing them at low baseline risk for conception.

Because pregnancy testing may not be readily available in low-resource countries, expanding the grace period to four weeks is reasonable in such settings. In high-resource countries, we continue to encourage women to return on time and allow a two-week grace period, and we require documentation of a negative pregnancy test in women who present more than two weeks (>15 weeks from their last injection).

Women who return early for a repeat injection – If it is more convenient for a patient to move up the date of her DMPA injection, a repeat injection may be given early [15].

Need for back-up contraception — Back-up contraception, such as pericoital contraception (eg, male or female condoms, single-size diaphragm), the previously used hormonal method, or abstinence, is indicated for seven days if [15]:

DMPA is initiated more than seven days from the onset of the last menstrual period.

The woman is postabortion and DMPA was not initiated at the time of the abortion.

The woman is postpartum, has not had a menstrual period, and (1) is fully breastfeeding and >6 months postpartum or (2) not fully breastfeeding and ≥21 days postpartum.

The woman had an IUD removed at the time of her first DMPA injection. In addition, these women are offered emergency contraception if they have had sex within seven days preceding IUD removal.

Follow-up after injection — Other than scheduling visits for repeat DMPA injection, no specific follow-up is required for DMPA users. As with all contraceptive users, clinicians should encourage the patient to contact them anytime to discuss side effects, questions, problems, or desire to change the method [15]. Patients should also be encouraged to contact their health care providers if they have any significant medical issues, such as starting a new medication that could impact contraceptive use.

SYMPTOMS THAT WARRANT EVALUATION — Unscheduled bleeding is common in individuals using DMPA. Other potential side effects and metabolic changes are discussed in related content. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits".)

Heavy uterine bleeding — Unscheduled bleeding with DMPA use is common. However, individuals who report very bothersome or heavy uterine bleeding should be evaluated for other causes and treated as indicated.

(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Menstrual changes'.)

(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

Symptoms for urgent evaluation — DMPA users who develop new-onset chest pain, shortness of breath, or deep unilateral leg pain should be evaluated for possible thromboembolic event, including myocardial infarction, pulmonary embolus, and deep venous thrombosis. The absolute increased risk of cardiovascular and thromboembolic events in women using DMPA is unclear. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)

DISCONTINUATION — One-year discontinuation rates range from 40 to 75 percent [34].

Return to fertility after discontinuation — Although DMPA does not permanently impact endocrine function, return of fertility may be delayed. Within 10 months of the last injection, 50 percent of women who discontinue DMPA to become pregnant will conceive [35]. However, in a small proportion of women, fertility is not re-established until 18 months after the last injection. The persistence of ovulation suppression following DMPA discontinuation is not related to the duration of use but is related to body weight; women with lower body weights conceive sooner after discontinuing DMPA than women with higher body weights.

Before initiating DMPA contraception, clinicians should counsel candidates about the possible prolonged duration of contraceptive action. Women who may want to become pregnant within the next one or two years should choose an alternative contraceptive.

Switching from DMPA to another method — In DMPA users changing to a new method, it is appropriate to initiate the new method any time but no later than 15 (ideally no later than 14) weeks after the previous injection. This ensures that the woman is not pregnant at the time she initiates a new contraceptive method. Initiation of the new contraceptive method should not be delayed until resumption of menses. Amenorrhea after discontinuing DMPA injections does not mean the woman is protected against pregnancy if she has unprotected intercourse.

DRUG INTERACTIONS — Use of DMPA is associated with relatively high progestin levels [2]. Accordingly, one benefit of DMPA use is the lack of drug interactions compared with some other hormonal contraceptives [12].

Potential drug interactions of concern:

Aminoglutethimide – As discussed above, use of aminoglutethimide (usually for the treatment of Cushing's syndrome) is contraindicated because aminoglutethimide may increase metabolism of progestins. (See 'Contraindications' above.)

Fosamprenavir – While there is theoretical concern that progestin use could decrease levels of the protease inhibitor fosamprenavir, use of DMPA is acceptable in women taking this medication [12].

Efavirenz and rifampicin – Combination treatment with efavirenz and rifampicin has been reported to increase DMPA clearance based on one study of 42 female participants with HIV and tuberculosis co-infection [36]. Until this finding is confirmed by larger trials, UpToDate does not advise a change in dosing schedule for patients receiving combined treatment with efavirenz and rifampicin.

Although the United States package insert for DMPA also warns against coadministration of DMPA with antiseizure medications, rifampin, or St. John's wort, the Centers for Disease Control and Prevention and the World Health Organization do not support such restriction and list DMPA as having "advantages that generally outweigh theoretical or proven risks" [12,31].

SPECIAL POPULATIONS

Adolescents — Rates of oral contraceptive failure and discontinuation can be very high among adolescents. By contrast, DMPA provides highly effective and acceptable contraception in this population [37-43].

A study of postpartum teens found that DMPA users were more likely to continue their contraception than oral contraceptive users (55 versus 27 percent) and had lower rates of repeat pregnancy (3 versus 24 percent) during a minimum of 12 months follow-up [44]. If the implant or intrauterine devices are not available, appropriate, or acceptable to the patient, DMPA, coupled with condoms for protection against sexually transmitted infections, should be considered the contraceptive of first choice for sexually active teens [39,45].

The effect of DMPA on bone mineral density in adolescents is reviewed separately. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

Overweight and obese women — Since DMPA results in high progestin levels, efficacy is not reduced by high body weight [46,47]. (See "Contraception: Counseling for females with obesity", section on 'Depot medroxyprogesterone acetate'.)

Perimenopausal women — There is no age limit to DMPA use; women can safely continue DMPA injections until they become menopausal [12]. As long-term DMPA users have high rates of amenorrhea, perimenopausal DMPA users may not experience the irregular bleeding that characteristically accompanies the perimenopausal transition. Likewise, such women may not experience vasomotor symptoms because they are suppressed by DMPA use. (See "Menopausal hot flashes".)

The median age of menopause (when contraception is no longer needed) is 51 to 52 years, meaning that 50 percent of women of this age are still ovulatory. By age 55 years, in contrast, at least 80 percent of women are menopausal [48,49]. Therefore, it is reasonable to continue DMPA without gonadotropin testing until the patient is in her mid-50s. At that time, contraception can be discontinued.

Although serum follicle-stimulating hormone (FSH) concentrations increase across the menopausal transition, a single elevated FSH level is not useful in determining menopausal status in any woman because FSH levels vary from cycle to cycle and may fluctuate between the normal premenopausal and postmenopausal ranges [50]. FSH testing is even less useful in DMPA users because DMPA suppresses FSH production; thus, menopausal DMPA users may have FSH levels in the premenopausal range related to DMPA. These relationships were illustrated in a study of 82 amenorrheic long-term DMPA users age 40 to 55 years who had FSH testing every 90 days immediately before their DMPA injection; 41 percent of women with a high initial FSH level subsequently had a low FSH level [51]. If FSH is measured in a DMPA user ≥age 50 years, the level is most informative of menopausal status if measured immediately before the next DMPA injection is due [52] and is in the menopausal range on two consecutive occasions [51].

The effect of DMPA on bone mineral density is discussed separately. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Reduction in bone mineral density'.)

Postabortion and postpartum women — Use of DMPA after abortion or delivery, and in breastfeeding women, is discussed separately. (See "Contraception: Postabortion", section on 'Depot medroxyprogesterone acetate' and "Contraception: Postpartum counseling and methods".)

FACTORS IMPACTING COST — Cost to the patient varies due to multiple factors, including geographic region, charge for drug, and insurance coverage. Additionally, use of multi-dose vials are typically less expensive than premeasured subcutaneous DMPA. However, in some regions, uniject vials for self-administration of subcutaneous DMPA are the cheapest source. Clinicians should familiarize themselves with the available formulations in their regions and the relative costs of each.

RESOURCES FOR PATIENTS AND CLINICIANS

World Health Organization – Family Planning: A Global Handbook for Providers.

Planned Parenthood – A nonprofit organization dedicated to reproductive health with resources for patients and clinicians.

Bedsider – A free website developed by the National Campaign to Prevent Teen and Unplanned Pregnancy, a private nonprofit group.

CHOICE Project – A free website sponsored by the Washington University School of Medicine in St. Louis that provides resources on contraceptive options and training resources for clinicians.

Center for Young Women's Health – A free website run by Boston Children's Hospital that addresses reproductive health needs of teens and young adults.

Beyond the Pill – A free website run by the University of California San Francisco.

Sex & U – An educational site run by the Society of Obstetricians and Gynaecologists of Canada that includes descriptions of various methods and a tool to help with selection of birth control.

ACOG Contraceptive FAQs – American College of Obstetricians and Gynecologists addresses frequently asked questions (FAQs) about progestin-only contraception, including DMPA injection.

ACOG LARC Program – American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception Program.

United States Medical Eligibility Criteria (US MEC) for Contraceptive Use.

United States Selected Practice Recommendations (US SPR) for Contraceptive Use.

World Health Organization: Medical Eligibility Criteria for Contraceptive Use.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Choosing birth control (The Basics)")

Beyond the Basics topics (see "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Birth control; which method is right for me? (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Formulation and dosing – Depot medroxyprogesterone acetate (DMPA) is highly effective reversible contraceptive (figure 1) that is available in two formulations: 150 mg/1 mL for intramuscular injection and 104 mg/0.65 mL for subcutaneous injection. Either formulation is given every 3 months (13 weeks). (See 'Formulations and pharmacology' above.)

Patient selection – Most adolescent and adult females can use DMPA, including those with relative contraindications to estrogen-containing contraceptives. (See 'Patient selection' above.)

Individual characteristics (eg, breastfeeding) and medical conditions that may impact patient selection can be found through:

The Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use and

The World Health Organization Medical Eligibility Criteria for Contraceptive Use

Examination not required for DMPA administration – Routine pelvic and breast examinations, blood pressure measurement, and laboratory tests are not required before initiating DMPA. (See 'Screening' above.)

Initiation and repeat dosing – The ideal time to initiate DMPA is within seven days of the onset of menses or before discontinuing another method of contraception, but it can be started at almost any time. (See 'Timing of injections' above.)

Timing of repeat injection – The dose is repeated every 3 months (13 weeks), with up to a 2-week grace period (15 weeks total from prior injection). (See 'Repeat injections' above.)

If a repeat dose is missed – We advise excluding possibility of pregnancy by history (table 2) or performing a pregnancy test before administering DMPA in women more than two weeks late for their injection. (See 'Repeat injections' above.)

Need for back-up contraception – In some clinical scenarios, back-up contraception, such as pericoital contraception (eg, male or female condoms, single-size diaphragm), the previously used hormonal method, or abstinence, is indicated for seven days after initial DMPA injection. (See 'Need for back-up contraception' above.)

Symptoms that warrant evaluationDMPA is generally well tolerated despite the prevalence of unscheduled bleeding. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits".)

Heavy uterine bleeding – Unscheduled bleeding is common with DMPA use and generally tolerated. Individuals who report very bothersome or heavy bleeding should be evaluated for other causes and treated as indicated. (See 'Heavy uterine bleeding' above.)

Symptoms for urgent evaluation – Individuals who develop new-onset chest pain, shortness of breath, or deep unilateral leg pain should be evaluated for possible thromboembolic event, including myocardial infarction, pulmonary embolus, and deep venous thrombosis. (See 'Symptoms that warrant evaluation' above.)

Return of fertility after stopping DMPA – Fifty percent of persons who desire pregnancy will be pregnant within 10 months after their last DMPA injection. However, return of fertility may be delayed after discontinuing DMPA; in a small proportion of individuals, fertility is not re-established until 18 months after the last injection. Accordingly, DMPA is generally not advised for those who wish to conceive in the next one to two years. (See 'Return to fertility after discontinuation' above.)

Special populations – Adolescent, obese, and perimenopausal females are all potential candidates for DMPA use. DMPA users can safely continue without gonadotropin testing until in their mid-50s. Perimenopausal DMPA users will not experience the bothersome irregular bleeding that characteristically accompanies the perimenopausal transition and may not experience vasomotor symptoms. (See 'Special populations' above.)

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Topic 5468 Version 75.0

References

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