Medroxyprogesterone acetate: Drug information

For additional information see "Medroxyprogesterone acetate: Patient drug information" and "Medroxyprogesterone acetate: Pediatric drug information"

For abbreviations, symbols, and age group definitions show table

ALERT: US Boxed Warning

Cardiovascular disorders (tablet):

Estrogen plus progestin therapy should not be used for the prevention of cardiovascular disease. The Women's Health Initiative (WHI) estrogen plus progestin substudy reported increased risks of deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction in postmenopausal women (50 to 79 years of age) during 5.6 years of treatment with daily oral conjugated estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg), relative to placebo.

Breast cancer (tablet):

The WHI estrogen plus progestin substudy demonstrated an increased risk of invasive breast cancer.

Dementia (tablet):

Estrogen plus progestin therapy should not be used for the prevention of dementia. The WHI Memory Study (WHIMS) estrogen plus progestin ancillary study of the WHI reported an increased risk of developing probable dementia in postmenopausal women 65 years or older during 4 years of treatment with daily conjugated estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg), relative to placebo. It is unknown whether this finding applies to younger postmenopausal women.

Long-term use (injection [contraceptive, endometriosis formulations]):

Medroxyprogesterone is not recommended as a long-term (ie, longer than 2 years) birth control method or medical therapy for endometriosis-associated pain unless other options are considered inadequate.

Loss of bone mineral density (injection [contraceptive, endometriosis formulations]):

Women who use medroxyprogesterone may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible. It is unknown if use of medroxyprogesterone during adolescence or early adulthood, a critical period of bone accretion, will reduce peak bone mass and increase the risk for osteoporotic fracture in later life.

Risk vs benefits (tablet):

In the absence of comparable data, these risks should be assumed to be similar for other doses of conjugated estrogens and medroxyprogesterone acetate and other combinations and dosage forms of estrogens and progestins. Estrogens with progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.

Brand Names: US

Depo-Provera;
Depo-SubQ Provera 104;
Provera

Brand Names: Canada

Depo-Provera;
Provera

Pharmacologic Category

Contraceptive;
Progestin

Dosing: Adult

Abnormal uterine bleeding, acute

Abnormal uterine bleeding, acute (off-label use):

Note: Hemodynamically unstable patients should generally be managed with surgical interventions (Ref). Typically used for hemodynamically stable patients with anovulatory bleeding and a thickened endometrium (Ref).

Oral: 10 to 20 mg 3 times a day for 5 to 10 days (Ref). Note: Transition to maintenance dosing after resolution of acute bleeding (refer to dosing for “Abnormal uterine bleeding, nonacute”) or to another type of progestin (eg, levonorgestrel IUD) (Ref).

Abnormal uterine bleeding, nonacute

Abnormal uterine bleeding, nonacute (alternative agent): Note: Dosing not intended for management of acute abnormal bleeding (ie, excessively heavy or prolonged bleeding that requires urgent evaluation). Alternative for patients who cannot or choose not to use preferred agents (eg, estrogen-progestin contraceptives, levonorgestrel IUD) (Ref).

Oral: 5 to 20 mg per day in 1 to 3 divided doses; adjust dose at 1- to 3-month intervals within this range to the lowest effective dose to control bleeding and minimize adverse reactions (Ref); some experts use up to 30 mg/day (Ref). Note: Continuous therapy is preferred in most patients due to increased efficacy and patient adherence; however, for patients who do not desire contraception, cyclic therapy (eg, administration only on days 5 to 26 of the menstrual cycle) may be preferred (Ref).

Contraception

Contraception: Note: Patients not currently using a hormonal contraceptive may receive the first dose at any time during the menstrual cycle if reasonably sure the patient is not pregnant. If administration is ≤7 days since menstrual bleeding started, no additional contraception is needed. If >7 days since menstrual bleeding started, abstain from sexual intercourse, or use additional contraceptive protection (nonhormonal) for the next 7 days (Ref). Use is not recommended for long-term (ie, longer than 2 years) birth control unless other options are considered inadequate.

Depo-Provera Contraceptive: IM: 150 mg every 3 months (every 13 weeks)

Depo-SubQ Provera 104: SUBQ: 104 mg every 3 months (every 12 to 14 weeks)

**Patients Switching from Another Contraceptive Method to Depo-medroxyprogesterone Acetate (DMPA)** **104 mg/0.65 mL or 150 mg/mL Contraceptive Injection**
^a CDC [Curtis 2016a]. ^b Depo-Provera CI prescribing information. ^c Depo-SubQ Provera 104 prescribing information. ^d Also refer to prescribing information for product-specific information.
• DMPA may be initiated if it is reasonably sure the patient is not pregnant^a • Ensure continuous contraceptive coverage based upon the mechanism of action of both contraception methods^b
Current method	Instructions for switching to DMPA
Combined oral contraceptive^c	Administer first injection within 7 days of taking the last active tablet
DMPA- IM^c	When switching from the DMPA-IM to DMPA-SUBQ formulation, the DMPA-SUBQ dose should be administered 12 to 14 weeks after the last DMPA-IM injection
Implant^c	Administer first injection on day of implant removal
Intrauterine device (IUD)^a,c,d	If sexual intercourse occurred since the start of the current menstrual cycle and it is >5 days since menstrual bleeding began: • Initiate DMPA and keep the IUD in place for ≥7 days before removing • Alternately, abstain from sexual intercourse or use barrier contraception for 7 days before removing the IUD and switching to DMPA • Consider use of emergency contraception if either option is not available (refer to guideline for details)
Transdermal system^c	Administer first injection on day the next application would be scheduled
Vaginal insert^c	Administer first injection on the day when the next insertion would be scheduled

**Use of Depo-medroxyprogesterone Acetate (DMPA) 104 mg/0.65 mL or 150 mg/mL Contraceptive Injection After Childbirth or Abortion**
Use after childbirth	Patients who are breastfeeding: • The first injection may be administered the sixth week after birth (per manufacturer) or anytime <1 month postpartum^a,b,c • The first injection may be administered ≥1 month postpartum if it is reasonably certain the patient is not pregnant^a Patients who are not breastfeeding: • The first injection may be administered anytime it is reasonably certain the patient is not pregnant^a Patients ≥21 days postpartum who have not had a return of menses, or who are not fully or nearly fully breastfeeding should abstain from sexual intercourse or use barrier contraception for the next 7 days^a Patients ≥21 days postpartum who have had a return of menses, but the injection is administered >7 days since menstrual bleeding started should abstain from sexual intercourse or use barrier contraception for the next 7 days^a
Use after abortion	The first DMPA injection may be administered within the first 7 days after a spontaneous or induced abortion^a DMPA may be administered immediately following a septic abortion^d Additional contraceptive protection (nonhormonal) is needed for the next 7 days unless the injection is administered at the time of surgical abortion^a
^a CDC [Curtis 2016a]. ^b Depo-Provera CI prescribing information. ^c Depo-SubQ Provera 104 prescribing information. ^d CDC [Curtis 2016b].

**Early or Late Doses of Depo-medroxyprogesterone Acetate (DMPA) 104 mg/0.65 mL or 150 mg/mL Contraceptive Injection^a**
^a CDC [Curtis 2016a].
Early dose	A repeat dose of DMPA may be administered early when necessary.
Late dose	If >2 weeks since dose was due (>15 weeks since last injection) the injection may be administered if is reasonably certain the patient is not pregnant. Additional contraceptive protection (nonhormonal) is needed for the next 7 days. Consider use of emergency contraception if appropriate.

Endometrial carcinoma, recurrent or metastatic

Endometrial carcinoma, recurrent or metastatic (adjunctive/palliative treatment):

IM (Depo-Provera): Initial: 400 to 1,000 mg/week.

Oral: Canadian manufacturer's labeling: Usual dose: 200 to 400 mg daily. Doses >200 mg daily may not confer additional benefit (Ref). If improvement or disease stabilization occurs, 200 mg daily may be sufficient for maintenance. Discontinue use if no improvement within 2 to 3 months.

Endometrial hyperplasia, treatment

Endometrial hyperplasia, treatment (off-label use): Note: The optimal duration of therapy has not been established (Ref).

Endometrial hyperplasia with atypia (also known as atypical endometrial hyperplasia or endometrial intraepithelial neoplasia ): Oral: 10 to 20 mg once daily (continuous dosing) or 10 to 20 mg once daily (cyclic dosing) for 12 to 14 days per month (Ref).

Endometrial hyperplasia without atypia (also known as nonatypical endometrial hyperplasia or benign endometrial hyperplasia): Oral: 10 mg once daily (continuous dosing); however, higher doses have been reported (Ref) or 10 mg once daily (cyclic dosing) for 10 to 12 days per cycle (Ref). Note: Limited data suggest higher regression rates with continuous oral dosing compared to cyclic oral dosing (Ref).

Endometriosis

Endometriosis (104 mg/0.65 mL injection): SUBQ: 104 mg every 3 months (every 12 to 14 weeks). Note: Use is not recommended for long-term (ie, longer than 2 years) endometriosis-associated pain unless other options are considered inadequate.

Estrogen therapy-associated endometrial hyperplasia, prevention

Estrogen therapy-associated endometrial hyperplasia, prevention (alternative agent):

Note: Indicated in patients with a uterus receiving estrogen therapy (eg, for vasomotor symptoms associated with menopause or secondary amenorrhea). May be administered either cyclically (preferred in late menopausal transition and early postmenopause or functional hypothalamic amenorrhea) or continuously (preferred if >2 to 3 years postmenopause) (Ref). Discontinue when estrogen therapy is discontinued.

Oral: 5 to 10 mg daily for 10 to 14 days each month (Ref) or 2.5 to 5 mg daily continuously (Ref).

Secondary amenorrhea, diagnostic aid

Secondary amenorrhea, diagnostic aid ("progestin challenge"): Oral: 5 to 10 mg daily for 5 to 10 days (Ref). Note: Withdrawal bleeding may be expected during therapy or within 3 to 7 days after cessation of therapy; absence of withdrawal bleeding suggests low endometrial estrogen exposure and/or uterine or outflow tract abnormality (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Dosing: Hepatic Impairment: Adult

Medroxyprogesterone is extensively metabolized in the liver and elimination is significantly reduced in patients with advanced hepatic disease. Most products are contraindicated in patients with hepatic impairment. If needed for the palliative treatment metastatic endometrial carcinoma, monitor closely; withhold or discontinue treatment if liver dysfunction develops and do not resume until hepatic function has returned to normal.

Discontinue if jaundice develops or if acute or chronic hepatic function disturbances occur; do not resume until liver function returns to normal. In patients with a history of cholestatic jaundice, discontinue if cholestatic jaundice recurs.

Dosing: Obesity: Adult

Depo-SUBQ Provera 104: No dosage adjustment necessary.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Medroxyprogesterone acetate: Pediatric drug information")

Abnormal uterine bleeding

Abnormal uterine bleeding: Adolescents: Oral: 5 to 10 mg for 5 to 10 days starting on day 16 or day 21 of menstrual cycle

Amenorrhea

Amenorrhea: Adolescents: Oral: 5 to 10 mg/day for 5 to 10 days

Contraception

Contraception: Adolescents: First dose to be given only during first 5 days of normal menstrual period; only within 5 days postpartum if not breast-feeding, or only at sixth postpartum week if exclusively breast-feeding. When switching from other contraceptive methods, depo-subQ provera 104 should be administered within 7 days after the last day of using the last method (pill, ring, patch).

IM (Depo-Provera): 150 mg every 3 months (every 13 weeks)

SubQ (depo-subQ provera 104): 104 mg every 3 months (every 12 to 14 weeks)

Endometriosis-associated pain

Endometriosis-associated pain: Adolescents: SubQ (depo-subQ provera 104): 104 mg every 3 months; treatment longer than 2 years is not recommended due to impact of long-term use on bone mineral density

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Dosing: Hepatic Impairment: Pediatric

Use is contraindicated with severe impairment. Discontinue with jaundice or if liver function disturbances occur. Consider lower dose or less frequent administration with mild to moderate impairment. Use of the contraceptive injection has not been studied in patients with hepatic impairment; consideration should be given to not readminister if jaundice develops.

Adverse Reactions (Significant): Considerations

Bone loss

Various degrees of bone loss with medroxyprogesterone use have been reported in the literature with most estimates ~1% to 4% decreased bone mineral density (BMD) at the hip and spine after 1 year, ~6% to 8% after 2 years, and ~5% after 5 years (Ref). Data are lacking to conclude that the surrogate marker of decreased BMD translates to increased fracture risk (Ref). Current evidence suggests that changes in BMD may be transient, similar to changes observed during pregnancy or lactation (Ref). Some studies report full recovery of bone loss 1 to 5 years after medroxyprogesterone discontinuation (Ref).

Mechanism: Time-related; while the exact mechanism remains unclear, proposed hypotheses include changes in estrogen and/or insulin like growth factors (IGFs) eliciting alteration of osteoclast activity and bone formation; and decreased proliferation of osteoblasts due to glucocorticoid action (Ref).

Onset: Delayed; decreases in BMD have been observed after 1 year of therapy with the most impact within the first 2 years (Ref).

Risk factors:

• Current versus prior use of therapy (Ref)

• Longer duration of use (some studies cite increased risk with therapy duration >2 years and others cite >4 years) (Ref)

• Parenteral medroxyprogesterone (Ref)

• Adolescents and young adult females (eg, use prior to 20 years of age), and females >50 years of age (Ref)

Menstrual bleeding irregularities

Medroxyprogesterone is commonly associated with gynecological bleeding, including irregular or unpredictable bleeding patterns, breakthrough bleeding, spotty menstruation, heavy bleeding, prolonged bleeding, and amenorrhea (Ref). Rates of menstrual bleeding irregularities decrease with longer duration of use. While menstrual bleeding irregularities are common, they rarely have precarious health implications (Ref). However, the unpredictability of bleeding may lead to discontinuation, potentially leading to unplanned pregnancy (Ref). According to the manufacturer, ~8% of subjects discontinued intramuscular medroxyprogesterone due to menstrual bleeding irregularities, while ~3% discontinued subcutaneous medroxyprogesterone. Counseling on the anticipated bleeding irregularities has been associated with a higher rate of therapy continuation (Ref).

Mechanism: Time-related; maybe due to changes in the endometrium (Ref); however, the exact mechanism has not been elucidated as various interventions for management have yielded little consistency (Ref).

Onset: Varied; menstrual bleeding irregularities are highest during the first year (Ref). Users are more likely to experience amenorrhea with longer duration of use, which may be perceived as a positive adverse reaction, leading to less reported complaints of menstrual bleeding irregularities (Ref).

Risk factors:

• Longer duration of therapy/number of injections received: breakthrough bleeding and spotting decrease with continued use while amenorrhea becomes more common (Ref)

Weight gain

A mean weight gain of <2 kg was reported during the first year of intramuscular (IM) medroxyprogesterone (Ref). After 2 to 4 years, weight gain at least doubled with an increase of 4 to 10 kg reported with IM use (Ref). It is inconclusive if weight gain is directly related to the drug or normal weight gain over time, independent of contraceptive use (Ref). Weight gain is cited as one of the most common reasons for discontinuation (Ref). Counseling on typical weight gain and the importance of a healthy lifestyle may decrease discontinuation rates (Ref).

Mechanism: Dose related; may be due to hormone-mediated changes in fat deposition (Yancey 2014). More sources agree that the etiology of weight gain is unclear and may be independent of contraceptive use (Ref).

Onset: Delayed; reported most after 1 year of use and increases with continued therapy (Ref).

Risk factors (IM):

• Longer duration of therapy (Ref)

• Early excessive (>5% increase from baseline weight) weight gain maybe a predictor for continued weight gain (Ref)

• Nulliparity (Ref)

• Unmarried status (Ref)

• Prior use of IM medroxyprogesterone (Ref)

• Younger age at initiation of therapy (Ref)

• Underweight at initiation of therapy (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse effects as reported with any dosage form.

>10%:

Endocrine & metabolic: Amenorrhea (6% to 68%), hot flash (≤36%), weight gain (7% to 38%), weight loss (≤12%)

Gastrointestinal: Abdominal pain (4% to 11%)

Genitourinary: Gynecological bleeding (IM: 32% to 57%; SUBQ: 18%; including irregular, increase or decrease flow, and spotting)

Nervous system: Headache (9% to 17%), nervousness (11%)

1% to 10%:

Cardiovascular: Edema (2%)

Dermatologic: Acne vulgaris (1% to 4%), alopecia (1%), skin rash (1%)

Endocrine & metabolic: Decreased libido (3% to 6%)

Gastrointestinal: Bloating (2%), nausea (3%)

Genitourinary: Bacterial vaginosis (≤5%), breast tenderness (≤2%), dysmenorrhea (≤2%), leukorrhea (3%), mastalgia (≤3%), urinary tract infection (4%), vaginitis (≤5%), vulvovaginal candidiasis (≤5%)

Local: Atrophy at injection site (≤1%), induration at injection site (≤1%), injection-site reaction (5% to 6%)

Nervous system: Anxiety (1%), asthenia (≤4%), depression (2% to 3%), dizziness (1% to 6%), fatigue (≤4%), insomnia (1%), irritability (1%)

Neuromuscular & skeletal: Arthralgia (1%), back pain (2% to 3%), lower limb cramp (4%)

<1%:

Cardiovascular: Chest pain, syncope, tachycardia

Dermatologic: Pruritus, urticaria

Endocrine & metabolic: Fluid retention, galactorrhea not associated with childbirth

Gastrointestinal: Abdominal distension, diarrhea

Genitourinary: Dyspareunia, lump in breast

Hematologic & oncologic: Anemia

Hypersensitivity: Hypersensitivity reaction

Nervous system: Drowsiness, facial nerve paralysis, paresthesia

Respiratory: Asthma, dyspnea

Frequency not defined:

Cardiovascular: Acute myocardial infarction

Endocrine & metabolic: Cushing syndrome, decreased glucose tolerance, hypercalcemia

Genitourinary: Change in cervical erosion, change in cervical secretions, nipple discharge

Hepatic: Cholestatic jaundice

Local: Injection-site nodule, skin discoloration at injection site, tenderness at injection site

Nervous system: Cerebrovascular accident, euphoria, malaise

Neuromuscular & skeletal: Lipodystrophy

Ophthalmic: Optic neuritis, retinal thrombosis

Postmarketing:

Cardiovascular: Deep vein thrombosis, pulmonary embolism, thrombophlebitis, varicose veins

Dermatologic: Chloasma, diaphoresis, skin discoloration (melasma)

Endocrine & metabolic: Hirsutism, increased libido, increased thirst, spotty menstruation (Abdel-Aleem 2013)

Gastrointestinal: Change in appetite, rectal hemorrhage

Genitourinary: Anovulation (prolonged), breast changes, delayed return to fertility, genitourinary infection, lactation insufficiency, malignant neoplasm of breast, malignant neoplasm of cervix, nipple bleeding, uterine hyperplasia, vaginal cyst

Hepatic: Jaundice

Hypersensitivity: Anaphylaxis (Lestishock 2011), angioedema, nonimmune anaphylaxis

Local: Residual mass at injection site, sterile abscess at injection site

Nervous system: Chills

Neuromuscular & skeletal: Axillary swelling, decreased bone mineral density (Quintino-Moro 2019), osteoporosis, pathological fracture due to osteoporosis, systemic sclerosis

Miscellaneous: Fever

Contraindications

Injection (104 mg/0.65 mL): Hypersensitivity to medroxyprogesterone or any component of the formulation; active thrombophlebitis; thromboembolic disorders (current or history of); cerebral vascular disease; undiagnosed vaginal bleeding; breast cancer (known, suspected, or history of); significant hepatic disease.

Injection (150 mg/mL): Hypersensitivity to medroxyprogesterone or any component of the formulation; active thrombophlebitis; thromboembolic disorders (current or history of) or cerebral vascular disease; undiagnosed vaginal bleeding; breast cancer (known, suspected, or history of); significant hepatic disease; pregnancy; diagnostic test for pregnancy.

Injection (400 mg/mL): Hypersensitivity to medroxyprogesterone or any component of the formulation; active thrombophlebitis; thromboembolic disorders (current or history of); cerebral vascular disease.

Tablet: Anaphylactic reaction or angioedema to medroxyprogesterone; DVT or PE (current or history of); active or history of arterial thromboembolic disease (eg, stroke, MI); estrogen- or progesterone-dependent tumor (known or suspected) (excludes Canadian product indicated for endometrial cancer); undiagnosed abnormal genital bleeding; breast cancer (known, suspected, or history of); hepatic impairment or disease; pregnancy.

Canadian labeling: Additional contraindications (not in the US labeling):

Injection (50 mg/mL, 150 mg/mL): History of or current benign or malignant liver tumors; current or history of migraine with focal aura; any ocular lesion arising from ophthalmic vascular disease, such as partial or complete loss of vision or defect in visual fields; undiagnosed breast pathology; known or suspected progestin-dependent neoplasia; MI or coronary artery disease (current or history of); urinary tract bleeding; presence of severe or multiple risk factors for arterial or venous thrombosis including the following: severe hypertension (persistent bp ≥160/100 mm Hg); hereditary or acquired predisposition for venous or arterial thrombosis (eg, Factor V leiden and Prothrombin G20210 A mutation, activated protein C (APC) resistance, antithrombin-III-deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinanemia and antiphospholipid-antibodies (anticardiolipin antibodies, lupus anticoagulant); severe dyslipoproteinemia; heavy smoking (>15 cigarettes per day) and older than 35 years of age; diabetes mellitus with vascular involvement.

Tablet: Partial or complete loss of vision due to ophthalmic vascular disease.

Warnings/Precautions

Concerns related to adverse effects:

• Adrenal suppression: May cause suppression of hypothalamic-pituitary-adrenal (HPA) axis, resulting in decreased plasma cortisol concentrations, decreased cortisol secretion, and low plasma ACTH concentrations. Cushingoid symptoms may occur.

• Anaphylaxis/hypersensitivity reactions: Anaphylaxis or anaphylactoid reactions have been reported with use of the injection; medication for the treatment of hypersensitivity reactions should be available for immediate use.

• Breast cancer: Estrogen with or without progestogen for the management of menopausal symptoms may be associated with an increased risk of breast cancer. The risk of breast cancer in postmenopausal patients on hormone therapy may depend upon type of estrogen and/or progestogen, dose, timing of therapy initiation, duration of therapy, route of administration, and individual patient characteristics (AACE/ACE [Cobin 2017]; NAMS 2022). Hormone therapy may be associated with increased breast density (NAMS 2022); an increase in abnormal mammogram findings requiring further evaluation has been reported with estrogen alone or in combination with progestogen therapy. Most studies do not see an increased risk of breast cancer following medroxyprogesterone use for contraception (Chelmow 2020). However, breast cancer is a hormonal sensitive tumor and the prognosis for patients with a current or recent history of breast cancer may be worse with progestin-only contraceptive use (CDC [Curtis 2016b]). Use of medroxyprogesterone for the treatment of endometrial carcinoma is not recommended in patients with known or suspected breast cancer; carefully monitor patients with a strong family history of breast cancer.

• Ectopic pregnancy: When used for contraception, consider the possibility of ectopic pregnancy in patients with severe abdominal pain.

• Endometrial hyperplasia: MPA is used to reduce the risk of endometrial hyperplasia in nonhysterectomized postmenopausal patients receiving conjugated estrogens. MPA is not the preferred progesterone for this indication (AACE/ACE [Cobin 2017]). The use of unopposed estrogen in patients with a uterus is associated with an increased risk of endometrial cancer. The addition of a progestogen to estrogen therapy may decrease the risk of endometrial hyperplasia, a precursor to endometrial cancer. Perform adequate diagnostic measures, including endometrial sampling if indicated, to rule out malignancy in postmenopausal patients with undiagnosed abnormal vaginal bleeding. The use of a progestogen is not generally required when low doses of estrogen are used locally for vaginal atrophy, although long-term data (>1 year) supporting this recommendation are lacking (NAMS 2020; NAMS 2022).

• Hypertriglyceridemia: In patients using estrogen plus progesterone therapy, triglycerides may be increased in patients with preexisting hypertriglyceridemia; discontinue if pancreatitis occurs.

• Ovarian cancer: Available information related to the use of menopausal estrogen or estrogen/progestogen therapy and risk of ovarian cancer is inconsistent. If an association is present, the absolute risk is likely rare and may be influenced by duration of therapy (ES [Stuenkel 2015]; NAMS 2022).

• Retinal thrombosis: Discontinue pending examination in cases of sudden partial or complete vision loss, sudden onset of proptosis, diplopia, or migraine; discontinue permanently if papilledema or retinal vascular lesions are observed on examination.

Disease-related concerns:

• Asthma: Use with caution in patients with asthma; may exacerbate disease.

• Cardiovascular disease: Manage risk factors for cardiovascular disease (eg, diabetes mellitus, hypercholesterolemia, hypertension, systemic lupus erythematosus [SLE], obesity, tobacco use, and/or history of venous thromboembolism [VTE]) appropriately; discontinue use immediately if adverse cardiovascular events occur or are suspected. When used for contraception, use caution in patients with risk factors for cardiovascular disease (CDC [Curtis 2016b]). If thrombosis develops with contraceptive treatment, discontinue treatment (unless no other acceptable contraceptive alternative).

• Dementia: Hormone therapy is not recommended at any age to prevent or treat cognitive decline or dementia (NAMS 2022).

• Depression: Monitor patients with a history of depression; consider discontinuing if depression recurs.

• Diabetes: Medroxyprogesterone therapy may have adverse effects on glucose tolerance; monitor patients with diabetes mellitus.

• Diseases exacerbated by fluid retention: Use with caution in patients with diseases that may be exacerbated by fluid retention, including cardiac or renal dysfunction.

• Epilepsy: Use with caution in patients with epilepsy; may exacerbate disease.

• Hepatic dysfunction: Use caution in patients with a history of cholestatic jaundice associated with prior estrogen use or pregnancy.

• Hepatic hemangiomas: Use estrogen plus progestogen therapy with caution in patients with hepatic hemangiomas; may exacerbate disease.

• Hypoparathyroidism: Use estrogen plus progestogen therapy with caution in patients with hypoparathyroidism; estrogen-induced hypocalcemia may occur.

• Migraine: Use caution in patients with migraine; may exacerbate disease.

• Porphyria: Use estrogen plus progestogen therapy with caution in patients with porphyria; may exacerbate disease.

• Systemic lupus erythematosus: Use estrogen plus progestogen therapy with caution in patients with SLE; may exacerbate disease.

Special populations:

• Body weight: Dose adjustment of depo-medroxyprogesterone 150 mg/mL IM or 104 mg/0.65 mL SUBQ contraceptive injections is not required based on body weight.

• Surgery: Whenever possible, discontinue progestogens in combination with estrogens at least 4 to 6 weeks prior to surgery associated with an increased risk of thromboembolism or during periods of prolonged immobilization.

Dosage form specific issues:

• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley, 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer's labeling.

Other warnings/precautions:

• Abnormal uterine bleeding: When considering specific treatment for acute or chronic abnormal uterine bleeding due to ovulatory dysfunction (not structural causes), consider medical contraindications to available therapies as well as if simultaneous contraception is needed or pregnancy is desired (ACOG 2013a; ACOG 2013c).

• Endometrial carcinoma: When used for endometrial carcinoma, the effects of long-term use on adrenal, hepatic, ovarian, pituitary, and uterine function is not known. Use for endometrial carcinoma may mask the onset of menopause.

• HIV infection protection: Injectable contraceptives do not protect against HIV infection or other sexually transmitted diseases.

• Menopause: When used for the relief of menopausal symptoms, the benefit-risk of combination hormone therapy is most favorable if started in patients who have no contraindications to therapy, are <60 years of age, within 10 years of menopause onset, have a favorable lipid profile, and do not have the factor V Leiden genotype or metabolic syndrome. Consider cardiovascular disease risk factors when evaluating therapy and route of administration (AACE/ACE [Cobin 2017]; NAMS 2022). Estrogens with progestogen should be used for the shortest duration possible at the lowest effective dose consistent with treatment goals and risks for the individual patient.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Suspension, Intramuscular, as acetate:

Depo-Provera: 150 mg/mL (1 mL) [contains methylparaben, polyethylene glycol, polysorbate 80, propylparaben]

Depo-Provera: 400 mg/mL (2.5 mL) [contains polyethylene glycol]

Generic: 150 mg/mL (1 mL)

Suspension Prefilled Syringe, Intramuscular, as acetate:

Depo-Provera: 150 mg/mL (1 mL) [contains methylparaben, polyethylene glycol, polysorbate 80, propylparaben]

Generic: 150 mg/mL (1 mL)

Suspension Prefilled Syringe, Subcutaneous, as acetate:

Depo-SubQ Provera 104: 104 mg/0.65 mL (0.65 mL) [contains methylparaben, polyethylene glycol, polysorbate 80, propylparaben]

Tablet, Oral, as acetate:

Provera: 2.5 mg, 5 mg [DSC] [scored]

Provera: 5 mg [contains corn starch, fd&c blue #2 aluminum lake]

Provera: 10 mg [scored]

Generic: 2.5 mg, 5 mg, 10 mg

Generic Equivalent Available: US

Yes

Pricing: US

Suspension (Depo-Provera Intramuscular)

150 mg/mL (per mL): $63.16

Suspension (medroxyPROGESTERone Acetate Intramuscular)

150 mg/mL (per mL): $41.27 - $97.85

Suspension Prefilled Syringe (Depo-Provera Intramuscular)

150 mg/mL (per mL): $65.94

Suspension Prefilled Syringe (Depo-SubQ Provera 104 Subcutaneous)

104 mg/0.65 mL (per 0.65 mL): $63.16

Suspension Prefilled Syringe (medroxyPROGESTERone Acetate Intramuscular)

150 mg/mL (per mL): $66.00 - $115.20

Tablets (medroxyPROGESTERone Acetate Oral)

2.5 mg (per each): $0.31

5 mg (per each): $0.47

10 mg (per each): $0.49

Tablets (Provera Oral)

2.5 mg (per each): $3.14

5 mg (per each): $4.72

10 mg (per each): $6.16

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Suspension, IM, as acetate:

Depo-Provera: 50 mg/mL (1 mL)

Tablet, Oral, as acetate: 100 mg

Provera: 2.5 mg, 5 mg, 10 mg

Administration: Adult

IM: Depo-Provera Contraceptive: Administer first dose during the first 5 days of menstrual period, or within the first 5 days postpartum if not breastfeeding, or at the sixth week postpartum if breastfeeding exclusively. Shake vigorously prior to administration. Administer by deep IM injection in the gluteal or deltoid muscle. Rotate administration site with each injection. Injection must be administered by a health care professional only. Patients should return every 3 months (range: 10 to 13 weeks) for subsequent doses; the interval between injections should not exceed 13 weeks.

SUBQ: Depo-SubQ Provera 104: Administer first dose during the first 5 days of menstrual period, or at the sixth week postpartum if breastfeeding. Shake vigorously for at least 1 minute prior to administration. Administer by SUBQ injection in the upper anterior thigh or abdomen; avoid boney areas and the umbilicus. Administer slowly over 5 to 7 seconds. Do not rub the injection area. Rotate administration site with each injection. Product labeling recommends the SUBQ injection be administered by a health care professional; however, patient administration is also an option (Ref).

Administration: Pediatric

Oral: Administer with food

Parenteral:

IM: (Depo-Provera Contraceptive): Shake suspension vigorously; administer by deep IM injection in the gluteal or deltoid muscle

SubQ (depo-subQ provera 104): Shake vigorously for at least 1 minute; administer by subQ injection slowly over 5 to 7 seconds in the anterior thigh or abdomen; avoid boney areas and the umbilicus. Do not rub the injection area; not for IM or IV use.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 2]).

Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2016; USP-NF 2020).

Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.

Use: Labeled Indications

Abnormal uterine bleeding, nonacute (tablet): Treatment of nonacute abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as fibroids or uterine cancer.

Contraception (104 mg/0.65 mL and 150 mg/mL injection): For the prevention of pregnancy.

Limitations of use: For use in patients who may become pregnant; not for use prior to menarche or postmenopause. Use is not recommended for long-term (ie, longer than 2 years) birth control unless other options are considered inadequate.

Endometrial carcinoma (400 mg/mL injection) (100 mg tablet [Canadian product]): Adjunctive therapy and/or palliative treatment of inoperable, recurrent, and/or metastatic endometrial carcinoma.

Endometriosis (104 mg/0.65 mL injection): Management of endometriosis-associated pain.

Limitations of use: For use in patients who may become pregnant; not for use prior to menarche or postmenopause. Use is not recommended for long-term (ie, longer than 2 years) endometriosis-associated pain unless other options are considered inadequate.

Estrogen therapy-associated endometrial hyperplasia, prevention (tablet): Prevention of endometrial hyperplasia in patients with a uterus receiving with estrogen therapy (eg, for vasomotor symptoms associated with menopause or secondary amenorrhea).

Secondary amenorrhea, diagnostic aid ("progestin challenge") (tablet): For use as a diagnostic aid to determine endometrial estrogen exposure and/or uterine or outflow tract abnormality.

Use: Off-Label: Adult

Abnormal uterine bleeding, acute; Endometrial hyperplasia, treatment; Menstrual suppression

Medication Safety Issues

Sound-alike/look-alike issues:

Depo-Provera may be confused with DEPO-Medrol, depo-subQ provera 104

MedroxyPROGESTERone may be confused with HYDROXYprogesterone caproate, methylPREDNISolone, methylTESTOSTERone

Provera may be confused with Covera, Femara, Parlodel, Premarin, Proscar, PROzac

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs (contraindicated in pregnancy) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Community/Ambulatory Care Settings).

Administration issues:

The injectable dosage form is available in different formulations. Carefully review prescriptions to assure the correct formulation and route of administration.

Metabolism/Transport Effects

Substrate of CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Adalimumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Antidiabetic Agents: Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents. Risk C: Monitor therapy

Aprepitant: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration with aprepitant, and to continue back-up contraception for 28 days after discontinuing aprepitant to ensure contraceptive reliability. Risk D: Consider therapy modification

Asparaginase Products: Hormonal Contraceptives may enhance the thrombogenic effect of Asparaginase Products. Management: Consider discontinuing hormonal contraceptives and using an alternative contraceptive method in patients treated with asparaginase products. Risk D: Consider therapy modification

Atazanavir: May decrease the serum concentration of Hormonal Contraceptives. Specifically, atazanavir/ritonavir may decrease concentrations of estrogens. Atazanavir may increase the serum concentration of Hormonal Contraceptives. Specifically, atazanavir alone may increase concentrations of estrogens and atazanavir alone or boosted may increase concentrations of progestins. Management: Dose adjustment of hormonal contraceptives or use of alternative or additional nonhormonal contraceptive may be needed when combined with atazanavir. See full interact monograph for details. Atazanavir/cobicistat with drospirenone is contraindicated. Risk D: Consider therapy modification

Bimekizumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Brigatinib: May decrease the serum concentration of Hormonal Contraceptives. Management: Use a non-hormonal contraceptive during brigatinib use and for at least 4 months after the last brigatinib dose. Males with partners of reproductive potential should use contraception during treatment with brigatinib and for 3 months after brigatinib use. Risk D: Consider therapy modification

Carfilzomib: Hormonal Contraceptives may enhance the thrombogenic effect of Carfilzomib. Management: Consider alternative, non-hormonal methods of contraception in patients requiring therapy with carfilzomib, especially patients using carfilzomib in combination with dexamethasone, lenalidomide plus dexamethasone, or daratumumab plus dexamethasone. Risk D: Consider therapy modification

Chlorprothixene: Progestins may enhance the adverse/toxic effect of Chlorprothixene. Progestins may enhance the therapeutic effect of Chlorprothixene. Risk C: Monitor therapy

Choline C 11: Antiandrogens may diminish the therapeutic effect of Choline C 11. Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Cobicistat: May decrease the serum concentration of Hormonal Contraceptives. Specifically, cobicistat may decrease serum concentrations of estrogens. Cobicistat may increase the serum concentration of Hormonal Contraceptives. Specifically, cobicistat may increase serum concentrations of progestins. Management: Use alternative or additional nonhormonal forms of contraception when estrogen-containing hormonal contraceptives are combined with cobicistat. Progestin-only contraceptives can be used without back up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Colchicine: May enhance the adverse/toxic effect of Hormonal Contraceptives. Risk C: Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a moderate CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inducers (Strong): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a strong CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inducers (Weak): May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing a weak CYP3A4 inducer to ensure contraceptive reliability. Risk D: Consider therapy modification

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Hormonal Contraceptives. Risk C: Monitor therapy

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Efavirenz: May decrease the serum concentration of Hormonal Contraceptives. Management: Use a back-up method during coadministration, and to continue back-up contraception for 12 weeks after stopping efavirenz to ensure contraceptive reliability. Injected depot medroxyprogesterone acetate does not appear to participate in this interaction. Risk D: Consider therapy modification

Elagolix: Hormonal Contraceptives may diminish the therapeutic effect of Elagolix. Specifically, estrogen-containing hormonal contraceptives may diminish the therapeutic effects of elagolix. Elagolix may decrease the serum concentration of Hormonal Contraceptives. Specifically, concentrations of progestins may be decreased with elagolix therapy. Elagolix may increase the serum concentration of Hormonal Contraceptives. Specifically, concentrations of ethinyl estradiol may be increased with elagolix therapy. Management: Use an alternative, nonhormonal contraceptive during treatment with elagolix and for at least 28 days following discontinuation of elagolix treatment. Use of elagolix 200 mg twice daily with an estrogen-containing hormonal contraceptive is not recommended Risk D: Consider therapy modification

Elexacaftor, Tezacaftor, and Ivacaftor: Hormonal Contraceptives may enhance the adverse/toxic effect of Elexacaftor, Tezacaftor, and Ivacaftor. Specifically, the risk for rash may be increased. Risk C: Monitor therapy

Encorafenib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Etravirine: May decrease the serum concentration of Hormonal Contraceptives. Specifically, progestin concentrations may decrease. Etravirine may increase the serum concentration of Hormonal Contraceptives. Specifically, estrogen concentrations may increase. Risk C: Monitor therapy

Exenatide: Hormonal Contraceptives may diminish the therapeutic effect of Exenatide. Exenatide may decrease the serum concentration of Hormonal Contraceptives. Management: Administer oral hormonal contraceptives at least one hour prior to exenatide. Monitor blood glucose more frequently when patients treated with exenatide initiate therapy with a hormonal contraceptive. Increases in exenatide doses may be needed. Risk D: Consider therapy modification

Felbamate: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing felbamate to ensure contraceptive reliability. Risk D: Consider therapy modification

Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Flibanserin: Hormonal Contraceptives may increase the serum concentration of Flibanserin. Risk C: Monitor therapy

Flotufolastat F18: Antiandrogens may diminish the diagnostic effect of Flotufolastat F18. Management: Therapies targeting the androgen pathway may result in changes in the uptake of flotufolastat F18 in prostate cancer. The impact of these therapies on the performance of flotufolastat F18 is unknown; consider use of alternative agents. Risk D: Consider therapy modification

Fosaprepitant: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration with fosaprepitant, and to continue back-up contraception for 28 days after discontinuing fosaprepitant to ensure contraceptive reliability. Risk D: Consider therapy modification

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Consider avoiding this combination if possible. If required, monitor patients closely for increased adverse effects of the CYP3A4 substrate. Risk D: Consider therapy modification

Gallium Ga 68 PSMA-11: Antiandrogens may diminish the therapeutic effect of Gallium Ga 68 PSMA-11. Management: Therapies targeting the androgen pathway may result in changes in the uptake of gallium Ga 68 PSMA-11 (gozetotide) in prostate cancer. The impact on the performance of gallium Ga 68 PSMA-11 (gozetotide) is unknown; consider use of alternative agents. Risk D: Consider therapy modification

Griseofulvin: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing griseofulvin to ensure contraceptive reliability. Risk D: Consider therapy modification

Indium 111 Capromab Pendetide: Antiandrogens may diminish the diagnostic effect of Indium 111 Capromab Pendetide. Risk X: Avoid combination

Interleukin-6 (IL-6) Inhibiting Therapies: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Ivosidenib: May decrease the serum concentration of Hormonal Contraceptives. Management: Consider alternative methods of contraception (ie, non-hormonal) in patients receiving ivosidenib. Risk D: Consider therapy modification

Ixazomib: May decrease the serum concentration of Hormonal Contraceptives. More specifically, use of ixazomib with dexamethasone may decrease the serum concentrations of hormonal contraceptives. Management: Patients of reproductive potential should use a non-hormonal contraceptive method during treatment with ixazomib and for at least 90 days after the last ixazomib dose. Risk D: Consider therapy modification

Lixisenatide: Hormonal Contraceptives may diminish the therapeutic effect of Lixisenatide. Lixisenatide may decrease the serum concentration of Hormonal Contraceptives. Management: Administer oral hormonal contraceptives 1 hour before or at least 11 hours after administration of lixisenatide. Additionally, monitor blood glucose more frequently when patients treated with lixisenatide initiate therapy with a hormonal contraceptive. Risk D: Consider therapy modification

Mavacamten: May decrease the serum concentration of Hormonal Contraceptives. Management: Use with ethinyl estradiol/norethindrone is permitted. With other hormonal contraceptives, use a back-up method (eg, condoms) during coadministration, and to continue back-up contraception for 4 months after stopping mavacamten. Risk D: Consider therapy modification

MetyraPONE: Progestins may diminish the diagnostic effect of MetyraPONE. Management: Consider alternatives to the use of the metyrapone test in patients taking progestins. Risk D: Consider therapy modification

MiFEPRIStone: May diminish the therapeutic effect of Hormonal Contraceptives. Management: Nonhormonal contraception should be used during, and for 4 weeks following, mifepristone treatment for hyperglycemia due to Cushing syndrome. If used for pregnancy termination, hormonal contraceptives can be used after pregnancy expulsion is confirmed. Risk D: Consider therapy modification

Mitotane: May decrease the serum concentration of Hormonal Contraceptives. Management: Effective nonhormonal contraception is recommended for those of reproductive potential during treatment with mitotane as well as after discontinuation of mitotane for as long as mitotane plasma levels are detectable. Risk X: Avoid combination

Mobocertinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Mycophenolate: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients of childbearing potential who are taking hormonal contraceptives should use an additional form of barrier contraception during treatment with mycophenolate and for 6 weeks after mycophenolate discontinuation. Risk D: Consider therapy modification

Nirmatrelvir and Ritonavir: May decrease the serum concentration of Hormonal Contraceptives. Specifically, nirmatrelvir and ritonavir may decrease concentrations of estrogens. Nirmatrelvir and Ritonavir may increase the serum concentration of Hormonal Contraceptives. Specifically, nirmatrelvir and ritonavir may increase concentrations of progestins. Management: Use additional nonhormonal forms of contraception (back-up method) when estrogen-containing hormonal contraceptives are combined with nirmatrelvir/ritonavir. Progestin-only contraceptives can be used without back-up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Octreotide: May decrease the serum concentration of Hormonal Contraceptives. Management: Women should use an alternative non-hormonal method of contraception or a back-up method when octreotide is combined with hormonal contraceptives. Risk D: Consider therapy modification

Olutasidenib: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Management: Avoid use of olutasidenib with sensitive or narrow therapeutic index CYP3A4 substrates when possible. If concurrent use with olutasidenib is unavoidable, monitor closely for evidence of decreased concentrations of the CYP3A4 substrates. Risk D: Consider therapy modification

Omaveloxolone: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

OXcarbazepine: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing oxcarbazepine to ensure contraceptive reliability. Risk D: Consider therapy modification

Pegloticase: May diminish the therapeutic effect of PEGylated Drug Products. Risk C: Monitor therapy

Pegvaliase: MedroxyPROGESTERone may enhance the adverse/toxic effect of Pegvaliase. Specifically, the risk of anaphylaxis or hypersensitivity reactions may be increased. Risk C: Monitor therapy

Perampanel: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients should use an alternative, nonhormonal-based form of contraception during the concurrent use of perampanel and for 1 month after discontinuing perampanel. Risk D: Consider therapy modification

Pexidartinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Piflufolastat F18: Antiandrogens may diminish the diagnostic effect of Piflufolastat F18. Management: Therapies targeting the androgen pathway may result in changes in the uptake of piflufolastat F18 in prostate cancer. The impact of these therapies on the performance of piflufolastat F18 is unknown; consider use of alternative agents. Risk D: Consider therapy modification

Pitolisant: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients using hormonal contraception should be advised to use an alternative non-hormonal contraceptive method during treatment with pitolisant and for at least 21 days after discontinuation of pitolisant treatment. Risk D: Consider therapy modification

Protease Inhibitors: May decrease the serum concentration of Hormonal Contraceptives. Specifically, protease inhibitors may decrease concentrations of estrogens. Protease Inhibitors may increase the serum concentration of Hormonal Contraceptives. Specifically, protease inhibitors may increase concentrations of progestins. Management: Use alternative or additional nonhormonal forms of contraception when estrogen-containing hormonal contraceptives are combined with protease inhibitors. Progestin-only contraceptives can be used without back up, but monitor for progestin toxicities. Risk D: Consider therapy modification

Repotrectinib: May decrease the serum concentration of Hormonal Contraceptives. Risk X: Avoid combination

Sugammadex: May diminish the therapeutic effect of Hormonal Contraceptives. Management: Patients receiving any hormonal contraceptive (oral or non-oral) should use an additional, nonhormonal contraceptive method during and for 7 days following sugammadex treatment. Risk D: Consider therapy modification

Taurursodiol: May decrease the serum concentration of CYP3A4 Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk X: Avoid combination

Tazemetostat: May decrease the serum concentration of Hormonal Contraceptives. Management: Individuals of childbearing potential should use a non-hormonal contraceptive method during treatment with tazemetostat and for 6 months after. Males with partners of childbearing potential should use contraception during treatment and for 3 months after. Risk D: Consider therapy modification

Tetrahydrocannabinol and Cannabidiol: May decrease the serum concentration of Hormonal Contraceptives. Management: Product labeling recommends that patients taking hormonal contraceptives should use an additional, non-hormonal contraceptive or reliable barrier method during treatment with tetrahydrocannabinol and cannabidiol buccal spray. Risk D: Consider therapy modification

Thalidomide: Hormonal Contraceptives may enhance the thrombogenic effect of Thalidomide. Risk C: Monitor therapy

Tirzepatide: May decrease the serum concentration of Hormonal Contraceptives. Management: Patients using oral hormonal contraceptives should switch to a non-oral contraceptive method, or add a barrier method of contraception, for 4 weeks after initiation of tirzepatide and for 4 weeks after each dose escalation of tirzepatide. Risk D: Consider therapy modification

Topiramate: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing topiramate to ensure contraceptive reliability. Risk D: Consider therapy modification

Tovorafenib: May decrease the serum concentration of Hormonal Contraceptives. Management: Avoid concurrent use when possible. If combined use is unavoidable, use of an additional nonhormonal method of contraception is recommended during combined use and for 28 days after stopping tovorafenib. Risk D: Consider therapy modification

Tranexamic Acid: Hormonal Contraceptives may enhance the thrombogenic effect of Tranexamic Acid. Risk X: Avoid combination

Ulipristal: May diminish the therapeutic effect of Progestins. Progestins may diminish the therapeutic effect of Ulipristal. Risk X: Avoid combination

Ustekinumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Vaborbactam: May decrease the serum concentration of Hormonal Contraceptives. Management: Advise patients to use an alternative method of contraception or a back-up method during coadministration, and to continue back-up contraception for 28 days after discontinuing meropenem/vaborbactam to ensure contraceptive reliability. Risk D: Consider therapy modification

Vedolizumab: May decrease the serum concentration of CYP Substrates (Narrow Therapeutic Index/Sensitive with Inducers). Risk C: Monitor therapy

Vitamin K Antagonists (eg, warfarin): Hormonal Contraceptives may increase the serum concentration of Vitamin K Antagonists. Hormonal Contraceptives may decrease the serum concentration of Vitamin K Antagonists. Risk C: Monitor therapy

Voriconazole: Hormonal Contraceptives may increase the serum concentration of Voriconazole. Voriconazole may increase the serum concentration of Hormonal Contraceptives. Risk C: Monitor therapy

Food Interactions

Bioavailability of the oral tablet is increased when taken with food; half-life is unchanged. Management: Administer without regard to food.

Reproductive Considerations

Depo-medroxyprogesterone 104 mg/0.65 mL and 150 mg/mL injections are used for contraception. Use is not recommended as a long-term (ie, longer than 2 years) birth control method unless other options are considered inadequate.

All available forms of contraception, including depo-medroxyprogesterone acetate (DMPA) injection, can be considered for patients on gender-affirming testosterone therapy after evaluating patient preferences and medical conditions (Bonnington 2020; Krempasky 2020). DMPA may help induce amenorrhea more rapidly than other progestin-only methods when testosterone is initiated. DMPA may cause weight gain; other forms of contraception may be preferred for patients already experiencing weight gain with testosterone therapy (Bonnington 2020).

Median time to conception/return to ovulation following discontinuation of DMPA contraceptive injection is 10 months following the last injection and is unrelated to the duration of use.

High doses of medroxyprogesterone used for indications other than contraception would be expected to impair fertility.

Pregnancy Considerations

In general, there is not an increased risk of birth defects following inadvertent use of the injectable depo-medroxyprogesterone acetate (DMPA) contraceptives early in pregnancy. Hypospadias has been reported in male babies, and clitoral enlargement and labial fusion have been reported in female babies exposed to medroxyprogesterone during the first trimester of pregnancy. When used for contraception, consider the possibility of ectopic pregnancy in patients with severe abdominal pain; ectopic pregnancies have been reported with use of the DMPA contraceptive injection.

Breastfeeding Considerations

Medroxyprogesterone acetate (MPA) is present in breast milk.

The concentrations of MPA have been reported following maternal administration of depot medroxyprogesterone acetate (DMPA) 150 mg/mL IM injection to 10 females. Administration occurred 6 to 7 weeks' postpartum; milk and maternal plasma were sampled over 12 weeks. A large variation in MPA milk to plasma concentrations was observed between females and within the same female at different sampling times. In this study, the greatest milk concentrations occurred within 2 weeks of injection and generally decreased over time. In most samples, milk concentrations were lower than those in the maternal plasma (Koetsawang 1982).

MPA metabolites were not detected in the urine of breastfed male infants following maternal DMPA IM administration. In addition, urine concentrations of luteinizing hormone, follicle-stimulating hormone, and unconjugated testosterone were not different in breastfed male infants compared to male infants not exposed to MPA via breast milk (Virutamasen 1996).

Composition, quality, and quantity of breast milk are not affected; adverse developmental and behavioral effects have not been noted following exposure of infant to MPA while breastfeeding. The manufacturer does not recommend the use of MPA tablets in breastfeeding mothers; however, guidelines note that the injectable DMPA contraceptives can be initiated immediately postpartum in patients who are breastfeeding (CDC [Curtis 2016a]; CDC [Curtis 2016b]). The manufacturer recommends medroxyprogesterone 400 mg/mL be used with caution in patients who are breastfeeding.

Dietary Considerations

Ensure adequate calcium and vitamin D intake

Monitoring Parameters

Monitor blood glucose (in patients at risk for impaired glucose tolerance). Monitor for depression (in patients with a history of depression). Evaluate abnormal bleeding that persists or is severe.

Contraception: Assessment of pregnancy status (prior to therapy); weight (optional; BMI at baseline may be helpful to monitor changes during therapy); assess potential health status changes at routine visits (CDC [Curtis 2016a]). BMD with long-term use (per manufacturer). If time interval between IM injections is >13 weeks, or interval between SUBQ injections is not within 12 to 14 weeks, evaluate pregnancy status prior to injection.

Endometrial cancer: Consider evaluating bone mineral density in patients receiving long-term high medroxyprogesterone doses; breast cancer (in patients with a strong family history of breast cancer).

Endometrial hyperplasia, treatment (off-label use): Endometrial sampling every 3 to 6 months, although most appropriate frequency has not been determined (ACOG 2023; Trimble 2012)

Menopause: Prior to combination hormonal therapy, baseline risk for breast cancer and CVD. During therapy, age appropriate breast and pelvic exams; blood pressure; unscheduled bleeding lasting >6 months for endometrial pathology (sooner in patients with obesity, diabetes, or a history of endometrial cancer); serum triglycerides (2 weeks after starting therapy in patients with baseline level >200 mg/dL); TSH (6 to 12 weeks after starting oral therapy in patients taking thyroid replacement); efficacy beginning 1 to 3 months after starting therapy, then every 6 to 12 months as appropriate. Duration of treatment should be evaluated at least annually (ES [Stuenkel 2015]).

Mechanism of Action

Medroxyprogesterone acetate (MPA) transforms a proliferative endometrium into a secretory endometrium. When administered with conjugated estrogens, MPA reduces the incidence of endometrial hyperplasia and risk of adenocarcinoma. When used as an injection for contraception (doses of 150 mg IM or 104 mg SubQ), MPA inhibits secretion of pituitary gonadotropins, which prevents follicular maturation and ovulation and causes endometrial thinning. Progestogens, such as medroxyprogesterone when used for endometriosis, lead to atrophy of the endometrial tissue. They may also suppress new growth and implantation. Pain associated with endometriosis is decreased (ASRM 2014).

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Time to ovulation (after last injection): 10 months (range: 6 to 12 months)

Absorption: Oral: Rapid; IM: Slow

Protein binding: 86% to 90% primarily to albumin; does not bind to sex hormone-binding globulin

Metabolism: Extensively hepatic via hydroxylation and conjugation; forms metabolites

Bioavailability: 0.6% to 10%

Half-life elimination: Oral: 12 to 17 hours; IM (Depo-Provera Contraceptive): ~50 days; SubQ: ~43 days

Time to peak: Oral: 2 to 4 hours; IM (Depo-Provera Contraceptive): ~3 weeks; SubQ: ~1 week

Excretion: Urine

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(AE) United Arab Emirates: Apo-medroxy | Depo provera | Farlutal | Provera;
(AR) Argentina: Cycrin | Depo provera | Farlutale | Farlutale an | Livomedrox | Map an | Medrosterona | Medroxiprogesterona | Medroxiprogesterona gp pharm;
(AT) Austria: Depo provera | Depocon | Farlutal | Prodafem | Provera | Sayana;
(AU) Australia: Depo provera | Depo ralovera | Medroxyhexal | Medroxyprogesterone | Provera | Ralovera;
(BD) Bangladesh: Medogen | Medrina | Medrogest | Medroxy | Perlutex;
(BE) Belgium: Depo provera | Farlutal | Provera | Sayana | Veraplex;
(BF) Burkina Faso: Depo provera | Sayana press;
(BG) Bulgaria: Depo provera | Farlutal | Medroxyprogesteron | Provera;
(BR) Brazil: Acemedrox | Acetoflux | Contracep | Cycrin | Demedrox | Depo provera | Farlutal | Farlutal ad | Medroxitest | Procept | Progesan | Provera | Sayana;
(CH) Switzerland: Depo provera | Farlutal | Prodafem | Provera | Sayana;
(CI) Côte d'Ivoire: Depo subq provera | Sayana press;
(CL) Chile: Farlutal | Medroxiprogesterona | Medroxiprogesterone | Prodasone | Sayana | Sayana press | Sicrit;
(CN) China: Bei en | Depo Geston | Depo provera | Farlutal | Medroxyprogesteron | Provera;
(CO) Colombia: Depo provera | Ileine | Medroxiprogesteron | Medroxiprogesterona | Medroxiprogesterone | Provera | Sayana;
(CZ) Czech Republic: Depo provera | Farlutal | Medroplex | Provera | Sayana;
(DE) Germany: Clinofem | Clinovir | Depo clinovir | Depo progevera | Depo provera | Farlutal | Mpa | Mpa gyn | Sayana;
(DO) Dominican Republic: Depo provera | Depotrim | Medroxiprogesterona | Perlutex | Progest amina | Progestagen | Provera;
(EC) Ecuador: Clinomin plus | Depo provera | Depotrim | Lyndavel | Medroxiprogesterona acetato | Provera | Sayana | Solutres;
(EE) Estonia: Cycrina | Depo provera | Depocon | Farlutal | Perlutex | Provera | Veraplex;
(EG) Egypt: Depo provera | Farlutal | Megestron | Oxyprogest | Provera | Sayana;
(ES) Spain: Depo progevera | Farlutal | Progevera;
(ET) Ethiopia: Depo provera | Triclovera;
(FI) Finland: Cykrina | Depo provera | Farlutal | Gestapuran | Lutopolar | Mepastat | Provera;
(FR) France: Depo prodasone | Depo provera | Farlutal | Gestoral | Prodasone;
(GB) United Kingdom: Adgyn medro | Climanor | Depo provera | Farlutal | Medroxyprogesteron kent pharm | Provera | Sayana Press Uniject;
(GR) Greece: Depo provera | Farlutal | Gestoral | Progevera | Provera;
(HK) Hong Kong: Apo-medroxy | Farlutal | Fuan | Novo-Medrone | Provera | Triclofem;
(HR) Croatia: Provera;
(HU) Hungary: Depo provera | Farlutal | Provera;
(ID) Indonesia: Andalan | Depo Geston | Depo harmonis | Depo progestin | Depo provera | Deponeo | Farlutal | Planibu | Prothyra | Provera | Triclofem | Veraplex;
(IE) Ireland: Depo provera | Provera;
(IL) Israel: Aragest | Depo provera | Provera;
(IN) India: Db | Depo kare | Depo provera | Deviry | Dub | Dubloc | Embryogen | Empeea | Maxogest | Medanin | Medolin | Medona | Medrogest | Medronorm | Medtet | Megest | Megestone | Meprate | Meprate sr | Modus | Myone | Orgamed | Petogen | Provera | Regeeva | Sayana press;
(IT) Italy: Depo provera | Farlutal | Provera | Provera g;
(JO) Jordan: Depo provera | Provera;
(JP) Japan: Asconale e | Hysron | Hysron h | Hysron pfizer | Medkiron | Medroxyprogesterone acetate f | Nerfin | Progeston | Provera;
(KE) Kenya: Db | Depo provera | Mepro sterone | Mygesty | Petogen | Provera | Sayana;
(KR) Korea, Republic of: Cycrin | Cymeron | Depo provera | Farlutal | Farutal | Medrogen | Menopause | Progen | Progerone | Prosgen | Provera | Sayana | Veraplex;
(KW) Kuwait: Apo-medroxy | Depo provera | Provera;
(LB) Lebanon: Depo provera | Farlutal | Perlutex | Provera;
(LT) Lithuania: Cykrina | Depo clinovir | Depo provera | Farlutal | Perlutex | Provera;
(LU) Luxembourg: Depo provera | Farlutal | Provera | Sayana;
(LV) Latvia: Cykrina | Depo progevera | Depo provera | Depocon | Farlutal | Perlutex | Provera;
(MA) Morocco: Depo provera | Farlutal;
(MX) Mexico: Ciclotal | Cycrin | Depo provera | Farlutal | Medroxiprogesterona | Megestron | Provera | Sayana;
(MY) Malaysia: Condep | Depo provera | Deviry | Farlutal | Non-Preg | Provera | Ravimed | Veraplex;
(NL) Netherlands: Depo provera | Farlutal | Medroxyprogest | Medroxyprogesteronacetaat | Megestron | Provera | Sayana;
(NO) Norway: Depo provera | Farlutal | Perlutex | Provera;
(NZ) New Zealand: Depo provera | Farlutal | Provera;
(PE) Peru: Clinotrin 3 | Depo provera | Drokse | Drokse 3 | Medroges | Medroxiprogest | Medroxiprogesterona | Meprogen | Provera | Sayana | Solutres;
(PH) Philippines: Db | Depo provera | Depofemme | Deporeva | Lyndavel | Medroxcure | Provera | Provestin;
(PK) Pakistan: Ciclotal | Depo provera | Depo queen | Depotone | Famila | Medrosterona | Megestron | Roxyprog depo;
(PL) Poland: Depo provera | Farlutal | Gestomikron | Provera;
(PR) Puerto Rico: Amen | Cycrin | Depo provera | Depo subq provera | Medroxyprogesteron | Medroxyprogesteron acetate | Medroxyprogesterone | Provera;
(PT) Portugal: Depo provera | Medroxiprogesterona | Provera;
(PY) Paraguay: Medroxine | Medroxiprogesterona l.ch;
(QA) Qatar: Depo-Provera | Provera | Tarlusal;
(RO) Romania: Farlutal | Sayana;
(RU) Russian Federation: Ciclotal | Depo provera | Medroxyproges lens | Provera | Veraplex;
(SA) Saudi Arabia: Apo-medroxy | Depo provera | Provera;
(SE) Sweden: Depo provera | Farlutal | Provera;
(SG) Singapore: Depo provera | Farlutal | Provera;
(SI) Slovenia: Depo provera | Provera;
(SK) Slovakia: Depo provera | Medroplex | Provera;
(SL) Sierra Leone: Depo provera;
(TH) Thailand: Contracep | Controlan | D.m.p.a | Depo a | Depo m | Depo Progesno | Depo progesta | Depo provera | Depo provin | Depogestin | Depomoxie | Enaf-150 | Farlutal | Ladeesaef | Manodepo | Medeton | Medomax | Medroxyprogesteron | Mpa | Nomora | Non-Preg | Provera | Veraplex;
(TN) Tunisia: Depo prodasone | Depo provera | Farlutal;
(TR) Turkey: Depo provera | Farlutal | Tarlusal;
(TW) Taiwan: Depo provera | Farlutal | Fuan | Medorone | Medrone | Mepro | Meterone | Neolut | Provera | Puromin;
(UA) Ukraine: Depo provera | Provera;
(UG) Uganda: Sayana press;
(UY) Uruguay: M.p.a | Medrosterona | Medroxine | Provera;
(VE) Venezuela, Bolivarian Republic of: Cycrin | Depo provera | Farlutal | Provera | Sayana;
(ZA) South Africa: Depo provera | Farlutal | Medroxyprogest Fresenius | Medroxyprogesteron | Petogen | Provera | Sayana | Triclofem;
(ZM) Zambia: Depo provera | Deviry | Hexal mpa | Provera | Sayana

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Medroxyprogesterone acetate: Drug information