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Starting depo Provera

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

  • SPC advises that depot medroxyprogesterone acetate (DMPA) can be started up to Day 5 without additional contraceptive precautions

  • if quick starting beyond Day 5 a woman may start progestogen-only injectable contraceptives at any time if it is reasonably certain that she is not pregnant (1)
    • Criteria for excluding pregnancy
      • Health professionals can be 'reasonably certain' that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
        • she has not had intercourse since the start of her last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease

        • she has been correctly and consistently using a reliable method of contraception. (For the purposes of being reasonably certain that a woman is not currently pregnant, barrier methods of contraception can be considered reliable providing that they have been used consistently and correctly for every episode of intercourse.)

        • she is within the first 5 days of the onset of a normal (natural) menstrual period

        • she is less than 21 days postpartum (non-breastfeeding women)

        • she is fully breastfeeding, amenorrhoeic AND less than 6 months postpartum

        • she is within the first 5 days after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease

        • she has not had intercourse for >21 days AND has a negative high-sensitivity urine pregnancy test (able to detect hCG levels around 20 mIU/ml)

Circumstances

Starting day

Additional contraceptive protection required?

Any additional information

Women having menstrual cycles

Day 1-5 of cycle

No

It is advisable to check that the menstrual period is typical of the woman's usual bleeding pattern in terms duration, heaviness and timing.

Women having menstrual cycles

After Day 5 of cycle

Yes (7 days)

If there has been a risk of pregnancy consider EC and quick starting (see below) c

Women who are amenorrhoeic

Any time if it is reasonably certain she is not pregnant

Yes (7 days)

If there has been a risk of pregnancy consider EC and quick starting (see below) c

Postpartum (a)

<= 21 days postpartum

No

Postpartum (a)

> 21 days postpartum

Start as for other women having menstrual cycles

If there has been a risk of pregnancy consider EC and quick starting (see below) (c)

Postpartum (a)

> 21 days postpartum if menstrual cycles have not returned

Yes (7 days)

If there has been a risk of pregnancy consider EC and quick starting (see below) (c)

Post first- or second-trimester abortion

Up to and including Day 5 (b)

No

The injectable can be initiated after the first part of a medical abortion

Post first- or second-trimester abortion

At any other time if it is reasonably certain she is not pregnant

Yes (7 days)

The injectable can be initiated after the first part of a medical abortion

Quick starting after oral EC OR in other situations in which pregnancy cannot be excluded (c)

If pregnancy cannot be excluded ideally use a bridging method until negative PT at 3 weeks. If bridging method inappropriate or unacceptable consider quick starting injectable with advice to use additional precaution for 7 days after injection and pregnancy test no sooner than 3 weeks after most recent UPSI. Note that after UPA-EC, quick start should be delayed for 5 day

 

Key:

(a) Prior to 6 weeks postpartum use of DMPA in breastfeeding women is UKMEC 2

(b) The FSRH advises that women ideally start on the day or day after a first- or second-trimester abortion

(c) See FSRH guidance on Quick Starting Contraception

EC, emergency contraception; LNG, levonorgestrel; UPA, ulipristal acetate; UPSI, unprotected sexual intercourse.

Note that NICE suggest (2):

  • provided that it is reasonably certain that the woman is not pregnant, the use of injectable contraceptives may be started:
    • up to and including the fifth day of the menstrual cycle without the need for additional contraceptive protection
    • at any other time in the menstrual cycle, but additional barrier contraception should be used for the first 7 days after the injection
    • immediately after first- or second-trimester abortion, or at any time thereafter
    • at any time post-partum - the FSRH guidance here is more detailed see above
  • additional information about starting postpartum
    • women who are breast feeding should wait until 6 weeks post partum before starting Depo Provera because medroxyprogesterone acetate and its metabolites are excreted in breast milk. At 6 weeks of age the infant's enzyme system should be more mature (3,4)
  • depo-Provera can be started within 5 days of childbirth or abortion. However if Depo-Provera is started so soon after childbirth then this may cause heavy bleeding and so waiting until 6 weeks post partum is thought to be better (3,4)

Reference:

  • FSRH (April 2019). Progestogen-only Injectable Contraception
  • NICE (September 2014). Long-acting reversible contraception (update)
  • Prescriber 2001; 12 (5):83-95.
  • Drug and Therapeutics Bulletin 1996;34 (12): 93-5.

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