Check approach to DMPA and irregular bleeding
Many women might choose the contraceptive injection depot medroxyprogesterone acetate (DMPA, Depo-Provera) for its ease of use, but they might discontinue the method due to irregular bleeding. Results of a small study suggest that use of an estradiol vaginal ring for three months at DMPA initiation might decrease bleeding and improve method continuation.1
Irregular bleeding is one of the most commonly cited reasons for discontinuation of DMPA, observes Angela Dempsey, MD, MPH, assistant professor in the Department of Obstetrics and Gynecology at the Medical University of South Carolina in Charleston. Dempsey served as lead author of the current paper.
Irregular bleeding is most frequent in the first three months of DMPA use, and then it decreases steadily throughout the remainder of time a woman is using the method, Dempsey notes. There is evidence to suggest that treatment with estrogen supplementation is beneficial in decreasing the amount and duration of bleeding in women using progestin-only contraceptive methods.2,3
Investigators in the current study wanted to identify a possible intervention for the first three months of DMPA use that might decrease the amount of irregular bleeding and improve continuation and acceptability, says Dempsey. "We specifically chose to investigate the estradiol ring, as opposed to oral estrogen or estrogen patches, because it is designed to be used vaginally for three consecutive months, which would conveniently allow placement at the time of the initial DMPA injection and then require no further action on the part of the patient until it was time for the second injection," says Dempsey.
How did it work?
To conduct the prospective, randomized, controlled trial, women initiating DMPA were randomized to receive an estradiol vaginal ring for three months versus DMPA alone. Bleeding diaries and questionnaires at three and six months assessed bleeding, continuation, and ring acceptability.
Seventy-one participants enrolled; 49 completed the first follow-up period. The median number of bleeding or spotting days was 16 in the estrogen ring group (n = 26) versus 28 in the DMPA alone group (n = 23) (p = .19). Seventy-seven percent of the intervention group received a second injection compared with 70% in the DMPA alone group (p = .56). For each additional day of bleeding and/or spotting reported, women were 3% less likely to receive a second injection (odds ratio 0.97, 95% confidence interval 0.94-0.99). Acceptability of the vaginal ring was high among those in the intervention group, researchers report. Vaginal estrogen supplementation during DMPA initiation is acceptable to women and might decrease total bleeding, researchers conclude.1
Research shows that providers play an important role in ensuring the highest possible continuation rates for DMPA.4
Structured counseling for DMPA patients is effective, according to A Pocket Guide to Managing Contraception. Results of a Mexican study indicate discontinuation from bleeding problems (amenorrhea, irregular bleeding, and heavy bleeding) fell from 32% to 8%.5
Use the following structured counseling approach from the Pocket Guide for women who are considering DMPA use:
Communicate the message that DMPA will change a woman's period. Say that no woman's periods stay the same as they were before starting DMPA.
- Ask, "Will you find it acceptable if there are major changes in your period?" If no, steer clear of DMPA use, as well as other progestin-only methods, including progestin-only pills, the contraceptive implant Implanon, and the levonorgestrel intrauterine device Mirena.
- Have the patient repeat back her understanding of the message, particularly that over time, women using DMPA stop having periods most months. Counsel that women tend to have very irregular periods almost immediately after DMPA use.
- Provide written instructions that clearly highlight key messages about the method. [A free patient handout on DMPA from the Association of Reproductive Health Professionals is available.]
- Remember to ask at each three-month injection visit what has happened to a patient's pattern of bleeding, check whether amenorrhea has begun, and question the patient's feelings about her current bleeding patterns.6
References
- Dempsey A, Roca C, Westhoff C. Vaginal estrogen supplementation during Depo-Provera initiation: a randomized controlled trial. Contraception 2010;82:250-255.
- Alvarez-Sanchez F, Brache V, Thevenin F, et al. Hormonal treatment for bleeding irregularities in Norplant implant users. Am J Obstet Gynecol 1996;174:919-922.
- Said S, Sadek W, Rocca M, et al. Clinical evaluation of the therapeutic effectiveness of ethinyl oestradiol and oestrone sulphate on prolonged bleeding in women using depot medroxyprogesterone acetate for contraception. World Health Organization, Special Programme of Research, Development and Research Training in Human Reproduction, Task Force on Long-acting Systemic Agents for Fertility Regulation. Hum Reprod 1996;11(Suppl 2):1-13.
- Hubacher D, Goco N, Gonzalez B, et al. Factors affecting continuation rates of DMPA. Contraception 1999;60:345-351.
- Canto De Cetina TE, Canto P, Ordoñez Luna M. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception 2001;63:143-146.
- Zieman M, Hatcher RA, Cwiak C, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2010.
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