Patients satisfaction is crucial to maximizing long-term utilization and efficacy of any contraceptive method. Satisfaction is enhanced when appropriate preutilization counseling is offered and when side effects are successfully managed. This article provides a conceptual model for patient counseling, highlights the significant points that should be included in counseling patients about depot medroxyprogesterone acetate (DMPA) and offers clinical suggestions to help evaluate and treat the more common side effects associated with DMPA use.
PIP: Because no contraceptive agent is perfect, patients must weigh the benefits and risks of the contraceptive method they decide to initiate and continue. Individual decision making and provider-client communication interact in complex ways to determine contraceptive behavior. Use of the contraceptive injectable depot medroxyprogesterone acetate (DMPA) should be preceded by counseling which individualizes its risks and benefits, answers all questions (asked and unasked), and develops a longterm plan to minimize side effects. Counseling should cover the contraceptive and noncontraceptive benefits of DMPA; specific side effects such as bleeding changes, weight changes, and fertility changes; the mechanisms of action; and ways to avoid acquiring sexually transmitted diseases. When evaluating and managing side effects, a differential diagnosis independent of DMPA must be considered first (especially for postcoital bleeding and headache). A pregnancy test should be offered in the first month of amenorrhea, after which no treatment is necessary. Ovulation resumption after use may be spontaneous or may be induced with menotropin therapy. Spotting and breakthrough bleeding may be handled by counseling or by a short course of high-dosage ibuprofen or of low-dose estrogen supplementation. Counseling may help women manage weight gain through caloric reduction and an increase in exercise. Acne which occurs soon after adoption of the method may be managed pharmacologically. Increased intake of dietary fiber and fluids may ameliorate the symptoms of abdominal bloating, and temporary nausea can be treated with antacids. Recent research has shown that depression does not increase with DMPA use, although the contraceptive is sometimes implicated in mood changes. Breast tenderness decreases with prolonged DMPA usage and can be managed with proper support garments and a reduction in other causative agents such as caffeine. Women who experience an increase in varicose veins should wear support hose and elevate their legs when possible. Women with symptoms of hypoestrogenic side effects should undergo a serum estradiol level test and appropriate replacement therapy. DMPA can be used immediately postpartum even in breast-feeding women. Women with amenorrhea should be tested for pregnancy before initiating DMPA or reinitiating use at an interval longer than 11-13 weeks. No adverse side effects have been found if pregnancy does occur.