If the patient has prolonged un-acceptable vaginal bleeding following the first (1st) injection of depo provera

If the patient has non-acceptable prolonged bleeding following the first Depo Provera injection then it has been suggested (1)

1. exclude an unrelated cause of prolonged vaginal bleeding e.g. retained products of conception, carcinoma, infection (e.g. Chlamydia), or carcinoma. It may be necessary to request a pelvic ultrasound scan. If the uterus is non-tender and firm, with a normal closed os, then it is unlikely that the bleeding has any other cause than as a side effect of the Depo Provera
2. ensure that the patient has not been started on an enzyme inducing drug e.g carbamazepine, rifampicin, griseofulvin
3. Possible management options:
   1. Considered the best option (1) - give oestrogen if not contraindicated. If a patient has one or more packets of a 30 µg combined oral contraceptive pill then this stops the bleeding in most cases. There is no problem with the extra progestagen and so this option is often convenient
   2. Other options (considered rarely successful (1,2))

• give the next dose of Depo Provera early - can be given up to two weeks early (2)
• mefenamic acid 500 mg twice for 5 days for women with bleeding to reduce the duration of the bleeding interval (2)
• haemostatics such as tranexamic acid - however risks generally outweigh benefits (1)

Reference:

1. Guillebaud J. Contraception: Your Questions Answered (3rd Edition). Churchill Livingstone 1999.
2. FSRH (May 2009). Management of Unscheduled Bleeding in Women Using Hormonal Contraception