I have a 47 year-old patieny who has used Depo Provera as her primary form of birth control for more than 5 years and is amenorrheic. At which point should I transition her off of Depo?
Are studies indicated to determine if she is menopausal (i.e. FSH, LH, etc.)?
Physician in Baltimore, MD
You raise two very complex questions: How to diagnose menopause in a woman on Depo and when to stop Depo-Provera. Here are several thoughts:
DIAGNOSIS OF MENOPAUSE: (All women, not just when on Depo)
There are no blood tests to diagnose menopause early and reliably enough to guarantee a woman that she is no longer at risk for pregnancy. During the perimenopausal years, day-to-day fluctuations of both gonadotropins and hormones can be quite extreme: FSH levels can temporarily crest to very high levels, and estradiol levels can plunge into the menopausal range. There is no need to order FSH or luteinizing hormone (LH) levels to test for menopause in women with hot flashes who is still menstruating; her cycling verifies that she still has ovarian steriodogenesis and her symptoms classify her as preimenopausal. [Contraceptive Technology, page 78 - 2004]
For the same reason, hormone tests also are not reliable indicators of when to discontinue hormonal contraceptive methods that may mask the symptoms of menopause. Fortunately, the diagnosis of menopause need not be made precisely. Some experts recommend that healthy women continue their hormonal contraceptives until age 53 to 55, when the likelihood of pregnancy is very slight. [Contraceptive Technology, page 78 -2004]
For perimenopausal women who have relative contraindications (e.g., smoking) to the pharmacologic doses of estrogen found in combined hormonal contraceptives, a progestin-only contraceptive, such as the LNG-IUS, progestin-only pills, or DMPA, can be used for contraception. Menopausal treatment doses of estrogen may be added to DMPA to reduce losses in bone mineralization and to help control hot flashes as well as to reduce breakthrough bleeding due to endometrial atrophy. This combination may also be continued through the early menopausal years until it is reasonably likely that the woman is no longer at risk for pregnancy. [Contraceptive Technology, page 77 : 2004]
DMPA 150 mg IM or MPA 10 mg daily led to an 85% to 87% reduction in hot flashes in postmenopausal women. Side-effects can include mastalgia, mood changes, bloating, and weight gain. Micronized progestin, off-label, has also been recognized to reduce hot flashes. [Contraceptive Technology, page 82 : 2004]
DMPA can suppress gonadotropins, so measuring FSH or LH is not informative of menopausal state. DMPA use decreases endogenous estrogen levels. Long-term DMPA users in their 40s may benefit from estrogen supplementation. Kaunitz supplements long-term DMPA users in their 40s with 1.25 mg of conjugated estrogen (or equivalent drug). Arbitrarily at age 55, each woman, if she wants to and understands the risks and benefits, can be switched to conventional HRT. This is easy and minimizes need for laboratory testing, addresses the bone density issue, contraception, and vasomotor concerns while maintaining amenorrhea. [Kaunitz - 1998] [Managing Contraception - 2005-2007]
I have done my best. Does this help?
Fortunately, your patient's risk of pregnancy is very, very low in the years ahead.
This recently updated question from the website could provide you with additional information:
How can I tell if my 54 year-old patient on Depo-Provera is menopausal? #1038 Click here
Key Words: Depo-Provera, primary form of birth control, amenorrheic, transition, menopausal
Posted 10-2006, Updated 11-22-2008, Updated 2-25-2009
Nelson AL, Stewart FH. Menopause IN Hatcher RA, Trussell J. et al. Contraceptive Technology 18th Edition; pages 77, 78, 82: Ardent Media Inc. 2004.
Kaunitz AM. IN Hatcher RA, Zieman M. et al Managing Contraception, page 136: 2005-2007