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What actually causes spotting with Depo-Provera? #1113/11

I have a question that I have wondered about for a while. I have noticed I tend to spot more on Depo-Provera when I take certain over-the-counter medications or drink alcohol. I know that these things do not impact the shot's effectiveness. So my question is; if these things do not make the shot less effective, why might they be correlated with my spotting? And, on a more broad and general note, what triggers spotting with Depo Provera anyway? Is it that people spot when their hormone levels get lower or is it something else? I am really curious about the science behind the spotting.



Good morning!


Depo causes unpredictable bleeding from day #1 until well after it is discontinued and it is unrelated to alcohol, vitamins, or duration of use.


There is a tendency over time for a woman to stop having any periods at all.


Here is the description of the pattern of bleeding in the NEW 20th edition of Contraceptive Technology:


Injectable Contraceptives

Deborah Bartz, MD, MPH

Alisa B. Goldberg, MD, MPH


Menstrual cycle disturbances: Bleeding patterns with DMPA use are unpredictable, with the majority of women experiencing INJECTABLE CONTRACEPTIVES.


CONTRACEPTIVE TECHNOLOGY: infrequent but prolonged episodes of bleeding or spotting.

The overall incidence of irregular bleeding is 70% in the first year, with a decrease in irregular bleeding with each re-injection, and rates as low as 10% after the first year. Many women experience either an increased number of days of light bleeding or amenorrhea. Amenorrhea becomes more common over time among DMPA users. Approximately 40% to 50% of users experience amenorrhea after 1 year of use and 80% after 5 years of use. Similar patterns have been observed with DMPA-SC, with 55% of women achieving amenorrhea after 1 year of use.  Rarely do women using DMPA experience an increased number of days of heavy bleeding. Menstrual irregularity is the most common reason for discontinuation of DMPA.

Approximately 20% to 25% of women will discontinue DMPA within the first year because of menstrual disturbances. Of those who discontinue for menstrual disturbances, the majority discontinue for either prolonged bleeding or amenorrhea. The irregular bleeding associated with progestin-only contraception has been
associated with an increased fragility of endometrial capillaries.


MANAGING Menstrual changes.

Inform women in advance that changes will occur in their menstrual cycles. Do not dismiss the impact of bleeding changes: they are the major reason that women discontinue this method.  If bleeding occurs shortly after beginning DMPA, counsel patients that irregular bleeding decreases with use of DMPA. Spotting or break-through bleeding observed in prolonged use of DMPA may be managed by offering women one or more cycles of combined oral contraceptives, although the efficacy of this intervention has not been formally studied.  Other options include short courses of exogenous estrogen or a prostaglandin synthetase inhibitor such as mefenamic acid. Each of these interventions has been shown to decrease bleeding in the short term; however, when these interventions are discontinued, irregular bleeding patterns resume. A Cochrane Review of these interventions concluded there is not enough evidence of benefit to recommend the use of any one regimen in the treatment of menstrual irregularities experienced with DMPA. Counseling helps continuation rates (see section on Effectiveness).  Inform women that the irregular bleeding may return, but that over time the likelihood of amenorrhea will increase; in the context of DMPA use, amenorrhea is not harmful and does not require treatment.


Hope that this helps


To learn more about the advantages and disadvantages of Depo-Provera injections, go to our website: www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?


Key Words:  Depo-Provera injections, over-the-counter medications, alcohol, effectiveness, bleeding, spotting, cause, hormone level, unpredictable, discontinued, vitamins, periods, Dr. Deborah Bartz, Dr. Alisa Goldberg, Contraceptive Technology, menstrual cycles, disturbances, amenorrhea, endometrial capillaries



Bartz D, Goldberg A. Injectable contraceptives IN Hatcher RA, Trussell J, Nelson AL, Policar M. et al. Contraceptive Technology 20th edition, pages 214-215, 224-225: Ardent Media Inc. 2011

Posted 11-19-2011, Updated 11-30-2011


Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA

The directors and owners of this website and any publications and information concerning health matters offered here advise a person with a particular problem to consult a primary-care clinician or a specialist in obstetrics, gynecology, or urology (depending on the problem or the contraceptive) as well as the product package insert and other references before diagnosing, managing, or treating the problem.
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