Amenorrheic before Depo? Evaluate the reasons
How do you start a patient on Depo Provera (DMPA) who is typically amenorrheic? Should a challenge test be ordered? What guidelines should be used prior to administering the first injection? This month’s question comes from Merlyn Grossman, RNP, a nurse practitioner at Golden Care in Van Nuys, CA. Grossman usually does a pregnancy test, gives the patient foam or film with condoms, and schedules a second visit two weeks following the initial visit to begin Depo shots. However, some patients have a hard time negotiating condom use with partners, leaving open a window of opportunity for pregnancy between the first and second visits.
Suggestions on how to address this situation come from David Archer, MD, professor of obstetrics and gynecology at The Jones Institute for Reproductive Medicine at The Eastern Virginia Medical School in Norfolk; Willa Brown, MD, MPH, director of the Bureau of Personal Health at the Howard County Health Department in Columbia, MD; Andrew Kaunitz, MD, professor and assistant chair in the department of obstetrics and gynecology at the University of Florida Health Sciences Center in Jacksonville; Allan Rosenfield, MD, dean of the School of Public Health at Colum-bia University in New York City; and Michael Rosenberg, MD, MPH, clinical associate professor of obstetrics/gynecology and epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm in Chapel Hill. (Also, see the patient hand-out on Depo Provera inserted in this issue of Contraceptive Technology Update.)
Archer: This question requires more information. If the patient is amenorrheic following a pregnancy episode and within three months of the completion of the pregnancy, I would support only a pregnancy test and then give the injection of Depo-Provera. If the patient has spontaneous secondary amenorrhea or following stopping some other steroidal form of contraception, some diagnostic studies may be indicated.
Spontaneous secondary amenorrhea could be associated with running, weight loss, or other stress events. It also could represent anovulation from other causes such as polycystic ovarian disease, hyperprolactinemia, and in a few instances, hyperthyroidism. If there is no evidence of significant medical complications, then I would only perform the pregnancy test and immediately give the Depo Provera.
Brown: I would suggest that it is important to find out why she is amenorrheic. If she is anovulatory and has low estrogen levels, Depo would not be the best choice for her. On the other hand, if she has normal or high levels, Depo would be great. A progesterone challenge would answer this question. Of course, this may increase the possibility that she would ovulate, and then you are back to the problem of ruling out pregnancy when starting the shots.
Kaunitz: First, we need to make the patient history a little bit clearer. If this is a woman who may have chronic anovulation, DMPA does not represent the treatment of choice. This patient needs to be evaluated, and then she might be treated in one of three ways, if chronic anovulation is diagnosed:
• oral contraceptives;
• cyclical oral Provera, if she doesn’t need birth control;
• if neither of those is acceptable or appropriate for the patient, you could consider DMPA.
This is actually a reasonable treatment. The DMPA would provide therapeutic benefits, such as protecting against endometrial hyperplasia and preventing dysfunctional bleeding by causing amenorrhea, as well as provide contraception. However, the patient needs to be evaluated before starting her on any treatment.
Rosenberg: The approach [described by Grossman] is what I would do, though I am cognizant of the legal atmosphere as well.
Rosenfield: I would first want to know why the patient is amenorrheic and would take a careful history and see if a work-up is indicated. A challenge test would be reasonable, as would an immediate pregnancy test. If the pregnancy test is negative and there is no indication of pathology, then I think it would be reasonable to initiate the first Depo Provera injection.
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