Depo Bleeding: Will It Ever Stop?

Relief for a Depo Provera Side Effect

Stop Depo Bleeding
Stop Depo Bleeding. TEK IMAGE/Getty Images

Depo-Provera (DMPA) is a reversible prescription birth control method. Each Depo Provera shot slowly releases a synthetic form of progesterone medroxyprogesterone acetate that can protect against pregnancy for a period of 11 to 14 weeks. Many women stop using Depo-Provera during the first year of use due to irregular bleeding (spotting) and/or continuous bleeding, both of which are especially bothersome during the first three months of use.

The good news? After continuous Depo use for one year, the depo bleeding stops for almost 50% of women.

Frustrated with Unwanted Depo Bleeding?

The most common reason women choose to stop using hormonal contraception tends to be dissatisfaction with their bleeding patterns. Women seem to be most frustrated with unscheduled bleeding and spotting. It is estimated that discontinuation of contraception may account for almost 20% of the 3.5 million unintended pregnancies that occur each year.

Unfortunately, it seems that bleeding is the number one reason that women choose to stop using this birth control method. Depo bleeding side effects can occur as your body is adjusting to Depo Provera. Many women report experiencing irregular bleeding (spotting) and/or prolonged bleeding (like a continuous period) during this time. Unfortunately, there is no way to know ahead of time if you might experience this Depo-Provera side effect.

For some, the depo bleeding may continue until the injection wears off (12 to 14 weeks) whereas others may not have any bleeding/spotting at all.

Is There Hope For Me?

Even though this depo bleeding could occur right after your first Depo-Provera injection, according to Pfizer (the manufacturer of Depo-Provera), “in clinical trials, over a third of the women had stopped having periods (this is called "amenorrhea") by month 6.

By month 12, over half of the women had stopped.” A good number of women may be willing to “wait it out” knowing that the frequency and duration of their depo bleeding will decrease over time. These women are willing to go through the initial bleeding in exchange for not having to have a period anymore.

OK, so good for those women… But what about the 70% of women who experience depo bleeding during the first year of use and are feeling, is there any hope for me? You may really want to continue with Depo Provera use. After all, it is highly effective (97% to 99.7%) and super convenient to only have to think about birth control 4 times a year. Plus, you would love for your Depo Provera to be the agent preventing pregnancy and not the fact that you are not having sex (= no chance of becoming pregnant) due to this annoying bleeding! It just requires patience.

Depo Bleeding Interventions

If knowing that the depo bleeding should decrease isn’t cutting it for you (or if your bleeding is not decreasing), there may be some treatments available.

Keep in mind, though, these interventions and medications may help stop the bleeding, but there is no evidence to support the routine use of these options. Seeking such interventions may help increase your likelihood of sticking with Depo-Provera (and perhaps even being happy about your decision!).

Eager to see if I could uncover some hope for all of you complaining about depo bleeding, I researched an article on UpToDate -- a trusted electronic reference used by many doctors and patients. According to this excerpt from UpToDate, some treatments include:

"Supplemental estrogen -- Oral or transdermal estrogen (1.25 mg conjugated estrogens, 2 mg of micronized estradiol, or 0.1 mg estradiol patch) administered for 7 to 14 days, if there are no contraindications to exogenous estrogen administration. An estradiol-releasing vaginal ring for the first three months after initiation of DMPA has also been tried. Estrogen supplementation is thought to promote tissue repair and coagulation. It does not affect the contraceptive efficacy of DMPA.

Tranexamic acid -- Tranexamic acid is an antifibrinolytic used primarily in patients with hemophilia during operative procedures. A randomized placebo-controlled trial of 100 DMPA users with unscheduled bleeding found that tranexamic acid 250 mg orally four times per day for five days was effective in halting bleeding. The tranexamic acid group had a significantly higher percentage of subjects in whom unscheduled bleeding stopped during the first week of treatment (88 versus 8.2 percent with placebo), and during the four-week follow-up period (68 versus 0 percent with placebo). The mean number of bleeding/spotting days was also significantly different between the groups (5.7 versus 17.5 days)."

OK, what does this mean to you, the poor woman who is bleeding on depo and is desperate for some relief?

Estrogen: one option that you can discuss with your doctor is possibly using hormone replacement therapy/estrogen supplementation to get some relief from your depo bleeding.

  • Conjugated estrogens (Cenestin, Enjuvia, Premarin): these are a mixture of several different estrogens (estrogen salts) and are derived from synthetic sources.
  • Micronized estradiol (Gynodiol, Estrace): these are bio-identical estrogens, made from plant sources that are micronized (broken down into little pieces) so it is easily absorbed and used by your body.
  • Estradiol patch (Climara, Alora, Vivelle Dot, Estraderm): a transdermal skin patch that releases the estradiol and allows it to be slowly absorbed through your skin. These patches are NOT the same thing as the Ortho Evra contraceptive patch.
  • Estradiol vaginal ring (Estring, Femring): a flexible ring that provides vaginal estrogen. This is NOT the same thing as the NuvaRing.

These estrogen treatments, taken for 7-14 days (the ring is used for the first three months) may provide some relief from the depo bleeding. However, research is limited and mixed about how well estrogen supplementation may work. The largest trial investigating estrogen-use indicates that ethinyl estradiol was more effective than a placebo in stopping depo bleeding, yet the bleeding started up again once the estrogen was stopped. Likewise, there has been one major study on the use of estradiol patch for depo bleeding. The results show that women using this intervention had a higher rate of continuing with Depo Provera use. At this time, due to lack of research, birth control pills are not indicated to help with depo bleeding.

The therapeutic use of estrogen may help stop depo bleeding because it encourages blood clotting and tissue repair as well as promotes fast growth of uterine lining and stabilizes blood vessels. Estrogen therapy may also be a good option because it does not compromise Depo Provera’s effectiveness at preventing pregnancy. That being said, you and your doctor must weigh the therapeutic advantages of estrogen supplementation against its potential problems. Not everybody is a candidate for estrogen, and it can be dangerous to use if you have certain risk factors or are estrogen-intolerant. Also, extended use of estradiol medications may increase your risk of breast cancer, ovarian cancer or uterine cancer.

Tranexamic Acid: this medication may be another option to discuss with your doctor if you are experiencing bleeding discontentment associated with your depo injection. Though the name may sound a little scary, tranexamic acid (Lysteda) is actually a non-hormonal medication that prevents fibrinolysis (a normal body process that prevents naturally occurring blood clots; thereby preventing them from growing and/or bleeding).

It is a synthetic derivative of the amino acid lysine. Typically, tranexamic acid is used during dental surgeries (like tooth extractions) for people who have hemophilia or prolonged bleeding time. It can also be used during orthopedic surgery to reduce blood loss. Lysteda is used as the first choice nonhormonal treatment for dysfunctional uterine bleeding; in fact, in November 2009, the U.S. Food and Drug Administration (FDA) approved tranexamic acid oral tablets for the treatment of heavy menstrual bleeding.

One hundred women who received a depo injection (all of whom were experiencing bleeding on depo) participated in a double-blind, randomized, placebo-controlled study to evaluate the effectiveness of using tranexamic acid to control depo bleeding. After being split into two groups: 50 who received 250 mg of tranexamic acid 4 times a day, for 5 days 49 who received placebo medication (1 woman had initially dropped out).

Results indicated that at the end of the first week, the percentage of women whose depo bleeding had stopped was significantly higher in the tranexamic acid group than the placebo group (88% vs. 8.2%). Four weeks after initial treatment, a follow-up analysis was conducted. 68% of the women treated with tranexamic acid reported no bleeding for over 20 days whereas 0% of the women in the placebo group reported a similar bleeding-free interval.

Finally, the groups showed significantly different results for mean number of spotting/bleeding days -- 5.7 days for the tranexamic acid group vs. 17.5 days of spotting for the placebo group.

Though it appears that tranexamic acid is an effective short-term treatment for irregular bleeding/spotting associated with receiving a depo injection, just like with estrogen supplementation, you and your doctor must weigh the therapeutic advantages against potential problems. Tranexamic acid may not be the right choice for individuals with certain health issues or allergies. If you are a teenager unhappy about your depo bleeding, tranexamic acid may not be a viable solution given that its safety and efficacy have not been established in women under the age of 18.

Additional Treatments to Stop bleeding After a Depo Injection:

There are a few more treatments that could potentially provide you some relief from your continuous Depo Provera bleeding. I will briefly explain some of these because they are not without pitfalls:

  • Mefenamic acid (Ponstel): in short-term depo bleeding control, this medication has shown to be effective at a dose of 500 mg, two times a day, for 5 days. It does not seem to be an effective long-term solution. Mefenamic acid is a nonsteroidal anti-inflammatory drug, and there is a FDA mandated black box warning for this medication indicating that this medicine may increase the risk of heart attack, stroke, and high blood pressure, especially with long-term use. People with certain conditions should not use this medication. Using mefenamic acid may also increase the risk of ulcer or bleeding from the stomach or intestines. Another issue is that this medication does not mix well with several other medications, so serious drug interaction can occur. As always, you need to weigh all these pros and cons with your doctor.
  • Valdecoxib (Bextra): at a does of 40 mg orally, once per day, for five days, Valdecoxib reduces the duration of depo bleeding episodes as well as increases the number of days bleeding-free intervals before another episode occurs. There has only been one study to evaluate valdecoxib and depo bleeding. Results indicate that a significant amount of women who used valdecoxib reported that their depo bleeding had stopped during the first week after their depo injection and reported more bleeding-free days at a 4 week follow-up assessment. Sounds good – right? The bad news, though valdecoxib received FDA-approval in November 2001, it was removed from the market in 2005 due to concerns about potential increased risk of heart attack and stroke. So, Valdecoxib is not available in the United States.
  • Mifepristone (Mifeprex): this medication is best known for its use in medical abortion. However, it seems that low doses of mifepristone may actually help decrease the number of depo bleeding days in half for women who have just gotten their first depo injection. This does appear to be a potentially helpful approach; however, at this time, the only available mifepristone dose in the US is the 200mg amount intended for use to terminate a pregnancy. The low dose mifepristone formulation indicated for helping with depo bleeding is not available. It is also important to keep in mind that there are some serious health risks when using this medication. A FDA-mandated black box warning cautions that serious bleeding (that may require surgical intervention) may occur following use of this medicine. Also, severe infections could occur.
  • Don’t Be Fooled: finally, there is the widely used practice of increasing the frequency of your Depo Provera injections (having them earlier than when the next depo injection is due). Many doctors recommend shortening the time between depo shots, claiming that this helps to stop depo bleeding. There have been no studies examining how effective this practice is, so if your doctor suggests it, you may be better off saying no and sticking to your regular scheduled appointments.

Final Thoughts:

Hopefully, you now have some hope in managing your depo bleeding. Remember though, this situation (being stuck with unwanted side effects) is a perfect time to reiterate how important it is that you talk to your doctor about potential side effects BEFORE beginning any birth control option and especially before agreeing to your first depo injection. Research has shown that women who have been informed about the potential for either irregular (spotting) bleeding or prolonged, continuous bleeding before beginning to use Depo Provera are more likely to continue obtaining their scheduled depo injections. Knowing what to expect and being aware of side effects, like depo bleeding, prior to your first depo injection may help increase your success with this method. As always, knowledge is key when making informed contraceptive decisions.

Want to learn more? See UpToDate's topic, "Management of unscheduled bleeding in women using contraception," for additional in-depth medical information on ways to manage not only depo bleeding, but unscheduled spotting/bleeding while using Implanon, combination birth control pills, progestin-only pills and IUDs.

Source:

Edelman, Alison & Kaneshiro, Bliss. "Management of unscheduled bleeding in women using contraception." UpToDate. Accessed: April 2011.

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