Altered bleeding patterns

Irregular, prolonged or frequent bleeding is common with depot medroxyprogesterone use. Around 50 to 70% of users will be amenorrhoeic after 1 year of use.

Exclude other causes of bleeding, such as pregnancy, sexually transmitted infections (eg chlamydia), and vaginal, cervical or uterine pathology. If no other cause of bleeding is suspected, reassure the individual that bleeding can be expected and is not harmful.

Evidence for medical management of frequent or prolonged bleeding while using progestogen-only methods of contraception is limited; options include adding:

• a combined hormonal contraceptive taken continuously or cyclically (for up to 3 months)
• a 5-day course of a nonsteroidal anti-inflammatory drug (NSAID) or (if bleeding is heavy) tranexamic acid; see Heavy menstrual bleeding for dosages.

Other options (with low-level, anecdotal or conflicting evidence) include adding oral norethisterone (see Heavy menstrual bleeding for dosage), or adding a levonorgestrel progestogen-only pill (twice daily for 20 days).