MEDICATION: Perimenopause & The Depot (jab)

✅ Benefits

Contraception:

Provides highly effective contraception at a time when fertility is declining but still possible.

Useful for women who cannot take estrogen (e.g. history of VTE, migraines with aura, smokers >35).

Bleeding control:

Often reduces heavy or irregular perimenopausal bleeding.

Around 50–60% become amenorrhoeic after 12 months.

Endometrial protection:

Suppresses endometrial proliferation → lowers risk of endometrial hyperplasia and carcinoma.  BUT this is not enough endometrial protection alone when used in conjunction with estrogen therapy.

Can be an option for women with adenomyosis or endometrial protection needs.

Symptom management:

May reduce dysmenorrhea and endometriosis-related pelvic pain.

Some women value not having cyclic hormonal fluctuations.

Convenience:

12-weekly injection, no daily pill to remember.

⚠️ Risks and Drawbacks

Bone mineral density (BMD):

DMPA causes a hypoestrogenic state → associated with reduction in BMD.

Greatest concern in adolescents/young adults; in perimenopause, recovery time before menopause is shorter, so bone loss may not fully recover.

Important if additional osteoporosis risk factors exist.

Cardiometabolic:

Can cause weight gain (average 2–5 kg over 1–2 years, though variable).

May slightly worsen lipids and insulin resistance in some women.

Caution in women with obesity, diabetes, or metabolic syndrome.

Bleeding patterns:

Irregular/unpredictable bleeding common in the first 6–12 months.

May be distressing in perimenopause, where irregular bleeding is already an issue.

Delay in return to fertility:

Average of 9–12 months before ovulation resumes after last injection.

Less relevant in late 40s, but important if stopping early.

Hypoestrogenic symptoms:

May worsen vasomotor symptoms (hot flushes, night sweats).

Vaginal dryness or low libido can be exacerbated.

Mood effects:

Some women experience low mood, irritability, or anxiety.

Hard to separate from perimenopausal changes.

🧭 Clinical Considerations in Perimenopause

Not first-line for perimenopausal symptom relief — unlike combined hormonal contraception or MHT, DMPA doesn’t provide estrogen.

Use cautiously if:

Strong family history or personal risk of osteoporosis.

Significant cardiometabolic risk factors.

Prior mood sensitivity to progestins.

Best suited for:

Women needing reliable contraception and bleeding control, who cannot or prefer not to use estrogen.

Women approaching menopause who value amenorrhea and simplicity.

Alternatives:

Levonorgestrel IUS (Mirena): offers contraception, bleeding control, endometrial protection, and can be combined with estrogen if transitioning to MHT.

Combined hormonal contraception (if no contraindications): treats symptoms and provides contraception.

Progestogen-only pill or implant: less impact on BMD than DMPA.

🧘‍♀️ Key Takeaway

In perimenopause, DMPA can be helpful for contraception and bleeding control but is generally less favored due to its hypoestrogenic effects (bone, mood, vasomotor). It may be reasonable for short-term use in selected women who cannot use estrogen, but other options (especially LNG-IUS) are usually preferred.