Depot Provera and Perimenopause: Why It’s Usually Not Recommended After 40

When it comes to perimenopause, contraception and bleeding control are still important. Even though fertility is declining, pregnancy is still possible until menopause is reached, and for many, heavy or irregular bleeding is part of the journey. One option that sometimes comes up is Depot medroxyprogesterone acetate (Depo-Provera or “depot”), a three-monthly contraceptive injection.

Depot works by switching off ovulation and thinning the lining of the uterus. This makes it a highly effective contraceptive and often leads to lighter or absent periods. Some women love the sense of stability depot provides: no monthly bleeding, no daily pills, and fewer hormonal ups and downs. In some cases, if depot is well tolerated, clinicians can add in estrogen (via a patch or gel) for symptom relief and bone health while depot continues to provide reliable contraception.

The Bone Health Problem

The biggest drawback with depot, especially after age 40, is its effect on bone mineral density (BMD). By suppressing estrogen, depot can accelerate bone loss — a concern at any age, but especially in the years leading up to menopause when bone health is already under pressure.

Regulatory bodies have taken this seriously. The FDA places a black-box warning on Depo-Provera, noting that prolonged use can cause significant BMD loss, some of which may not be fully reversible. Clinical guidance also cautions that depot should be used with care in women over 40, and generally avoided unless other options are unsuitable.

What This Means in Practice

If you’re already using depot and doing well, it doesn’t automatically mean you need to stop. Your clinician may discuss adding estrogen support to protect bones, aiming for safe blood levels (around 250–300 pmol/L), and layering menopausal hormone therapy (MHT) if you’re amenorrhoeic. Lifestyle factors — weight-bearing exercise, calcium and vitamin D intake, limiting alcohol and smoking — also matter for protecting bone strength.

But for most women approaching menopause, depot is not the first choice. Other options such as the levonorgestrel IUS (Mirena), combined hormonal contraception (if suitable), or eventually MHT offer contraception and/or bleeding control without the same degree of bone risk.

Takeaway

Depot Provera can be helpful for some women in perimenopause — particularly for those who value its stability and amenorrhoea. But because of the bone health risks, it’s generally not recommended as a long-term option after 40. The best approach is to weigh up your personal health picture with your clinician and explore safer alternatives that provide both contraception and symptom support as you transition through menopause.

For more information on the Depot and Perimenopause - have a look on our Perimenopause Page