Lisa Sachdev, D.O.
Sachdev Wellness Clinic
Office: 281-542-7800, Fax: 281-542-7731
CONSENT FORM TO BEGIN DEPO PROVERA INJECTIONS
What is Depo-Provera?
Depo-Provera is a kind of birth control given by a shot. The shot contains only the hormone progestin. The
shot keeps a woman from getting pregnant for 12 weeks by stopping the ovaries from producing eggs.
Depo-Provera does not protect against HIV infection or any other sexually transmitted infections.
How effective is Depo-Provera?
The chances of getting pregnant while using Depo-Provera are 0.3 percent. Depo-Provera is as effective as
tubal ligation (having your tubes tied) and more effective than several other methods, including birth
control pills, condoms and diaphragms as long as you get another shot every 12 weeks. It is very
important to get you shots on time. If you get your shot on the first 5 days of your period, it starts
working right away. If you get your shot any other time, you should use a back-up method of birth
control for at least 7 days after your first injection.
Advantages of using Depo-Provera
 Has a similar effect to the pill and mini pill, but requires less effort. The female does not have to
remember to take daily pills; she simply has to visit her health care provider every three months
to receive the injection.
 Not dependent on remembering something daily.
 Can be used by women who cannot take estrogen or who require medication for seizures
 Reduces menstrual cramps and anemia
 Helps prevent serious health risks such as endometrial cancer and ovarian cysts
Disadvantages of using Depo-Provera?
 After a certain time period, you have to repeat the injection. If this time period lapses, you have to take a
pregnancy test before getting a repeat injection.
 The most common side effect is irregular bleeding in 70 percent of women in the first year, and in 10
percent of women thereafter. Absence of bleeding is common in 80 percent of women after two years.
 Bone loss (see more detailed discussion below)
 With Depo-Provera, it is not possible to stop the side effects until the shot wears, off which may take 12
to 14 weeks.
 If pregnancy is desired, it takes 12 to 18 weeks to get pregnant after the last shot is taken (sometimes
longer).
 In the rare case that pregnancy occurs during the use of Depo-Provera, there is an increased chance that
the pregnancy will be ectopic
Bone Mineral Density (BMD) Changes in Adult Women
Use of Depo-Provera Contraceptive Injection may cause you to lose calcium stored in the bones. The
longer you use Depo-Provera the more calcium you are likely to lose. Loss of calcium may cause weak,
porous bones (osteoporosis) that could increase the risk that your bones might break, especially after
menopause. In clinical study, adult women using Depo-Provera for up to 5 years showed decreases in
bone density of 5–6%. The decline in BMD was more pronounced during the first two years of use, with
smaller declines in subsequent years. More recent studies suggest that the calcium may return once you
stop using Depo-Provera. Clinical studies have demonstrated a partial recovery of BMD during the 2-year
period after injections were stopped. Longer duration of treatment was associated with less complete
recovery during this 2-year period following the last injection. It is not known whether your risk of
developing osteoporosis may be greater if you are a teenager when you start to use Depo-Provera.
Weight Gain
You may experience weight gain while you are using Depo-Provera CI. About two-thirds of the women
who used Depo-Provera CI in the clinical trials reported a weight gain of about 5 pounds during the first
year of use. You may continue to gain weight after the first year. Women who used Depo-Provera CI for 2
years gained an average of 8 pounds over those 2 years
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Lisa Sachdev, D.O.
Sachdev Wellness Clinic
Office: 281-542-7800, Fax: 281-542-7731
What if I want to get pregnant after using Depo Provera?
Return to ovulation and fertility is likely to be delayed after stopping Depo-Provera. Based on previous
clinic studies it is expected that 68% of women may conceive within 12 months of discontinuing DepoProvera injections, 83% may conceive within 15 months, and 93% may conceive within 18 months from
the last injection. The median time to conception for those who do conceive is 10 months following the
last injection with a range of 4 to 31 months, and is unrelated to the duration of use.
Can I use it if I am breastfeeding?
Women who are breastfeeding can safely use Depo-Provera. Long-term studies of babies whose mothers
used Depo-Provera while breastfeeding found no bad effects.
Side effects may include:
 Increased appetite and weight gain –
 NervousnessDizziness
 Headaches
 Skin rashes or spotty darkening of the skin
 Sore breasts
 Hair loss or increased hair on face or body
 Nausea
 Increased or decreased sexual desire
 Depression
 Vaginal dryness
Warning signs to report to your health care provider (physician or nurse practitioner);
 Sharp chest pain, coughing of blood, sudden shortness of breath
 Sudden severe headache, vomiting, dizziness, or fainting
 Visual disturbance (double vision, blurred vision, spots before your eyes or speech disturbance (slurred,
unable to speak)
 Weakness or numbness in arm or leg
 Severe pain or swelling in calf or leg
 Unusually heavy vaginal bleeding (unlike usual periods)
 Severe pain or tenderness in lower abdomen, pelvis
 Persistent pain, pus, or bleeding at injection site
Absolute Contraindications- if you have a history of any conditions listed below you SHOULD NOT begin or receive
Depo Provera injections.
 If you believe you MAY BE pregnant
 If you have abnormal or unexplained vaginal bleeding that has not been evaluated by a physician
 Past history of stroke or heart attack
 Past history of deep vein blood clot (DVT) or pulmonary embolus (blood clot in lung)
 Past or present history of breast or ovarian cancer
 Past or present history of liver disease
 Known or suspected sensitivity to Depo Provera or any of its ingredients
 Past or present history of Osteoporosis or Osteopenia
Interpreter’s Statement
Employee Initials ________
I have translated the information and advice presented orally to the patient who has chosen to use Depo-Provera. I
have also read to her the consent form in a language she understands and explained its contents to her. To the
best of my knowledge and belief she understands this explanation and voluntarily consents to an injection of
Depo-Provera. I have reviewed the absolute contraindications with the patient; she denies having any listed above
I verify that I have received adequate information to make an informed consent and wish to begin Depo-Provera
injections. I understand that it is recommended not to use this form of contraception for longer than two years.
Patient Signature_________________________________________________ Date______________
Last normal menstrual period______________
Pregnancy test performed and negative___________( OR) patient currently on her period___________.
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