Depot medroxyprogesterone acetate (DMPA) is an injectable, progestin only contraceptive administered every three months. It is highly effective and can be offered to women who cannot or should not use estrogen [1]. In Bangladesh, modern methods were used by 58.3% of currently married women in the 2022 national survey and injectables (12.1%) ranked second only to pills (29.3%) [2]. Because many women continue DMPA for years, its long-term metabolic effects are of practical importance to clinicians. Weight gain is the metabolic concern discussed most often. A Cochrane review of 22 studies found mean weight gain below 2 kg at 6 or 12 months in most studies, although some reported greater gain among DMPA users than among women using non-hormonal methods [1]. A systematic review also linked DMPA use with weight gain and higher body fat mass, though the supporting studies carried a moderate or high risk of bias [3]. Whether such changes extend to glycemic regulation is a separate question. That question matters because diabetes is common and rising. The global prevalence of diabetes among adults aged 20 to 79 years was estimated at 10.5% in 2021, with a projected rise to 12.2% by 2045 [4]. A meta-analysis of Bangladeshi studies reported pooled prevalence of 7.8% for diabetes and 10.1% for prediabetes [5]. Prediabetes is an intermediate state that carries a risk of progression to diabetes and of cardiovascular and kidney complications [6]. Contraceptive counselling for women with diabetes, or at risk of it, therefore needs to rest on evidence about how each method affects glucose metabolism [7]. Eligibility guidance for contraceptive use includes specific recommendations for women with diabetes [8]. The evidence on DMPA and glycemia is mixed. A meta-analysis of progestin only contraceptives found an indication of higher diabetes risk with injectable products, but the estimate was not significant and rested on two studies [9]. In a 12-month prospective study of non-obese new users, Cursino et al. observed significant rises in fasting insulin and HOMA-IR from baseline [10]. A later clamp study from the same group found similar insulin sensitivity in DMPA and copper intrauterine device users overall, with adverse changes in only a few women [11]. Prospective work has also examined body composition and inflammatory markers after 12 months of use [12]. A case report of a woman using DMPA for about ten years described impaired fasting glucose with insulin resistance and called for better quality safety data [13]. Most of this literature comes from short follow-up studies of non-obese women outside South Asia and, to our knowledge, data from Bangladeshi clinical settings are scarce. Little is known about how glycemic parameters vary by duration of use and body mass index among women attending routine gynaecological services in Bangladesh. This gap limits evidence-based counselling. This study therefore describes changes in fasting plasma glucose, 2-hour post-load glucose and fasting insulin among women using DMPA at two hospitals in Dhaka and examines glycemic status by duration of use and BMI category. Such information could help clinicians counsel women before and during DMPA use and decide when glycemic review is warranted.

This retrospective observational study was carried out in the Department of Obstetrics and Gynaecology, Saheed Suhrawardy Medical College Hospital and Lab One Hospital, Ashulia, Dhaka, Bangladesh, from January to December 2025. A total of 150 women using DMPA were included. Selection Criteria Inclusion criteria 1. Women aged 20 to 45 years using DMPA 2. Documented duration of DMPA use 3. Complete glycemic records at initiation and follow-up Exclusion criteria 1. Known diabetes mellitus before DMPA initiation 2. Pregnancy or lactation during follow-up 3. Use of other hormonal contraceptives or glucose altering drugs 4. Incomplete or inconsistent records Data Collection Procedure Data were retrieved from the outpatient and laboratory records of both hospitals using a structured data extraction sheet. Recorded variables included age, parity, height, weight, duration of DMPA use in months and glycemic parameters at DMPA initiation and at the most recent follow-up visit. Body mass index was calculated as weight in kilograms divided by height in metres squared and grouped as below 25.0, 25.0 to 29.9 and 30.0 kg/m² or above. Duration of use was grouped as 12 months or less, 13 to 36 months and more than 36 months. Fasting plasma glucose was measured after an overnight fast and 2-hour post-load glucose after an oral glucose load. Fasting insulin was recorded in µIU/mL. Fasting glucose at follow-up was classified as normal (below 100 mg/dL), impaired (100 to 125 mg/dL) or a single value in the diabetes range (126 mg/dL or above). Laboratory results were taken as reported by the respective hospital laboratories and no new investigations were performed for the purpose of this study. To maintain accuracy and consistency, the same extraction sheet and variable definitions were applied to every record. Entries were checked against the original files and discrepancies were resolved by re-examining the source documents. Data were then entered into a password protected spreadsheet and reviewed for completeness before analysis. Confidentiality was maintained throughout. Names and hospital identification numbers were not collected, each participant was assigned a serial code and access to the dataset was limited to the research team. Findings are reported only in aggregate form. Statistical Analysis Analysis used SPSS version 25.0. Continuous variables were summarised as mean and SD and categorical variables as frequency and percentage. Change from initiation to follow-up was assessed with the paired t test. The Pearson chi-square test compared glycemic status across duration categories and one-way analysis of variance compared glycemic parameters across BMI categories. A P value below 0.05 was significant.

A total of 150 women with complete retrospective records of DMPA use were analysed. Their mean age was 33.2 ± 6.4 years and the mean duration of DMPA use was 28.5 ± 14.2 months. Mean fasting plasma glucose, 2-hour post-load glucose and fasting insulin were higher at follow-up than at DMPA initiation. Most participants had normal fasting glucose at follow-up and the proportion with impaired fasting glucose did not differ significantly by duration of use. Follow-up glycemic values were progressively higher across increasing BMI categories. Table 1. Baseline Sociodemographic and Clinical Characteristics of Participants (n = 150) Characteristic Category Frequency (n) Percentage (%) Age group (years) 20-29 52 34.7 30-39 71 47.3 40-45 27 18.0 BMI (kg/m²) <25.0 68 45.3 25.0-29.9 57 38.0 ≥30.0 25 16.7 Parity Nulliparous 18 12.0 1-2 74 49.3 ≥3 58 38.7 Duration of DMPA use (months) ≤12 44 29.3 13-36 63 42.0 >36 43 28.7 Table 1 shows the baseline sociodemographic and clinical characteristics of the participants. Most women were aged 30 to 39 years (47.3%), followed by those aged 20 to 29 years (34.7%) and 40 to 45 years (18.0%). A BMI below 25.0 kg/m² was recorded in 45.3% of women, while 38.0% had a BMI of 25.0 to 29.9 kg/m² and 16.7% had a BMI of 30.0 kg/m² or above. Women with one or two children formed the largest parity group (49.3%), followed by those with three or more children (38.7%) and nulliparous women (12.0%). The duration of DMPA use was 13 to 36 months in 42.0% of participants, 12 months or less in 29.3% and more than 36 months in 28.7%. Table 2. Glycemic Parameters at DMPA Initiation and Follow-up (n = 150) Parameter At initiation (mean ± SD) At follow-up (mean ± SD) Mean change P value Fasting plasma glucose (mg/dL) 78.4 ± 8.2 83.3 ± 9.6 4.9 <0.001 2-hour post-load glucose (mg/dL) 112.6 ± 18.4 121.3 ± 21.7 8.7 <0.001 Fasting insulin (µIU/mL) 7.8 ± 3.4 10.2 ± 4.1 2.4 <0.001 Table 2 presents the changes in glycemic parameters between DMPA initiation and the most recent follow-up. Mean fasting plasma glucose increased from 78.4 ± 8.2 mg/dL to 83.3 ± 9.6 mg/dL, a mean increase of 4.9 mg/dL. Mean 2-hour post-load glucose rose from 112.6 ± 18.4 mg/dL to 121.3 ± 21.7 mg/dL (mean change 8.7 mg/dL) and mean fasting insulin increased from 7.8 ± 3.4 µIU/mL to 10.2 ± 4.1 µIU/mL (mean change 2.4 µIU/mL). All three changes were statistically significant (P < 0.001). Table 3. Glycemic Status at Follow-up According to Duration of DMPA Use (n = 150) Glycemic status ≤12 months (n = 44) 13-36 months (n = 63) >36 months (n = 43) Total (n = 150) Normal fasting glucose (<100 mg/dL) 39 (88.6%) 51 (81.0%) 33 (76.7%) 123 (82.0%) Impaired fasting glucose (100-125 mg/dL) 5 (11.4%) 11 (17.5%) 9 (20.9%) 25 (16.7%) Single fasting value in diabetes range (≥126 mg/dL) 0 (0.0%) 1 (1.6%) 1 (2.3%) 2 (1.3%) Total 44 (100.0%) 63 (100.0%) 43 (100.0%) 150 (100.0%) Table 3 describes glycemic status at follow-up according to the duration of DMPA use. Overall, 123 participants (82.0%) had normal fasting glucose, 25 (16.7%) had impaired fasting glucose and 2 (1.3%) had a single fasting measurement in the diabetes range. Impaired fasting glucose was found in 11.4% of women with 12 months or less of use, 17.5% of those with 13 to 36 months of use and 20.9% of those with more than 36 months of use. This difference was not statistically significant (χ² = 1.48, df = 2, P = 0.477). The two participants with diabetes range values were excluded from this comparison because of small expected cell counts. Table 4. Follow-up Glycemic Parameters According to BMI Category (n = 150) Parameter BMI <25.0 (n = 68) BMI 25.0- 29.9 (n = 57) BMI ≥30.0 (n = 25) P value Fasting plasma glucose (mg/dL) 81.2 ± 8.7 84.0 ± 9.8 87.6 ± 10.4 0.012 2-hour post-load glucose (mg/dL) 117.4 ± 19.2 122.8 ± 22.1 128.5 ± 23.6 0.041 Fasting insulin (µIU/mL) 9.1 ± 3.6 10.8 ± 4.2 12.3 ± 4.8 0.003 Table 4 presents follow-up glycemic parameters according to BMI category. Mean fasting plasma glucose was 81.2 ± 8.7 mg/dL, 84.0 ± 9.8 mg/dL and 87.6 ± 10.4 mg/dL among women with a BMI below 25.0, 25.0 to 29.9 and 30.0 kg/m² or above, respectively (P = 0.012). Corresponding mean 2-hour post-load glucose values were 117.4 ± 19.2, 122.8 ± 22.1 and 128.5 ± 23.6 mg/dL (P = 0.041). Mean fasting insulin was 9.1 ± 3.6, 10.8 ± 4.2 and 12.3 ± 4.8 µIU/mL, respectively (P = 0.003).

In this series of 150 women, mean fasting plasma glucose rose by 4.9 mg/dL, 2-hour post-load glucose by 8.7 mg/dL and fasting insulin by 2.4 µIU/mL between DMPA initiation and the latest follow-up and average values stayed within or close to the normal range. Dilshad et al. report that fasting serum glucose was significantly higher in DMPA users (84.6 mg/dL) than in controls (77.8 mg/dL) [14]. Our baseline mean of 78.4 mg/dL and follow-up mean of 83.3 mg/dL resemble these two values. Cursino et al. likewise found significant increases in fasting insulin and HOMA-IR over 12 months of DMPA use in non-obese women, which parallels the insulin rise seen here [10]. Witczak et al. summarise cohort evidence in which glucose rose by about 2 to 3 mg/dL and insulin by 3 to 4 units during the first 18 to 30 months of use before levelling off [13]. The glucose increase in our cohort was slightly larger and the insulin increase slightly smaller than these figures, which may reflect the longer mean duration of use of 28.5 months. Using the hyperinsulinemic euglycemic clamp, Melhado-Kimura et al. reported similar insulin sensitivity in DMPA and copper intrauterine device users at 12 months, with adverse carbohydrate changes confined to a few women [11]. Taken together, these reports suggest that the average shift is modest while susceptibility differs between individuals. Not every study has detected a difference. Sari et al. compared 48 DMPA users with 48 non-users in Indonesia and found mean glucose values of 91.3 and 88.8 mg/dL, respectively, with no significant difference in glucose or insulin [15]. That comparison was cross sectional, whereas the present analysis examined change within the same women over time, which may explain why a rise was detectable here. Differences in design, sample size and follow-up duration also make direct comparison difficult. The graded increase in follow-up glucose and insulin across BMI categories deserves attention. Mean fasting insulin was 9.1 µIU/mL in women with a BMI below 25.0 kg/m² and 12.3 µIU/mL in those with a BMI of 30.0 kg/m² or above. Czech notes that obesity is accompanied by greater insulin secretion alongside reduced insulin action in liver, muscle and adipose tissue [16], a pattern compatible with this gradient. Kantarama et al. followed centrally obese DMPA users for 12 months, reported significant changes in cardiometabolic markers and recommended assessing central obesity before initiation [17]. Witczak et al. also describe more pronounced glucose and insulin rises among overweight and obese users in earlier cohort data [13]. Cursino et al. observed that three of five users with abnormal HOMA-IR had gained more than 5 kg, which points to weight change as one possible pathway [10]. At follow-up, 16.7% of women had impaired fasting glucose and 1.3% had a single value in the diabetes range. Akhtar et al. estimate the pooled prevalence of prediabetes in the Bangladeshi general population at 10.1%, although definitions and age structures differ from those of our hospital sample [5]. The proportion with impaired fasting glucose rose numerically from 11.4% to 20.9% across duration categories without reaching significance. Glisic et al. found only a non-significant indication of higher diabetes risk with injectable progestin only contraceptives [9] and a similar lack of statistical certainty applies to our duration analysis. Witczak et al. describe a woman with impaired fasting glucose and insulin resistance after about ten years of use [13], which illustrates that long exposure merits attention even when group level trends are weak. The American Diabetes Association requires confirmatory testing in the absence of unequivocal hyperglycemia [18], so the two women with single diabetes range values need repeat testing before any diagnosis is made. Echouffo-Tcheugui and Selvin emphasise that intermediate hyperglycemia carries a risk of later diabetes and cardiovascular disease [6], which supports follow-up of women with impaired fasting glucose. Findings beyond glucose point in the same direction. Cursino et al. found higher triglycerides and apolipoprotein B-100 after one year of DMPA use [19] and Odelola and Akadri reported unfavourable lipid changes within six months of initiation in Nigerian women [20]. Alongside the modest weight changes described in the Cochrane review [1] and the body fat findings of Dianat et al. [3], these data support reviewing metabolic indicators of DMPA users at routine visits. Counselling should present possible glycemic effects together with the benefits of effective contraception [7]. LIMITATIONS AND RECOMMENDATIONS This study has limitations. Its retrospective design and two hospital settings restrict generalisability and the absence of a non-DMPA comparison group means that the observed changes cannot be attributed to DMPA. Follow-up intervals varied between women and potential confounders such as diet, physical activity and family history of diabetes could not be fully accounted for. A single fasting value cannot establish a diagnosis of diabetes. Prospective multicentre studies with matched comparison groups and standardised follow-up are recommended. Clinicians may consider periodic glycemic assessment of DMPA users, particularly those with a higher BMI.

Among 150 women using DMPA, fasting plasma glucose, 2-hour post-load glucose and fasting insulin were significantly higher at follow-up than at initiation and follow-up values rose progressively across BMI categories. Most women remained normoglycemic and impaired fasting glucose did not differ significantly by duration of use. These observations are descriptive only and do not establish causation. Periodic glycemic assessment and weight monitoring are reasonable for DMPA users, particularly those with higher BMI and prospective controlled studies should confirm these findings.

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