A PUBLICATION OF THE POPULATION AND DEVELOPMENT PROGRAM AT
Time to Take a Critical Look at Depo-Provera by Sara Littlecrow-Russell
My first experience with Depo-Provera was as a young welfare mother. I had just finished my first post-partum check-up after having had my second child. The doctor pronounced me in great health and then pulled out a syringe and a vial.I am just going to give you a shot so that you won't have to worry about getting pregnant again. She smiled. I asked her what was in the vial and she told me that it was like the pill, but that I didn't have to worry about remembering to take it every day. I was assured that Depo-Provera was safe, but I was breastfeeding and didn't want to take even an aspirin. When I refused the shot, the doctor became visibly angry with me. She stopped making even the most rudimentary conversation, scribbled something on my chart and left, but not before heaving an exasperated sigh and slamming the vial and syringe into a tray on the counter. I was scared of this doctor and her power over me. Could she call Department of Social Services and have my baby taken away? Could she make it so I couldn't come to the free clinic any more? I wasn't taking any chances so I never returned for my other post-natal checkups.
It was months later that other questions surfaced in my mind: Is there an antidote if you take Depo-Provera and have a bad reaction? What kind of research has been done on this drug? Why didn't the doctor talk to me about condoms or any other kind of birth control? Did every woman get the same treatment? How much harder would it have been to say no if I didn't speak English, or if I was an uncertain teenager, or if the doctor had been just a little more pushy? Paradoxically, I ended up taking Depo-Provera anyways. Several years later, as a college student close to graduation and fearful of getting pregnant, I chose to try Depo-Provera through my college clinic. My doctor and I had a great rapport and she answered every Depo-Provera question with thoughtfulness and impartiality. However, on Depo-Provera, I became depressed, fat, irritable, and uninterested in sex. My loss of libido while on Depo-Provera was so great that it seemed only natural when I found out that it is routinely used as a chemical castration agent to suppress the libidos of male sex offenders.
What is Depo-Provera? Depo-Provera (medroxyprogesterone acetate) is an injectable contraceptive marketed by Pharmacia & Upjohn, Inc. Depo-Provera injections are administered once every three months and have a greater than 99% effectiveness rate at preventing pregnancy. Injectable depot medroxyprogesterone acetate has been utilized for more than 30 years as
a chemotherapy agent for the treatment of certain types of uterine cancer. However, it only gained approval for use as a contraceptive in the U.S. in 1992. By 1996, Depo-Provera had cornered 7% of the contraceptive market and garnered the Upjohn Company $160 million in sales revenues.1
Depo-Provera is now approved in more than 70 countries including the U.S., France, Germany, Sweden, and the United Kingdom. A once-monthly version of Depo-Provera, called Cyclofem (also known as Cyclo-Provera) has undergone clinical trials in Chile, Indonesia, Jamaica, Mexico, Thailand, and Tunisia. Medical Advertising News predicts strong market potential in Latin American, China and Eastern Europe.2
Who Uses Depo-Provera?: The Image and the Reality In the United States, despite extensive print and groundbreaking television advertising campaigns targeted toward middle-class women, Depo-Provera is more often utilized by poor or working class women and women receiving primary healthcare from federal and many state-funded health clinics. This is buoyed by an agreement that Upjohn Company made in 1994 to supply Depo-Provera on a "buy one, get one free" basis to Title X- funded agencies and clinics.3 Across the U.S., Depo-Provera has been further subsidized by state and local governments (Houston, Texas recently purchased $1.3 million worth of Depo-Provera for dispensation at city health clinics serving the poorer strata of Houston).4
In less than a decade, Depo-Provera has had a significant impact. Depo-Provera use has been credited with a dramatic reduction in teen pregnancies and is the contraceptive choice for approximately 8% of white teens and 19% of black teens. The increased media focus on teen pregnancy reduction coupled with the lack of similar focus on the potentially adverse effects of Depo-Provera use are likely to ensure that the numbers of teens on Depo-Provera will continue to rise. A recent study of Massachusetts family planning clinics found that Depo-Provera use has risen 77% over the past three years among women ages 20 and younger.5
A 1997 issue of Drug Topics notes that Depo-Provera was among the top ten drugs for which the FDA received reports of adverse experiences.6 Teenagers in particular need to be concerned with the potential (and considerable) side effects of Depo-Provera.
Important Side Effect Considerations For Teen Users Body Image: At the 1999 Master of Pediatrics Conference in Miami, Paul Jenkins noted some teen Depo-Provera related weight gains upwards of thirteen pounds in a year and warned pediatric practitioners to "expect significant weight gain in teenagers using Depo- Provera contraception, especially if they are already heavyset".7 For teens excess weight gain can contribute markedly to depression, poor body image, and eating disorders - serious problems to which young women are already very vulnerable. Other side effects of Depo-Provera that can negatively impact body image include hair loss, delayed hair growth, acne, and rashes. Bone Loss: Over the long term Depo-Provera results in decreases in bone mineral density that can inhibit bone growth and substantially increase the risk for fractures and future osteoporosis. High rates of lactose intolerance and/or milk allergies among women of color mean that this calcium loss can have a much greater impact.8
Emotional Side Effects: The most serious side effects of Depo-Provera are depression and irritability. For young women depression can translate to loss of friendships, failure in school, disturbed eating and sleeping patterns, substance abuse, and even suicide attempts. Chronic irritability can also increase the likelihood of anti-social behavior and destabilize relationships with family and other sources of emotional support. Other Side Effects: Other side effects of Depo-Provera include menstrual irregularity, breakthrough bleeding, increased nervousness, headaches, backaches, painful breasts, nausea, dizziness, weakness and chronic fatigue. Although these side effects are considered by most physicians (and the Upjohn Company) to be minor, it is difficult to imagine living normally while experiencing them. Although so far studies are inconclusive, there is also concern that Depo-Provera may increase the risk of breast cancer.
The Implications of Depo-Provera for HIV Infection One of the major disadvantages of Depo-Provera as a form of contraception is that unlike condoms, it does not prevent the transmission of sexually transmitted diseases and HIV. Time Magazine goes so far as to promote Depo-Provera as a condom substitute--"unlike condoms, Depo-Provera is a set it and forget it birth control".9 Dr. Anita Nelson, the medical director of a Los Angeles clinic serving mostly indigent Latina women, notes "[Depo-Provera] has soared from being nothing to now being the second most popular method in my clinic, surpassing condoms".10
While clear links between HIV transmission and Depo-Provera use have not been established, preliminary studies on female rhesus monkeys receiving progesterone (the main hormone in Depo-Provera) found them eight times more likely to contract SIV (a monkey version of AIDS) than a group not given progesterone.11 In these studies, it appeared that the progesterone significantly thinned vaginal linings and made it easier for SIV to enter the body.
In a 1998 report, the Center for Disease Control (CDC) notes a sharp increase in young people (ages 13-24) becoming infected with HIV. The CDC recommends "targeted prevention efforts to reach those in greatest need.young African American and Hispanic men and women at risk through sexual.behaviors".12 These groups are precisely the groups most likely to use Depo-Provera. If further studies establish increased rates of HIV transmission in conjunction with progesterone use, the implications for these groups is enormous.
Depo-Provera as a Population Control Device Depo-Provera has been used as a population control method in the Third World for over two decades. Now in the United States, it is being viewed as the magic bullet to reduce teen pregnancy rates (primarily among women of color).Under a heading which cheers "A Boost for the Shot," The Baltimore Sun credits Depo-Provera with cutting teen pregnancy in Baltimore and notes that "the shot is most popular among urban teens"(my emphasis).13 The 20% decline in teenage African American pregnancies and the four decade low in African American women's fertility rates (along with the unspoken but implicit suggestion that Depo-Provera can reduce non-white pregnancy) are touted internationally as a model for other countries to examine. In an article in the London Sunday Times, Dr. Anne Szarewski is quite blunt about encouraging Depo-Provera use
among low-income women, stating, "Doctors feel uncomfortable saying it's the lower classes taking it but it does seem to suit those who are less educated".14
Despite the statistics and hype, preliminary studies indicate that Depo-Provera may not be so popular in the long-term. In one study, a mere 31.5% of the subjects continued to use Depo-Provera after a year. Researchers noted similar findings in other studies (27% and 34% respectively).15 Ironically, these studies were based in inner-city clinics with the majority of Depo-Provera users being Latina or African American (precisely the groups that are most targeted for teen pregnancy reduction via Depo-Provera) and all concluded that Depo-Provera does not function as a long-term method for most inner-city adolescents.
Depo-Provera may prevent pregnancy, but it does not take into account the social factors that surround teen pregnancy or question why teen pregnancy is more prevalent in the social groups who benefit least from new economic opportunities for women. Anne Furedi of the Pregnancy Advisory Service succinctly notes that most young girls who get pregnant never even make it through the door of a family planning clinic. "The problem isn't specifically an issue of access or the type of contraceptive. For a whole range of reasons many people are not highly motivated to avoid pregnancy. Some even desire it".16 This is powerfully echoed in a 1997 US survey of teen women where more than 90% listed that having self-respect and being satisfied with life are the crucial factors in preventing pregnancy. 17
Truly addressing the issue of teen pregnancy requires removing the focus from injectable contraception to answers for the difficult questions about young women's lack of self-respect and dissatisfaction with life. Meanwhile Depo-Provera will continue to be used as a medical "bait and switch" to distract us from reality.
Sara Littlecrow-Russell is a single mother of two, a former welfare recipient, a domestic violence survivor, and a graduate of Hampshire College. Her activism is centered around Native American women's healthcare, welfare rights, prison reform, and domestic violence in marginalized communities. She is a published poet and a law student at Northeastern Law School.
1. The Columbus Dispatch July 9, 1997 Business Section, p.2F.
2. Medical Advertising News May 1997, p.76.
3. PR Newswire Association , Upjohn Increases Availability of Depo-Provera to Title X Clinics Financial News Section, Kalamazoo MI--November 8, 1994.
4. Staff, Contraceptives; City right to OK money for dispensation of drug The Houston Chronicle January 31, 1998 Sec. A p.36.
5. Lawrence, J. Herald Focus: Health; The safe (and secret) option; Injection a popular choice for birth control The Boston Herald November 18, 1998.
6. FDA got 131,000 complaints about Rxs and OTCs Drug Topics February 17, 1997 p.08.
7. Goldman, Erik Weight Gain in Depo-Provera a Problem for Teens Family Practice News May 15, 1999 v29 i10 p.42.
8. Ms. Editors"Is Depo-Provera Really Safe?" Ms. Magazine January/February 1993 pps.72-3.
9. Kluger, J. The Hot Shot Time October 26,1998 p.69 (1).
10. Whitemire, R. Shot may be contributing to fewer births among teens. Low-income women favor Depo-Provera The Courier-Journal (Louisville, KY) November 3, 1996 p.9A.
11. Marx, P., Spira, A., Gettie, A., Dailey, P., Veazey, R., Lackner, A., Mahoney, C., Miller, C., Claypool, L., Ho, D., & Alexander, N. Progesterone Implants Enhance SIV Vaginal Transmission & Early Virus Load Nature Medicine Vol.2 No.10 October 1996.
12. Center for Disease Control, Trends in the HIV & AIDS Epidemic 1998 CDC Reports-Department of Health And Human Services, 1998 p.3.
13. Kennedy, M. A Boost for the Shot The Baltimore Sun February 21, 1999 p.9N.
14. Williams, A. & Rhodes, T. Contraceptive jab cuts teen pregnancies Sunday Times (London) October 18, 1998 Sec: Home News.
15. Lim, S., Rieder, J., Coupey, S., Bijur, P. Depot Medroxyprogesterone Acetate Use in inner-city, Minority Adolescents: Continuation Rates and Characteristics of Long-term Users Archives of Pediatrics & Adolescent Medicine October 1999 v153 i10 p.1068.
16. Forna, A. A bitter pill; Promoting a particular contraceptive can dramatically cut teen pregnancy rates--but at what cost? The Guardian (London) Sec. Guardian Features October 20, 1998 p.7.
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