Time to Take a Critical Look at Depo-Provera


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 anyway. 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.

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.

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.

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).

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.

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. 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". 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.

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". 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".

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. 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). 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".

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). 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". 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.

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.