Time to Take a Critical Look at Depo-Provera
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?
(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
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
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
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,
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
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.
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
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".
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
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
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.