Critical Condition

Depo Provera: What the NYT Did Not See Fit to Print

The New York Times recently gave front-page, above-the-fold treatment to an article by Pam Belluck concerning the doubled risk of HIV acquisition among couples using the injectable contraceptive Depo Provera. In less than a month, the story has generated over 4 million mentions online, many of which cite concerns about the drug, but none (that I read) giving the whole ugly truth about Depo Provera. A summary of Depo’s shortcomings is offered below, but first let’s turn to the question of why the new study has attracted so much interest.

One reason for the high level of publicity and counter-spin following Belluck’s article is that the study she describes undercuts a major reason given for including all FDA-approved contraceptives under “preventive services” in the Affordable Care Act: to eliminate the cost barrier for women who otherwise would use more effective but very expensive long-acting reversible contraceptives (referred to as “LARCs” in the literature). If the advantage of the more effective LARCs is hugely offset by the awful health risks they pose, then why would anyone encourage a switch to their use?

Planned Parenthood and manufacturers of contraceptives have hundreds of millions of reasons to encourage the switch: their huge windfall from taxpayer-funded LARC will help offset the pharmaceuticals’ settlements and liability judgments due to deaths and serious adverse events associated with the use of their products.

How much money are we talking about? Instead of handing out cheap condoms and cheap, government-subsidized birth-control pills, Planned Parenthood stands to profit handsomely from the LARCs. Its website puts the cost of Implanon (including insertion) at $400–600, and of an IUD (with insertion) at $500–$1,000. This is almost as lucrative as performing a first-trimester abortions! Depo looks like a comparative bargain at $300–400 a year, however, office exams when getting the quarterly injections can quickly run the price up.

But don’t even think about switching to Depo or other types of LARC until you’ve heard the rest of the story. There was much that the New York Times did not find fit to print.

The very first words of Belluck’s article are “The most popular contraceptive for women in eastern and southern Africa.” This could lead one to think that the doubled risk of acquiring HIV must be offset by fabulous benefits inherent in Depo, to make it so hugely popular. Not so.

Depo Provera is popular in much the same way that chlamydia is “popular” on college campuses — it is widespread. In eastern and southern Africa, 12 million women use Depo, equal to 6 percent of all women of reproductive age, but only because Western suppliers of “reproductive health care” to the world’s poorer nations are foisting it on them, as it doesn’t require remembering to take a pill every day. One just shows up every three months for a shot.

In the U.S., where women have more contraceptive choices, there are only 1.2 million users (about 3.2 percent of reproductive age women), but the 3.2 percent usage figure is a misleading measure of contraceptive “choice.” The level of use is a high 20 percent among sexually active teenagers, who are easily talked into getting Depo shots instead of pills so their parents won’t discover a telltale pill pack lying around. And many Depo users in the United States discontinue the shots fairly quickly.

For example, a two-year study of over 5,000 women receiving Depo injections at Planned Parenthood of the Rocky Mountains reported: “Of the 5,178 women who received an initial injection, only 57% returned for a second administration; [another third dropped out after two shots]. . . . The overall one-year continuation rate was 23%.

The main reason women gave for not returning for subsequent injections was “difficulty tolerating side effects.”

Belluck did not point out that the study she summarized — R. Heffron et al., “Use of Hormonal Contraceptives and Risk of HIV-1 Transmission: a Prospective Cohort Study” — is but the last in a very long line of studies finding an increased risk of HIV and/or STD acquisition among those using hormonal contraceptives, and not just Depo.

The Heffron study describes plausible reasons given in the scientific literature explaining why hormonal contraceptives would actually increase women’s risk of becoming infected: “Clinical and laboratory studies have suggested possible mechanisms by which hormonal contraception could influence HIV-1 susceptibility and infectiousness including changes to vaginal structure, cytokine regulation, CCR5 expression, and cervicovaginal HIV-1 shedding” (emphasis added).

Some more ugly truths about Depo:

Returning to the 77 percent of women in Planned Parenthood’s study who discontinued Depo in the first year, their decision to quit may have had little to do with the risk of acquiring HIV and a lot to do (as they reported) with some nasty side effects or from recent FDA warnings, for example:


Women who use Depo-Provera Contraceptive Injection may lose significant bone mineral density. Bone loss is greater with increasing duration of use and may not be completely reversible. 

Depo-Provera Contraceptive Injection should not be used as a long-term birth control method (i.e., longer than 2 years).

Other warnings and precautions include the following:

Serious thrombotic events (blood clots), which can lead to cardiac arrest and stroke. Here’s a helpful tip for doctors: “Do not readminister Depo-Provera CI pending examination if there is a sudden partial or complete loss of vision.”

Breast cancer: Hormone sensitive breast cancers (which often strike younger women) occur twice as often in women under 35 who have used Depo in the previous four years. After discontinuation, the additional risk diminishes over time.

Ectopic pregnancy: Women who become pregnant while using Depo have an increased risk of a potentially life-threatening ectopic pregnancy.

Depression, irritability, and mood swings are frequent complaints of women discussing their reactions to Depo online, but the drug label does not provide statistics on frequency in actual use (post-trials) other than noting these may occur.

Bleeding irregularities” are described on the drug label and include “irregular or unpredictable bleeding or spotting, prolonged spotting or bleeding, and heavy bleeding.” By the twelfth month of use, 55 percent of women had stopped menstruating entirely.

Excessive weight gain (as well as fluid retention and bloating) are factors women often cite for discontinuing Depo use. In clinical trials, almost one in four women gained over 10 pounds in 24 months.

The list of post-marketing adverse reactions is too long to repeat in its entirety. Here are some highlights:

Cardiovascular — syncope, tachycardia, thrombophlebitis, deep vein thrombosis, pulmonary embolus

Digestive — changes in appetite, gastrointestinal disturbances, jaundice, excessive thirst

Hematologic — anemia, blood dyscrasia

Musculoskeletal — osteoporosis

Nervous — paralysis, facial palsy, paresthesia, drowsiness

Skin and appendages — hirsutism, excessive sweating and body odor, dry skin, scleroderma

Urogenital — cervical cancer, breast cancer, lack of return to fertility, unexpected pregnancy, prevention of lactation, breast lumps, nipple bleeding or milky discharge

In light of all this, even when it’s “free” under the Affordable Care Act, Depo Provera does not look like much of a bargain. But Depo has one advantage over some other contraceptives — the Ortho Evra patch and NuvaRing, for example. Depo’s awful side effects usually get women off Depo before irreversible harm occurs. Not so with the patch and the vaginal ring.            

About 130 deaths have been linked to the patch, and over 2,400 women have claimed that the patch caused them to have blood clots that resulted in heart attack, stroke or pulmonary embolism. The doubled risk of these events has resulted in settlements totaling over $68 million. NuvaRing has caused only 40 known deaths so far (per the FDA database), but the manufacturer is facing 730 lawsuits for blood clot-related injuries and deaths.

The sobering risks and side effects of every contraceptive drug and device are described on its drug label, posted on the FDA website. Learn the facts before you become the victim of a contraceptive-related injury or death.


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