Recently, I’ve been contacted by a few journalists inquiring about the link between hormonal contraception, specifically depo-provera, and mood. Some have asked excellent questions about medical evidence, position statements, and my experience as an OB/GYN. However, the line of questioning from some seemed designed to support a specific narrative regarding mood with leading questions such as, “Depo-provera causes severe, profound depression, doesn’t it?” When the conclusion has been reached before I’ve even opened my mouth then the interview is just not me.
And then I thought, well, I should just write the article that I want women to read, after all that’s the purpose of this little blog. For the record, I have no stake in the contraception business except A) evidence based medicine and B) the desire for all women to have access to the safest, most effective contraceptive method that works best for them.
Depo-provera is an injectable contraceptive that is given every 12 weeks. It is a progestin-only method so can be used when estrogen, which is in the majority of birth control pills, is contraindicated. It is highly effective with a failure rate of 0.3% over a year if used perfectly (i.e. the injection is given every 12 weeks) and a “real world” pregnancy rate over a year of 3% because people don’t always get their injections on time. Because depo-provera doesn’t require remembering every day it is often favored by adolescents and women who have difficulty with a daily method.
There are a lot of depo-provera “horror stories,” but I hear horror stories about every single medicine I have ever recommended or prescribed. I’m not sure I hear more about depo-provera compared to anything else, but that doesn’t qualify as evidence. Neither does chat room conversations, although recently I saw that referenced as “evidence” in an article about contraception safety. People do take medications and bad things do happen, but that does not imply cause and effect. That is why we need science.
Looking at the CHOICE study (a large, high quality, prospective study) we know that women are overall about as happy with depo-provera as they are with the birth control pill. When the method of contraception is free with no barrier to access 55% of women who chose the pill are still taking it and 56% who chose depo-provera are still using it at one year. So, clearly depo-provera is not a universal horror story.
The product monograph for depo-provera states, “Monitor patients who have a history of depression and do not readminister Depo-Provera CI if depression recurs.” It also indicates that 1.5% of women reported depression as an adverse reaction, but this data is NOT from a study comparing depo-provera to non-hormonal methods, such as a copper IUD or condoms, so it is not possible to say from this data that depo-provera causes depression. Product monographs often contain all kinds of legal mumbo jumbo based more on urban medical myths than anything else. We have known for years that the intrauterine device (IUD) does NOT cause infertility and are safe for women who have never had a baby, but it wasn’t until 2005 that the product monograph for the copper IUD removed the requisite for having one or more children and the product monograph for a Mirena IUD still indicates that women should have at least one child.
So what’s the real evidence for depo-provera and depression?
The US Medical Eligibility Criteria for hormonal contraception indicates that depo-provera is category 1 for depression, meaning there is no restriction for the use of this contraceptive method with depression, and the monograph specifically states that progestin only contraceptives (like depo-provera) do not “increase depressive symptoms in women.”
There are several high quality prospective studies of adult women and adolescents that indicate no increased risk of depression or adverse mood changes and a smaller retrospective study indicates that there is no link between depo-provera and post-partum depression
While there are a few studies, prospective and cross-sectional, that suggest a higher incidence of depression among women who use a progestin only method like depo-provera or the progestin only pill, these studies must be considered with a highly critical eye as they don’t address confounders (other factors that could influence depression, such as irregular bleeding from depo-provera, finances, or medical history) and/or were not designed or powered to draw conclusions about cause and effect. These studies therefore cannot refute the higher quality evidence.
One diary study indicated a higher incidence of negative mood in adolescent depo-provera users compared with the pill, but as there was absolutely no demographic data or medical data that I could find on the subjects, so zero attention to confounders. I can’t say this paper contributes to the body of knowledge on anything (from a quality standpoint it isn’t much better than a chat room), however, It does lend credence to my belief that one’s inability to get one’s research published is limited only by the number of times one is willing to hit the send button.
Misinformation about depo-provera and mood is rife, even among doctors. In one study from 2007, 77% of health care professionals believed that depo-provera caused mood changes. Journalists need to be especially careful about who they interview, cross-reference stats, and specifically mention when something is opinion and if that opinion is supported by evidence.
The majority of people turn to the Internet for medical information and so medical journalists and even bloggers play an indirect but vital role in health care. Knowledge is power, but only when the information is accurate. We have seen the effect of spreading misinformation about vaccines.
A significant body of literature says there is no medical evidence to suggest that depo-provera causes or worsens depression. Misleading information is disempowering so contraceptive scares are not only the exact opposite of feminism, but potentially dangerous.