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Contraception, evidence based medicine

Does depo-provera cause depression? Or why we need real medical journalists.

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.


10 thoughts on “Does depo-provera cause depression? Or why we need real medical journalists.

  1. Interesting read, very well-collated. I’m glad to read your conclusion, as I’ve been on high-dose oral provera for 4 years and I don’t want that to have affected my mental health (I still think there was a link between it and my extreme anxiety levels when I first started it, but it improved after a few months/when I reduced the dose).

    Incidentally, I think the Mirena monograph won’t change. Mirena comes off patent in 2 years, and they’re hoping to bring out a new IUD specifically for primiparous women. (It is stressed that this is not a mini-Mirena). But they’re therefore not going to licence Mirena, which is about to be off-patent and therefore available to any manufacturer, for primips when the new IUD specifically for primips will have its own 25 year patent.

    Personally I’m holding out for the new one as I think it could be quite good for me… Not heard anything about it in the UK so far.

    (Yes, this is inside info as I’m a former Pharma employee, but it’s nothing someone can’t find online if you google hard enough)

    Posted by TTBA(v)JD | August 10, 2013, 10:18 am
    • The Mirena EU monographs and patient information leaflets are different to those for the Mirena US.

      The FDA refused to grant a license to Bayer if the govt-mandated scaremongering about nullips wasn’t added.

      Posted by neverdefiled | August 11, 2013, 3:54 pm
  2. I’ve been on dep provera for
    about 3 years. I’ve gotten checked for the bone density and showing signs of osteoporosis in my lower sign. prescribed vitamin D and calcium… what bothers me is, it does cause some type of mood swings. I’m up and I’m down, up and down. I get headaches before the next shot is due and it’s weird not having a period… it doesn’t feel right like my body knows. I have anxiety more than ever. I’ve always been the type to control
    my “moods” even with the stresses of life, but lately it’s getting worse. I have good days and I have really really bad days. some days I’d rather sleep and do nothing. I have an almost 3 year old and I want to be stronger for her! and I take
    a lot out on my fiancé. I want my old fun loving self back! next shot appt will be the last. hoping to switch to something where I can be me again. I honestly believe it affects everyone differently…

    Posted by Sm | June 30, 2014, 3:41 pm
  3. Years ago when oral contraceptives became common I heard rumours that some women became depressed, but the theory suggested was psychological. That the women were in conflict. They used contraception because they couldn ‘t afford pregnancy but really wanted a child. It was the certitude of not getting pregnant that caused depression.
    I used depo for years and wished I’d known about it earlier. I didn’t want children so total peace of mind, you virtually don’t have to think of contraception except 4 times a year, no periods and no mood swings.
    Some women complained to me that they wouldn’t use oral contraceptives nor depo because it took away their sex drive. That didn’t bother me as I never had one, but I wonder if that would make teenage girls stroppy, or they are just stroppy anyway.

    Posted by prayerwarriorpsychicnot | September 9, 2014, 12:15 pm
  4. This looks like a relatively old thread, but thought I would post anyway. I’ve been an RN for over 10 years, and in my early 20’s I had this injection for roughly a year with little to no side-effects. As I am into my 78th day (that’s right – I’m actually counting the days) I can say, hand on my heart, irrespective of ‘scientific research’, that this is the worst contraceptive I have ever used. I acknowledge we are all different; our cycles and bodies change all the time. From a professional woman working and studying full-time, I am now just a shell of a person, barely keeping my marriage together – day 2: Cheerio, sex drive – to spending majority of my days sleeping. We have done the research, recounted the days back. This is not the same fun-loving, outgoing, compassionate, personable person that lived here 78 days ago. Instead I am a monster. No history of depression, drug or alcohol abuse. Just a shell of a human being waiting and praying to a God I don’t even believe in, that I will come back. This all sounds very melodramatic, and I’ve been one of the unlucky ones to have virtually EVERY side-effect this drug can have, but I wouldn’t let my worst enemy have this injection, just on the off-chance they experience any of these side-effects to this extreme. I would give anything for my life back. I know this is rare; I am not discouraging people from taking the precautions they need for planned parenthood, but be informed and know the risks.

    Posted by NeverAgain | September 22, 2014, 9:20 pm
    • I took this same shot in February of this year (before marriage in march) and currently goimg through the exact feelings you have. I was reading this and thinking I wrote this myself (except the not believe in God because I am a Christian ).

      I truly wished I had never ever taken the shot either….

      Posted by Sha | August 14, 2016, 7:44 am
  5. Best thing for ME ever!!
    Ok so again every medication effects everybody differently. Woman need to remember that most any prescription birth control has a hormonal component. you mess with your hormones and depending on your body / system or chemistry your hormones can change your moods.
    My personal experience is
    As a teen I never regulated moods or periods. 17-20 I tried different oral “pills”, I could not remember to take them on a regular basis. Along came the “Shot”. I was on – mostly on- Depo from 20 to 28 would occasionally take 3-6 months off.

    I would randomly get my period for 2-3days -2 or 3 times a year -usually on when super stressed. Which while inconvient and generally annoying I could deal with that.
    at 28 I got off of depo and got sterilized – essure coils implanted in the fallopian tubes

    It 2 years for the depo to totally leave my system so for 3 years 30- 33 I have been on more of an emotional roller coaster then most middle schoolers! think becoming a woman sucks try it at 30!

    Everything the 2 horror stories above state is how I have been off of depo. But my moods were AMAZING when on depo. I don’t mean High and giddy but “normal” balanced and out of the way!!

    Now full disclosure I have had mental health issues all my life. Physical, emotional and sexual abuse as a child and most of my adult life as a female mechanic in the military. . .

    I had tried many different treatments medication, behavioral and therapy but nothing besides depo has shown any significant change. Significantly better with -able to function and significantly worse off – a shell of a person.

    I was forced off of depo because the providers I saw were more concerned with the possible bone loss in connection to the “black box warning” – I asked then begged to have a density test. I wanted to know what my actual risk but was told that even though the black box warning was their concern that the test was contraindicated and proven inconclusive in relation to the long term onset of osteoporosis.

    I chose serialization because I couldn’t get pregnant and couldn’t ensure access to on going contraceptive that worked for me. Please please provider or otherwise don’t limit or eliminate care or treatment based on anything but the individual patient being or receiving treatments specific needs or established response to depo.

    Last note veterinarians routinely dose mares with depo to even out their attitude if it works the mare stays on it if it doesn’t they take her off of it!!

    Posted by LivinLifesDream | April 9, 2017, 1:17 am


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