An epidemiological review of the injectable contraceptive Depo-Provera. C Sathyamala. Medico Friend Circle, Forum For Woman’s Health, Mumbai, 2000. pp. 160, Rs 100.

Long-acting injectable hormonal contraceptives have been the subject of much controversy. Health activists have opposed them while most doctors and officials have supported them. The arguments made in this book by a feminist epidemiologist and health advocate are based on a critical review of about 200 scientific papers and monographs on Depo-Provera, or Depot Medroxy Progesterone Acetate (DMPA).

DMPA has been touted as a highly effective contraceptive. But the book points out that in field conditions, its use-effectiveness in low. In one study,40% of women got their first injection at the wrong time of their menstrual cycle. Almost 30% discontinued injectable contraceptives within a year.

DMPA causes significant menstrual disturbances. The pro-DMPA lobby tends to belittle the problem. The book points out that menstrual disturbances are not a minor issue for women and they are often the reason for discontinuation.

Some commentators discount the significance of heavy bleeding, arguing that haemoglobin levels are not lower amongst DMPA users. Sathyamala notes that long-acting injectable contraceptives lead to a fall in serum ferritin levels even without lower haemoglobin levels, and are responsible for some symptoms of anaemia such as fatigue.

DMPA causes amenorrhoea – for 55% of women within a year of use. DMPA protagonists consider this a beneficial side-effect, improving women’s haemoglobin levels. However, the author notes that haemoglobin levels are not higher amongst DMPA users. Second, most Indian women find amenorrhoea in the absence of pregnancy unacceptable. Third, such amenorrhoea is due to ovarian and endometrial atrophy which may be irreversible. Overall, menstrual disturbances are significant both subjectively and medically.

A survey found women complaining of a decrease in libido, vaginal dryness, night sweats, hot flushes following the use of DMPA. loss of libido for women is considered a minor sideeffect by the health care system -even as it discounts DMPA as a male contraceptive because it reduces libido in men.

The book quotes a number of studies, some of which clearly show that DMPA induces osteoporosis. A substantial proportion of Indian women already suffer from calcium deficiency.

A key controversy has centred around DMPA and the risk of breast cancer. Findings of toxicological studies were the basis of the US Public Board of Inquiry decision, in 1984, that DMPA should not be approved for contraceptive use there. However, in 1991, a WHO multinational case-control study on the risk of breast, cervical, endometrial and liver cancers due to DMPA concluded that it did not enhance the overall risk of malignancy. The US FDA approved DMPA as a contraceptive, followed by the Drugs Controller General of India. The author challenges the study’s design and conduct, and therefore the scientific validity of its conclusions.

The author quotes studies that DMPA increases the risk of mutagenicity and teratogenicity by five to 10 times. It may be argued that birth defects occur only after failure of contraception and are therefore a remote possibility. First, such a high relative risk for birth defects is unacceptable. Second, the drug and its metabolites circulate in the blood for up to 200 days. Women who discontinue DMPA may become pregnant within six months, exposing their foetuses to DMPA. Under field conditions, women may get DMPA even when pregnant.

Some of the author’s points may be less conclusive. There is limited evidence of the drug’s effect on breast-feeding infants. And while DMPA delays return of fertility after discontinuation there is no evidence of irreversible infertility.

However, overall the book presents a solid epidemiological critique of DMPA as a contraceptive. It demonstrates that leading gynaecologists are off the mark in their assessment of safety of DMPA. Worse, they favoured DMPA despite formidable evidence against it. WHO and US FDA approval is presumably under the pressure of the population control lobby.

The book was researched and written without funding. The printing was supported by donations from well wishers, and members of the two publishing organisations. Overall, this is a product of the author’s and a small group’s determination to expose the irrationality of DMPA as a contraceptive. It is a must for anybody interested in women’s health issues.