It’s been exactly 30
months since I last blogged. I joined school for my specialization and this
being my first time in a public Kenyan university, I wasn’t certain how the
idea of blogging would be perceived; my original plan was to remain unnoticed
and to keep a low-profile as much as possible. I guess I had so many myths
running through my mind about treatment of students in Kenyan Universities;
that you are there to be seen and not heard - I later learned that all that was
not true; no teacher would punish their student for wanting to disseminate
knowledge and for exploring their talents. I also had a total change in setting
from rural Meru where I experienced firsthand unique situations in a rural
setting which was more or less a Primary Health Care set-up where I was the
first contact with a diverse pool of patients. In the 30 months I underwent
self-discovery, a lot of growing up, understanding my new group of friends and
acquaintances; had a slight brush with depression at some point and generally
life happened. I decided to wait for the writing bug to attack me naturally and
spontaneously. I tried writing at some point last year but the write-up turned
out so plastic and therefore I kept a draft unpublished copy.
One week back, a
relative approached me and wanted a quick prescription for her usual
‘Depo’contraception injection which she could easily get from a local Chemist
without having to queue at a hospital or clinic. I got into doctor-mode and
asked her if she was aware that there were better more reliable methods of
contraception. She unleashed all these myths about the methods I was advising
her about and even pulled a ‘IUCD is Haram in Islam’ statement. What worried me
more was that she had used injectable progestin for more than 24 months
straight and was already exhibiting some of the side-effects associated with
its prolonged use.
DISCLAIMER : For purpose
of this blog post, we will not use Depo or Depo-Provera brand name ,
we will use the chemical name of 3monthly injectable progestin
- Depot Medroxyprogesterone Acetate (DMPA). This post is not about a
brand but the chemical components of the mentioned drugs.
DMPA is among many
progestin only contraceptives. This group of contraception contains an analogue
of the hormone progesterone; this is in comparison to combined contraceptive
methods that contain derivative of both progesterone and estrogen in
combination (will write about combined contraceptive methods in subsequent blog
posts). Other progestin only contraceptive methods include the mini-pill that
is taken daily especially in breastfeeding women, implants such as Implanon and
Jadelle (implants are more reliable methods) and the progestin-containing
intra-uterine devices - Mirena (very reliable!!!).
DMPA is an injectable
method that is given every 3 months . It is a very popular method in Kenya with
a use of 15%. It is administered as an intramuscular injection every 90 days;
we have other formulations that are given once every 2 months. Its actual mode
of action is by thickening cervical mucus making it non-penetrable to sperm and
by making the lining of the uterus unsuitable for implantation. It may have an
effect in suppressing ovulation (ovum release).
Most notable advantages
of DMPA include;
- · It is suitable for patients who may forget the daily pill
- · It is suitable for breastfeeding women (after 4 weeks of delivery) because it doesn’t suppress milk production
- · Is suitable for patients who may have contraindications to combined hormonal contraceptives use such as smokers, patients with hypertension, patients with risk of developing deep venous clots, patients with history or risk of (uterine)cancers.
- · It is reliable with a failure rate of only 7 % in typical use (perfect use has a failure rate of 0.3%)
- · Less likelihood of anemia especially in women who get decreased or total lack of menses
- · Confidentiality – there is no evidence that anyone can use to figure out that you are on dmpa. It is an injection; no rods that can be felt e.t.c. This is particularly important in clients whose spouses are opposed to contraceptives, or unmarried women wanting to avoid stigma
- · No complicated process during uptake ; no unnecessary vaginal examination
- · Has been shown to reduce the symptoms of endometriosis
- · It’s cheaper - although when you calculate the number of 3 monthly injections you will have in 3-5 years , implants are definitely cheaper in the long-run
Disadvantages include,
·
May cause irregular
menstrual bleeding – some women report heavy irregular bleeding, some women may
have light irregular spotting, while some women have a total lack of menses
especially after extended use
·
Prolonged ovulation
suppression may cause difficulty in return to fertility. Some cases may take up
to 18 months to 2 years to conceive after cessation of use of DMPA
·
Prolonged use for more
than 2 years continuously causes loss of bone mineral density (due to lowered
estrogen levels). This is particularly of concern in adolescents who should be
undergoing a growth spurt and in women approaching menopause (these women will
soon be in menopause which is associated with a further accelerated bone loss).
The return of normal bone density has been postulated to take around 5 years
after stoppage of use
·
Depression and mood
swings has been noted in women on prolonged DMPA use
·
Weight gain due to fluid
overload. Women who gain weight in the first 6 months of DMPA use are more
likely to have increased weight gain in the long-term
·
Headaches and migraines
·
Doesn’t protect against
STI or HIV (condom-up!!!!!)
·
Others – e.g bloating,
breast tenderness
Contraindications
include,
·
Pregnancy
(obviously!!!!)
·
Uterine bleeding of
unexplained cause
·
Breast cancer or
abnormal breast masses
·
Active or history of
thromboembolic disease e.g deep venous clots, strokes etc
·
Cerebrovascular disease
·
Significant liver
disease or liver masses
·
Not advisable in the
first 4 weeks of breastfeeding (highly controversial issue)
The main point I wanted
to drive home with this post is about the side-effects of DMPA on prolonged
use. Of main concern is the issue of decreased bone mineral density and
prolonged return to fertility with DMPA. There are definitely better progestin
methods such as Implanon (three year implant) and Jadelle (5 year implant).
Implants have the same
mode of action as DMPA because they have they have the same componenet ;
progesterone although in different formulations.
Advantages of Implants
over injectable progestins include;
·
Long term method hence
reliable (you only have to remember after the years have lapsed!!!)
·
Highly efficient family
planning method (failure rate less than 1%)
·
These are not associated
with decreased bone mineral density,
·
The return to fertility
is quicker, rapid. This is of importance in women who have not started their
families yet and in women who have not achieved their ideal family size
·
Although they may be
associated with decreased menstruation or total lack of menses, they are mostly
not associated with heavy bleeding
·
Have decreased prevalence
of weight gain, headaches, mood swings, acne
·
Can be inserted
immediately after delivery and doesn’t affect breastfeeding at any point
NB: Some of the effects
of DMPA like headache, breast tenderness etc may be felt with implants but to a
lesser intensity
I hope this read was
helpful in clearing things up. I tried to make it as layman’s as possible and
avoided jargon use. Feel free to email or comment below for any queries,
criticism, corrections or more information.
Next blog will be on
IUCDs and there will be a special segment on its use in Islam ; demystifying
any myths.
Have a blessed weekend!
Dr. K
