I owe you an apology.
Remember when you were perimenopausal (or as we called it, “going through menopause”)? Remember when you experienced hot flashes? And remember when you did, how we, your loving family, either 1) ignored 2) trivialized or 3) mocked you? Your hot flashes were a constant source of humor around our house and I recall you joining the fun.
But I am betting that while you were yukking it up, you felt lonely and misunderstood. I think you were just ‘being a good sport’ because what choice did you have?
You deserved better.
I admit that until recently, until I began hotflashing myself, I forgot about your transition and how we responded to it. But now that I am living with my own body thermostat on the fritz, I get it.
Now that I am consumed by cycles of heat and chill with no warning, I am having a major A HA ! moment. Now that I find myself waking in the night, my pillow wet, my face wetter, my sleep disrupted, I am time traveling to our sunny kitchen on 2nd Street—you: flapping your blouse, face flushed. Me: rolling my eyes.
I feel badly that I did not appreciate that this process is HARD. I feel badly that I made fun of you, thinking you just a silly old woman whining about something meaningless.
In short, I was a total brat.
Sure. I did not have models for compassionate support. It seems that the discourse of peri/menopausel has two nodes 1) joking 2) patholgizing—another distorted binary that fails to capture the complexity of human experience.
I know that today, struggling through my own perimenopause, I need some simple understanding. I am normal. This is normal. AND this normal reproductive transition can suck to high heaven.
While, we don’t need to stop the clocks or call the midwife, I would like some acknowledgement (minus the sexist aging jokes, please) that doesn’t make me (or my body) the butt of a joke.
You deserved better when it was your time, Mom, and I am so sorry you didn’t get it.
I was curious. If Cameron Diaz’s purpose in writing The Body Book: The Law of Hunger, the Science of Strength, and Other Ways to Love Your Amazing Body was empowerment, helping women to understand how their bodies work, would she include information about the menstrual cycle?
There was no way of knowing from her Jan. 22, 2014 radio interview with Jian Ghomeshi on CBC’s Q. I listened to Diaz explain that conversations she’d had and overheard in the last few years made it clear to her that women are completely confused about their bodies. She said this had her thinking, “Wow, that’s such a crazy thing that after so many years of living in your body that you actually don’t have an understanding of it.”
Then she revealed her intention in writing the book – to empower women to make “informed decisions about their nutrition and their physical activity.” Judging from this comment, the book’s subtitle, and the fact she did not mention menstruation during the interview, I wondered if the menstrual cycle would even be mentioned.
I sought out The Body Book at my local bookstore and quickly scanned the table of contents and index. I found myself smiling, thinking about Betty Dodson, author of Sex for One: The Joy of Selfloving, and how she revealed in Chapter 1 that whenever she gets a new sex book she “immediately” looks up “‘masturbation’ to see where the author really stands on sex.” Whenever I see a new book about women’s health I look up “menstruation” to see what the author really knows about the menstrual cycle. Turns out Diaz, and/or her co-author Sandra Bark, know both a lot and not so much.
In Chapter 21, Your Lady Body (the book’s introduction starts with the salutation Hello, Lady!), she presents a fairly accurate endocrinological description of the three phases of the menstrual cycle: follicular, ovulatory, luteal. So far so good. But then, in the last paragraph of the luteal phase section, comes the big, fat menstrual untruth, the implication that whether you use hormonal birth control or not, this is how your menstrual cycle unfolds. It’s an absolute falsehood, and one that many women in this age of burgeoning body literacy are sure to see through.
The last paragraph of this luteal phase description (page 182) is ridiculously misleading. If a woman’s birth control method is the pill, patch, ring, implant or (Depo-) Provera shot, the synthetic hormones each contains will shut down her normal menstrual cycle function. She most definitely will not experience a cycle with follicular, ovulatory and luteal phases. Hormonal contraception does not “protect” her eggs. She will not ovulate, therefore the egg will not die. She may have a “withdrawal bleed” but it is not a true period. This is the truth.
I can understand, possibly, why Diaz made this egregious implication. What were her choices? Open a can of worms? State categorically, as every description of menstrual cycle function should, that you don’t ovulate or experience a normal menstrural cycle while taking hormonal contraception? Maybe something like this?
Hey Lady! If you use hormonal birth control none of this fascinating menstrual information applies to you. Wish I could tell you what this means for your health and fitness but, sorry, that’s beyond my area of expertise.
If Diaz’s intention for this book is to empower women to better understand their bodies, then she failed when it comes to the menstrual cycle. I hope she’ll correct this big mistake in any future editions.
According to a recent piece in The Times, a reputable English newspaper, symptoms are demeaning AND feminine. More specifically, the article reports on the prostate cancer experiences of Sir Michael Parkinson, or “Parky,” a famous British talkshow host. Parkinson reveals his harrowing experience of getting prostate cancer treatment and its “grueling” side-effects. While the treatments worked, they apparently produced menopause-like symptoms (hot flushes and weight gain) that reminded him of “how women feel when they are going through menopause.” Parkinson is quoted directly as saying, “In a sense you become a woman. I’m getting fitted for a bra next week!” The reporter goes on to say “he’s joking but he’s also deadly serious.” The “menopausal” symptoms that Parkinson had during his prostate cancer treatments are also described as “demeaning” in the same paragraph.
Parkinson is a major public figure in the UK, with significant media influence. I’m certain that this article was read by many as a result, and it makes me wonder about the far-reaching impact of the negative characterizations made about both women and bodily symptoms in this article. When I read this article, I find the equation of symptoms and femininity problematic, for lots of health conditions that produce bodily changes and sensations are not only experienced by women. Experiencing a hot flush or hot flash, while often attributed to menopause, is not menopause-specific all of the time. You can have hot flushes from exercising hard, from the flu, from medications that treat a range of diseases, or when you’re embarrassed. You can have weight gain at midlife (or any time of life for that matter) for a variety of reasons unrelated to menopause. Both the equation of women with symptoms and the definitions of symptoms as negative and “demeaning” show exactly how little progress we have made in eradicating gendered ideologies that harm us. Women are equated with their bodies and seen as lesser than men because of this equation. Men are supposed to be able to rise above their bodily functions, signs, and symptoms and live the life of the mind. Thus, when men experience a symptom they must rid themselves of it because, oh, the horror, they might be “like women” if they have to pay attention to their bodies at all. Research studies show quite often that women are ignored by doctors when they report a long list of symptoms and are not given the treatments they need to ease those symptoms as much as men are, because doctors learn to assume that women are just overreacting. Symptoms are not real if reported by women, studies suggest. Yet, when men experience symptoms and report them they are treated for them more often, especially when they report things such as pain. I interviewed a woman once who told me that “symptoms are always negative” and I wonder if that is partially because of the equation of symptoms with femininity and women’s bodies.
I am certain that it was difficult for Parkinson to undergo treatments for his prostate cancer. I also know that hot flushes and weight gain are never comfortable for people, especially when they seem uncontrollable. BUT, when we go on to support the characterization of symptoms as “what women feel” and then in the next breath say that those symptoms are “demeaning,” we head right into reifying gender ideologies that harm every single one of us. Men should be able to notice changes in their bodies without feeling “feminine.” We should recognize bodily symptoms as part of both health and illness that everyone experiences. And women should not have to be defined only by the fact that they go through certain reproductive transitions that include symptoms. I know Parkinson is perhaps from a generation that might still be holding tightly to gender ideologies that do not make much sense for the contemporary world, but I hold the reporter responsible for some of the characterizations made in this article, too. It is 2014, and aren’t we supposed to be more progressive than this? Because you experience a hot flush you should be fitted for a bra? In the YouTube video that appears along with this post, Parkinson himself admits “men are silly about their health.” I’ll say. But comments reported in the recent Times article go way past being silly.
Questioning and quitting the pill are current hot topics, fueled in no small part by Holly Grigg-Spall’s recently released Sweetening the Pill Or How We Got Hooked on Hormonal Birth Control. Her book has drawn ample backlash, brilliantly addressed by re:Cycling blogger Elizabeth Kissling.
Adding to the media clamour was Ann Friedman’s New York Magazine online piece No Pill? No Prob. Meet the Pullout Generation which explores how and why women she knows are ditching hormones and depending on withdrawal and period tracking apps for birth control.
Both writers, along with Toronto freelancer Kate Carraway, recently discussed the topic Rebelling against the pill: ‘Pulling-Out’ of conventional birth control on CBC Radio-Canada’s The Current.
Listening to Grigg-Spall, Friedman, and Carraway discuss the pill rebellion affirms that while many young women are through with hormonal birth control, their transition off the pill, etc., is not without risk-taking and pushback.
Grigg-Spall nailed the pivotal point when she said “It’s a provider issue.”
The rise of the “pullout generation” is proof that sexual health-care providers and educators, among whom I count myself, have failed on two counts:
1) We’ve failed to address a key aspect of contraceptive use: how to transition successfully between method groups, in this case from hormonal to non-hormonal methods. We’d rather present the so-called “latest and greatest” hormonal methods and say – earnestly, pleadingly – try this! The CBC panelists provided strong anecdotal evidence that more and more women are having none of it.
2) We’ve failed to adequately acknowledge and serve women who can’t, won’t or don’t want to use hormonal methods. We are NOT providing across-the-board support and programs that include easy access to diaphragms or certified training in fertility awareness based methods (FABM), either onsite or through collaborative referral strategies.
For over 25 years I’ve advocated for increased access to information, support and services for women who want to use non-hormonal methods of birth control. It’s self-evident such services must include access to qualified instruction to learn FABM that have effectiveness rates over 99%. This is not to say there isn’t a place for withdrawal as an effective back-up. Check out this confessional how-to post by fertility awareness instructor Amy Sedgewick.
As Friedman said on The Current, women are intimidated by the idea of learning fertility awareness. I believe this is mostly because mainstream sexual health-care providers have never fully educated themselves about FABM or fully committed to presenting these methods as viable options to drugs and devises. Do they think that most women can’t or don’t want to learn fertility awareness skills? That would be like thinking most girls can’t or don’t want to learn to read.
As I’ve written elsewhere: “Fertility awareness, like riding a bicycle, is a life skill.”
If you can learn to swim, ski or snowboard, knit a sweater, read a balance sheet or master Adobe InDesign, you can learn to observe, chart and interpret your menstrual cycle events. We can all acquire body literacy.
Until sexual health educators and care providers develop programs to fully serve women who won’t use or want to stop using drugs and devises for birth control, we will continue failing to meet the growing “unmet need” for effective non-hormonal contraceptive methods.
The reign of hormonal birth control as the top-of-the-contraceptive-hierarchy gold standard appears to be coming to an end. The pullout generation represents just one thread in this transition. The questions is: Are sexual health educators and care providers paying attention and, if so, what are they going to do about it?
I had the privilege of writing the foreword for Holly Grigg-Spall’s recently published book Sweetening the Pill: Or How We Got Hooked on Hormonal Birth Control. It’s astounding to me that more than 30 years ago, before Holly was born, I was asking some of the same questions she explores in her book. I thought we’d have more answers by now, but one thing is certain: Holly’s book has prompted long-overdue discussion and debate about issues related to hormonal birth control. Below is my foreword to Sweetening the Pill.
In a letter dated March 22, 1980, I proposed to the editor of an American woman’s magazine that they consider my enclosed article: The Contraceptive Dilemma – A Subjective Appraisal of the Status of Birth Control.
“Recent articles (about birth control) deal almost exclusively with the basic pros, cons, and how-tos of the various contraceptives available – matter-of-fact discussions that reduce birth control to a mere pragmatic decision. If only that were the case.
Contraception, like the sexual interaction that necessitates it, involves our emotions as much as it does the facts. Yet the subjective, personal aspect of contraception is so often ignored. In this age of scientific research we are expected to (subjugate) our emotional reactions to significant probabilities, our anger to logic. Very real fears and earnest questions are dismissed as irrelevant….”
Although today I wouldn’t use the phrase “emotional reactions,” it’s hard to believe that three decades later, the status of birth control and women’s relationship to it has not much changed. Websites, not magazines, now host information about the basic pros, cons and how-tos of available birth control methods. And it is writers like Holly, half my age, who honour women’s real fears and ask earnest questions that are still being dismissed as mostly irrelevant.
Just as my personal story with the pill – including over a year of distressing post-pill amenorrhea – set me on a course of research and advocacy, so too has Holly’s personal experience. Sweetening the Pill explores and challenges the ways in which the pill and other drug-based contraceptives damage women’s health, threaten our autonomy and thwart body literacy. What we don’t know about our bodies helps pharmaceutical companies “sell” their contraceptive drugs, and keeps us “addicted” to them.
At some point between my first attempt at non-hormonal contraceptive advocacy and Holly’s exploration of how we’ve become hooked on hormonal birth control, something disturbing transpired. Prescribing the pill, or other forms of hormonal contraception, has become, in the minds of most health-care providers, the “standard of care” for being a girl. It is all too common to subjugate a girl’s menstrual cycle to synthetic hormones that superficially “regulate,” but actually suspend the maturation of her reproductive system. And for many girls, the use of hormonal contraception continues well into their 20s, without awareness of what might be or has been sacrificed.
There are many women like Holly who are fed up with hormonal birth control. I’ve met scores of them during my 30 years involvement within the mainstream pro-choice sexual and reproductive health community, the one that prides itself on inclusion and diversity. Yet I’ve been unsuccessful in my constant advocacy for this community to accommodate a more inclusive, diverse approach to contraception, to provide acknowledgement, support and services to women who cannot or do not want to use drug- or devised-based methods. We pay lip service to the idea, but the message we convey is: “You’re on your own.”
I’ve found enthusiasm in other realms for my menstrual cycle advocacy and my belief that many women want to, and can, learn to use non-hormonal methods effectively and confidently. I’ve found scientific evidence of the value of ovulation to women’s health and well-being.
I’ve read, met or worked with several of the sources included in this book. Many have devoted their careers to understanding women’s bodies and our relationships with our bodies in ways the medical mainstream typically ignores and barely comprehends. They have made contributions that help us imagine a different way of thinking about fertility, contraception and our menstrual cycles in relation to our sexual, reproductive and overall health.
The North American Menopause Society held its annual meeting Oct. 9 to 12. An article posted a few days earlier stated that hot flashes would be “extensively discussed” at the meeting because “temperature control is such a preoccupation for menopause.” There would be 13 presentations on low-dose paroxetine mesylate (brand name Brisdelle), “the first nonhormonal treatment for hot flashes to be approved by the US Food and Drug Administration.” A link was provided to an article about the FDA approval.
The article is titled “Brisdelle okayed as first nonhormonal Rx for hot flashes.” However, the content of the article states: “The first nonhormonal drug for hot flashes associated with menopause was approved by the US Food and Drug Administration (FDA) today despite an agency advisory committee having rejected it as too much risk for minimal benefit. …The FDA’s Advisory Committee for Reproductive Health Drugs voted 10 to 4 against recommending approval. …The FDA is not obliged to follow the advice of its advisory committees, but …it usually does.”
With regard to risks, the same article states: “Critics said the drug’s minimal superiority to a placebo did not outweigh the risk for suicide ideation and osteoporosis, 2 adverse events associated with paroxetine. …The drug’s label features a boxed warning about the increased risk for suicidality. The label also warns clinicians that paroxetine mesylate can reduce the effectiveness of the breast cancer drug tamoxifen if taken together, increase the risk for bleeding, and comes with the risk for serotonin syndrome.”
Risks might be worth it if they are unlikely and there is a large benefit. In testing paroxetine did better than placebo, so it was accurate to state that the medication had an effect. However, the absolute advantage of the medication compared to placebo was small. For example, at week 4 of the study, 60% of the women taking the medication reported relief but so did 48% of the women taking a placebo; at 12 weeks, 47.5% vs. 36.3%.
Some clinicians with patients with severe hot flashes, and some women themselves, have had the experience that serotonin reuptake inhibitors (the class of drugs that includes Brisdelle) have worked. The article on the FDA approval speculates on why the medication was approved: “In a news release, the agency seemed to explain why it overrode the recommendation of its advisory committee when it came to paroxetine mesylate. ‘There are a significant number of women who suffer from hot flashes associated with menopause and who cannot or do not want to use hormonal treatments,’ said Hylton Joffe, MD, director of the Division of Bone, Reproductive and Urologic Products in the FDA’s Center for Drug Evaluation and Research.”
For women with severe hot flashes, an effective treatment is needed. Yet, surely, a treatment with potential side effects should pass a high bar before being FDA approved.
My forthcoming book ‘Sweetening the Pill or How We Got Hooked on Hormonal Birth Control’ began to take shape on the pages of this blog and much of the process of its development was spurred on by the work of members of SMCR. As such, it seems only fitting, with the release date of September 7th soon here, to share for my post this month an excerpt and to say thank you for the support of this community. I hope to have added something of interest and value to this on-going conversation.
Women often discuss menstruation and birth as happening to them, rather than as part of them and their experience. Emily Martin remarks in ‘The Woman in the Body’ that women often see their self as separate to their body. Women’s central image is that “your body is something your self has to adjust to or cope with” and therefore, Martin concludes,“your body needs to be controlled by your self.”
Martin explores the idea that women did not fit into the structure of the jobs that were open to them in industrialized society. These jobs most often required monotony, routine and repetition. Although in reality no more suited to men than they were women, it was women that were judged as innately unable to succeed in such positions due on the constantly changing and supposedly unpredictable nature of their physical state.
As Martin states, “Women were perceived as malfunctioning and their hormones out of balance,” especially when experiencing PMS and menstruation, “rather than the organization of society and work perceived as in need of transformation to demand less constant discipline and productivity.”
The rigidity of society was forcefully imposed on women as it was on men. For all, both men and women, it is inhumane but it was women that were required to adapt in a more dramatic and overt way. Men are viewed as naturally given to the industrious and disciplined way of life demanded of them and the structure of society is built on these assumed capabilities.
If we admit that women do change through the month, that we do menstruate, experience PMS, have differing moods week to week, we fear that this admission will be used as justification for negative judgment.
Martin counters the feminist refrain of “biology is not destiny”; “I think the way out of this bind is to focus on women’s experiential statements – that they function differently during certain days. We could then perhaps hear these statements not as warnings of the flaws inside women that need to be fixed, but as insights into flaws in society that need to be addressed.”
The idea that men are otherwise unchanging is falsified. Men also experience hormonal changes with studies suggesting they experience a cycle daily that is equivalent to the monthly cycle of women as well as changes in hormone levels across their lifetimes.
Women’s “experiential statements” as Martin describes them are often silenced in the discourse surrounding hormonal contraceptives. It is a betrayal of the feminist cause to speak out with openness about the side effects of the pill.
When Yaz and Yasmin were released the marketing strategy co-opted the idea of word of mouth. In a commercial women were seen passing along the “secret” of these new drugs with their host of beneficial yet superficial side effects. Receiving messages of increased physical attractiveness as the result of a drug that many women were using anyway, only a different brand, increased the transference of this experience from one woman to the next.
In the face of such powerful manipulation, what place does a skillfully worded informational insert have in women’s decision making process? The time of the Nelson Pill Hearings was a very different to today.
Naomi Wolf mentions the pill briefly in ‘The Beauty Myth.’ She remarks that it was originally marketed as a drug to keep women “young, beautiful and sexy,” concepts parallel to those promoted by Bayer through its contemporary advertising. Wolf quotes, in the context of the beauty industry, John Galbraith, “Behavior that is essential for economic reasons is transformed into social virtue.”
On June 24, the Journal of the American Medical Association (JAMA) released a report on the Women’s Health Initiative Memory Study of Younger Women (WHIMSY) in the JAMA Network publication JAMA Internal Medicine.
This study is of particular interest because hormone therapy caused significant deficits in cognitive functioning in women aged 65 and older, as documented in the Women’s Health Initiative Memory Study (WHIMS). The “Timing Hypothesis” proposes that, despite the serious risks of hormone therapy demonstrated in the Women’s Health Initiative (WHI) research, therapy with conjugated equine estrogens can benefit women when it is started during the menopausal transition and in early menopause. Last year, a position paper endorsed by 14 medical societies made that claim (Stuenkel, et al, 2012).
Why would so many in the medical profession continue to prescribe hormone therapy, and to believe that hormone therapy is beneficial, in the face of powerful evidence that the risks of such therapy far outweigh the benefits? Probably several reasons:
1) Few other therapies are as effective in relieving women who suffer from distressing symptoms during and after the menopausal transition.
2) Animal and laboratory studies strongly support a positive role for estrogen in cognitive function.
3) The pharmaceutical industry wields tremendous power, and provides financial support to most of the medical societies and research studies in this area.
It is, as the authors state, “reassuring” that this latest WHIMSY study found neither increased risk nor increased benefit in cognitive assessments an average of 7 years after the study was halted, among the 1,272 participants in the WHI who were 50 to 55 years old when the hormonal therapy was started. However, the lack of cognitive benefit makes one wonder why women would want to risk the serious consequences associated with hormone therapy.
Advocates for women’s health must continue to challenge the ethical and scientific basis for medical practices that can potentially be harmful to women. We need to support research on the mechanisms underlying the effects of hormones on women’s bodies, but also on the sociopolitical forces influencing medical practice.
Stuenkel, Cynthia A., Margery L. S. Gass, JoAnn E. Manson, Rogerio A. Lobo, Lubna Pal, Robert W. Rebar, and Janet E. Hall. “A decade after the Women’s Health Initiative—the experts do agree.” Menopause: The Journal of the North American Menopause Society 19.8 (2012): 846–847.
Do women using the Mirena hormonal IUD have their period?
Does it suppress the hormone cycle for all women or just some?
How does it work to prevent pregnancy exactly?
It seems these questions can’t be answered even by the assumed experts. We are told the Mirena “partially” suppresses ovulation and that some women will bleed and some won’t bleed at all. Mostly we hear that the impact must be limited to the reproductive organs because the level of synthetic hormone used is so low.
In an article entitled ‘Mirena: The Other Side of the Story’, AAA Ewies, a consultant gynaecologist at a UK NHS hospital wrote, “The argument used that serum concentration of LNG is extremely low and that its influence on ovarian function is limited has been disputed recently by many investigators. Xiao et al. found that Mirena was associated with substantial systemic absorption of the synthetic progesterone and recorded levels equivalent to two synthetic progesterone-containing ‘minipills’ taken daily on a continuous basis. A study documented that 21% of Mirena users experienced progestogenic adverse effects. Wahab and Al-Azzawi reported that Mirena suppresses oestrogen production, inducing a clinical situation similar to a premature menopause in at least 50% of treated women”.
In an effort to cut through the confusion, Bayer Pharmaceuticals went ahead and released the Skyla hormonal IUD in February of this year. Skyla is smaller than the Mirena, lasts three instead of five years, but contains the same synthetic progesterone and is also 99% effective at preventing pregnancy.
It was interesting timing, considering the American Congress of Obstetricians and Gynecologists (ACOG) almost simultaneously released a recommendation that doctors provide the IUD (it didn’t specify if they meant the hormonal or copper device in the statement) as “first-line contraceptive options for sexually active adolescents”. Teens often struggle with heavier or painful periods and are far more likely to be offered the Skyla, which is said to lighten bleeding, than the Paragard copper IUD, which is thought to increase bleeding. Not to mention the Skyla costs significantly more, has a shorter span of use, and is backed by a Bayer’s marketing department. The Mirena has been advertised heavily since its release in 2001 and the aggressiveness of the campaign – with television commercials proclaiming Mirena would make a woman “look and feel great” – was reprimanded by the FDA.
As a consequence of this combination of the ACOG recommendation and the release of Skyla we have seen articles in recent weeks with headlines such as ‘Could New Skyla Contraception Help Women Reach For The Stars’ and yet more that worry over the lack of knowledge that is preventing doctors from providing the IUD to young women or preventing young women from asking for an IUD. There was a time when IUDs were only given to women who had already had children – in part because of concerns regarding the devices causing damage that led to infertility. The tone is always the same – why are they keeping this near-perfect sounding birth control choice from us? If it is an undercover marketing technique to get women riled up about their access to hormonal IUDs then that department of Bayer deserves a raise.
Some of the doctors may have not received the memo but others may be concerned about the mounting lawsuits regarding the serious physical side effects of the Mirena, or at least they should be. The production of Skyla appears to be a deliberate effort by Bayer to reach the teens and twenty-somethings market. Even Bitch magazine got in on the advertorial action last week linking through their website to a suspicious looking post that seemed much like a marketing placement. Most of the media coverage does not flag the difference between the hormonal IUD and the copper, blithely using the term “IUD” in the same way the phrase “birth control” is now synonymous with “hormonal birth control.”
Professor at the University of California at Riverside Chikako Takeshita outlines in her book, The Global Biopolitics of the IUD, the history of the IUD, from its coercive use in developing countries to its presentation as a convenient method for the modern woman in the US and Europe. “The ACOG recommendation and release of Skyla is clearly going to expand the market for these devices”, she states, “This normalizes the use of long-acting contraceptives. Such normalization makes the use of the devices a technological imperative. The idea is that if a solution, a technological fix, to the problem of unintended pregnancy exists then you must take it. It silences other ways to approach the problem. The IUD doesn’t fix the fundamental issue which is the lack of sex education for teenagers”.
Rather than seizing the ACOG recommendation as simply a victory in the war against the teen pregnancy “epidemic” we must look critically at the potential result. This may seem like the easy answer, but is it the right one?
Laura Wershler interviews Ask Jerilynn, clinician-scientist and endocrinologist
With 250 comments – and counting – to my year-old post Coming off Depo-Provera is a women’s worst nightmare (April 4, 2012) I thought it was time to revisit this topic.
That blog post has become a forum for women to share their negative experiences with stopping Depo-Provera (also called “the shot,” or Depo), the four-times-a-year contraceptive injection. (Commenters reporting positive experiences have been extremely rare.) Many women have experienced distressing effects either while taking Depo and/or after stopping it. They report that health-care professionals seem unable to explain their problems or to offer effective solutions. What is puzzling for many is why they are experiencing symptoms like sore breasts, heavy and ongoing bleeding (or not getting flow back at all), digestive problems, weight gain and mood issues when they stop Depo.
This post aims to briefly explain how Depo works to prevent pregnancy, its common side effects and, most importantly, why and what to do about adverse experiences when stopping it.
What follows is my interview with Dr. Jerilynn C. Prior, Society for Menstrual Cycle Research board member, professor of endocrinology at the University of British Columbia, and scientific director of the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) Section 1 explains how Depo-Provera works and what causes its side effects. Section 2 explains the symptoms women are experiencing after stopping the drug.
1) Taking Depo-Provera: How it works and established side effects
Laura Wershler (LW): Dr. Prior, what is Depo-Provera® and how does it prevent pregnancy?
Ask Jerilynn: The term, “depo” means a deposit or injection and Provera is a common brand name of the most frequently used synthetic progestin in North America, medroxyprogesterone acetate (MPA). Depo is a shot of MPA given every three months in the large dose of 150 mg. Depo prevents pregnancy by “drying up” the cervical mucus so sperm have trouble swimming, by thinning the endometrium (uterine lining) so a fertilized egg can’t implant and primarily by suppressing the hypothalamic and pituitary signals that coordinate the menstrual cycle. That means a woman’s own hormone levels become almost as low as in menopause, with very low progesterone and lowered estrogen levels.
LW: Could you explain the hormonal changes behind the several established side effects of Depo? Let’s start with bleeding issues including spotting, unpredictable or non-stop bleeding that can last for several months before, in most women, leading to amenorrhea (no menstrual period).
Ask Jerilynn: It is not entirely clear, but probably the initial unpredictable bleeding relates to how long it takes for this big hormone injection to suppress women’s own estrogen levels. The other reason is that where the endometrium has gotten thin it is more likely to break down and bleed. These unpredictable flow side-effects of Depo are something that women should expect and plan for since they occur in the early days of use for every woman. After the first year of Depo (depending on the age and weight of the woman) about a third of women will have no more bleeding.
LW: What about headaches and depression?
Ask Jerilynn: It is not clear why headaches increase on Depo—they tend not to be serious migraine headaches but are more stress type. Perhaps they are related to the higher stress hormones the body makes whenever estrogen levels drop. Unfortunately, headaches tend to increase over time, rather than getting better as the not-so-funny bleeding does.
The reasons for depression are mysterious to me but this is an important adverse effect. I believe that anyone who has previously had an episode of depression (whether diagnosed or not, but sufficient to interfere with life and work) should avoid Depo.
LW: Although there has been little discussion about bone health concerns on the previous blog post, I think we should address the fact that Depo causes bone loss. How does it do this?
The Huffington Post published a story last week titled “Last Menstrual Cycle Could Be Predicted With New Model”. The story stated that a research study had just been published about a new method for predicting the end of menstruation in which researchers developed a formula for using the levels of two hormones, estradiol and follicle stimulating hormone (abbreviated FSH), to make this estimate. This “new method for predicting a woman’s last menstrual cycle could have broader implications for menopausal women’s health”. Since “in the year leading up to the final menstrual period, women are met with faster bone loss and a greater risk of heart disease”, if the end of menstruation could be predicted, medical monitoring and interventions would become possibilities. The research was also reported as news on the medical website Medscape.
Research results are often reported as news stories, as though these results are facts. However, “dog bites man” and “man bites dog” are facts, but research results are not facts in the same way. They are “evidence” that most often must be evaluated, understood, and put into the context of many other studies. There could very well be disagreement about whether a study’s methods really did accurately make a point, or whether the conclusions the researchers drew from their work were justified. Sadly, it happens all too often that research does not make the point that the headlines claim.
Here, we have a study by a respected researcher at a major institution, UCLA, funded by a grant from the National Institutes of Health and other prestigious grantors. However, we do not have the information with which to understand what the researchers actually did. UCLA issued a press release which states that the study “suggests” a way to predict the final period. The Medscape article states that “A new model MAY [my emphasis] help physicians determine how far a woman is from her final menstrual period”.
Suggests? May? I have no idea what this means. As a researcher, I want to look at the published article to see what was actually done. However, the publisher does not make a free copy of the article available. Anyone who wants to look at the published article—a researcher or an informed consumer—would need to pay the publisher $37.00 to access this 20-page article for one day. Predicting the last menstrual period from hormone levels, which is what is claimed, is something other researchers have tried but failed to do, so how these researchers worked with the difficult problems is an important question.
Assume for a moment that the model was a big success, and it did predict the last menstrual period. The idea that this has important implications for women’s health is stated as though it were another fact. However, this is not a fact; this is a complicated and controversial area. Bone density does decrease in the years surrounding menopause, but professionals disagree about how big an effect this has on bone disease. For example, current guidelines recommend testing bone density beginning at age 65, 15 years after the average age of menopause, because this is when the fracture rate has significantly increased. Heart disease risk factors may increase on average in the years surrounding menopause, but professionals disagree about whether menopause is important compared with other factors associated with aging.
Assume for a moment that bone disease really is an important negative health consequence of menopause. Whether interventions would be found that must be started in the year or two before menopause is another speculation. Such interventions might be found or might not. Predicting the last menstrual period, even if the claim is valid that a method to do so has been found, is a long way from preventing disease.
The medical satirist Andrew Vickers wrote an article called “News On Cancer Drug Fails to Raise False Hopes”, which begins: “A recent article on a novel cancer therapy has rocked the newspaper industry by giving a balanced and cautious review of an early-phase trial”. Satirists make extreme statements to make a point. Media reports are often written to sound definite and to portray a study as really important. A cautious approach to medical news is to withhold judgment unless the methodology of the study is clear and the context of the study is understood.