Blog of the Society for Menstrual Cycle Research

Depo Provera and menstrual management

April 8th, 2014 by Holly Grigg-Spall

Melinda Gates speaking at the London Summit on Family Planning; Photograph courtesy Wikimedia Commons

A few weeks back I did an interview with Leslie Botha regarding the distribution of Depo Provera to women in developing countries. Recently Leslie shared with me an email she received from someone working in a family planning clinic in Karnataka, India. He described how he was providing the Depo Provera injection to women and finding that, after they stopped using it, they were not experiencing menstruation for up to nine months. He asked for advice – “what is the procedure to give them normal monthly menses….is there any medicine?”

I have written previously about one potential problem of providing women with Depo Provera – the possibility of continuous spotting and bleeding that would not only be distressing with no warning that this might happen and no medical support, but could also be difficult to navigate in a place with poor sanitation or with strong menstrual taboos. As women in developed countries are so very rarely counseled on side effects of hormonal methods of contraception, it seems unlikely women in developing countries receive such information. As we know, some women will instead experience their periods stopping entirely during use of the shot and, as we see from this email and from the comments on other posts written for this blog, long after use.

In this context I find it interesting that the Gates Foundation’s programs for contraception access have a very public focus on Depo Provera. The method was mentioned again by Melinda Gates in a recent TED interview and when she was interviewed as ‘Glamor magazine Woman of the Year’ the shot was front-and-center of the discussion of her work. Yet the Foundation also funds programs that provide support for menstrual management and sanitation.  Continuous bleeding from the shot, or cessation of bleeding altogether, would seem to be an important connecting factor between these two campaigns.

Much has been written on the menstrual taboo in India and how this holds women back. In the US we have come to embrace menstrual suppression as great for our health and our progress as women. We see menstruation as holding women back in a variety of ways. However, in India could lack of menstruation also be seen as a positive outcome? Instead of dealing with the menstrual taboo with expensive programs that provide sanitary products and education, might suppressing menstruation entirely be seen as a far more cost-effective solution? It may seem like a stretch, but I am surprised this has not been brought up during debates about the need for contraceptive access in developing countries. Yet of course, the menstrual taboo may well extend to absence of menstruation – a woman who does not experience her period might also be treated suspiciously or poorly.

When Melinda Gates says women “prefer” and “request” Depo Provera I always wonder whether that’s after they’ve been told how it works (perhaps described as a six-month invisible contraception) or after they’ve had their first shot or after they’ve been on it for two years and then, via FDA guidelines, must find an alternative? How much follow up is there? As the self-injectable version is released widely how will women be counseled? Gates argues that the invisibility of the method is part of the draw as women do not have to tell their partners they are using contraception, but what happens when they bleed continuously or stop entirely?

It seems to me like there might be a real lack of communication – both between medical practitioners and their patients, drug providers and the practitioners, and those who fund these programs with everyone involved. It is often argued that the risks of pregnancy and childbirth in developing countries justify almost any means to prevent pregnancy – including the use of birth control methods that cause health issues. How much feedback are groups like the Gates Foundation getting on women’s preferences if they seem to be so unaware of the potential problems, even those that would greatly impact their wider work?

Stopping Depo-Provera: Why and what to do about adverse experiences

April 11th, 2013 by Laura Wershler

Laura Wershler interviews Ask Jerilynn, clinician-scientist and endocrinologist

A screen shot of comments to Laura Wershler’s blog post of April 4, 2012: “Coming off Depo-Provera can be a woman’s worst nightmare.”

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?

Does Depo-Provera work like a charm or a curse?

February 6th, 2013 by Laura Wershler
Author’s Update, February 14, 2013: As clarified by Bedsider.org in the comments section below, the Works Like A Charm Contest mentioned in this post is not current but ended in 2011. The contest website pages are now inactive.

If Bedsider.org sponsored a contest called Why I Hate My LARC, there would be no shortage of contest entrants. But I expect it will be a long time before the nay-sayers get as much attention as the yeah-sayers.

Composite illustration by Laura Wershler

Bedsider has jumped on the LARC bandwagon. The online birth control support network for women 18-29 has launched the Works Like a Charm contest encouraging “the awesome women and couples” who use long-acting reversible contraception to share why they love their LARCs for the chance to win up to $2000. This is a variation of the Why I Love my LARC video campaign sponsored by the California Family Health Council last November, only with prizes!

To quote my blog post about the earlier campaign: “Throughout the contraceptive realm, LARCs are being heralded as the best thing since Cinderella’s glass slipper with little acknowledgement that for many women LARCs are more like Snow White’s poisoned apple.”

One long-acting, not-so-reversible contraceptive in particular – Depo-Provera – is causing grief for many women. Yet “the shot” is front and center in the graphic on the contest website.

Considering the rah-rah tone of the Works-Like-a-Charm campaign messages, it seems that bedsider.org, a project of the National Campaign to Prevent Teen and Unplanned Pregnancy, is oblivious to the misery caused by this contraceptive. Often, Depo works like a curse.

I acknowledge that Bedsider is doing good work: The website provides youth-friendly, accessible information about the full range of birth control methods. But, in my opinion, any organization that promotes Depo-Provera as a contraceptive method should be totally transparent about the ill effects many women experience both while taking and after stopping the drug.

Depo-Provera, to put it bluntly, fucks with a woman’s endocrine system.

The long list of ill effects while on or after stopping this drug includes: continual bleeding (from spotting to heavy), mood disorders, severe anxiety, depression, digestive issues, loss of sex drive, extreme weight gain (often without change to exercise or eating habits), lingering post-shot amenorrhea, intensely sore breasts, nausea, and ongoing fear of pregnancy leading to repeated pregnancy tests. (Not to mention its documented negative effect on bone density.)

These effects are why the continuation rate of Depo-Provera is only 40-60% after one year of use, and why women are filling online comment pages with stories of their struggles coming off this drug.

At Our Bodies, Ourselves, the blog post Questions About Side Effects of Stopping Contraceptive Injections has been attracting comments since November 3, 2009, with no end in sight.

On my April 4, 2012 re:Cycling post – Coming off Depo-Provera can be a woman’s worst nightmare - there are over 130 comments. All but six were posted since mid-November when the post caught fire. Not more than a day or two goes by before another women shares her story of distress, confusion or frustration. I read each one and respond occasionally. Rarely, a positive experience appears; one criticized other commenters for complaining.

It’s one thing to read or hear about potential ill effects while trying to decide whether or not to use Depo-Provera. It’s quite another to experience some or many of them for months on end without acknowledgement or health-care support from those who promote or provide this drug.

The Works Like a Charm contest website says about LARCS:

Reversible = not permanent. If and when you’re ready to get pregnant, simply part ways with your LARC and off you go.

“Off you go?” Tell that to the thousands of women who are waiting, months post-Depo, to get their bodies and their menstrual cycles back to normal. Most of them still aren’t ready to get pregnant.

I am a pro-choice menstrual cycle advocate

January 9th, 2013 by Laura Wershler

As 2013 begins, I give thanks to each and every one of my colleagues at the Society for Menstrual Cycle Research and all my blogging buddies at re:Cycling. Without them I’d feel left out in the cold.  

Are menstrual cycle advocates left out in the cold? Photo by Laura Wershler

I’ve been a menstrual cycle advocate since 1979 when, during a year of post-pill amenorrhea that totally freaked me out, I began to research the ill effects of hormonal contraception. It is not an understatement to say that reading  Barbara Seaman’s national bestseller Women and The Crisis in Sex Hormones changed my life. It started me on a path of self-discovery, and commitment to the idea that healthy, ovulatory menstruation is integral to women’s health and well-being. If you don’t know about Barbara Seaman and her work in women’s health activism, please read about her.

My menstrual cycle advocacy took what could be considered a counter-intuitive path. I aligned myself with the pro-choice sexual health community, committed to comprehensive access to sexual and reproductive health information, education and services. I’ve been as much a contraception and abortion rights advocate over the last three decades as I’ve been a menstrual cycle advocate. But I was a successful user and ardent advocate of the fertility awareness method long before I became a board director at the pro-choice Calgary Birth Control Association in 1986. I went on to serve 10 years on the board of Planned Parenthood Federation of Canada and worked for six years as executive director of Planned Parenthood Alberta, which became Sexual Health Access Alberta in 2006. I’m currently on the board of Canadian Federation for Sexual Health, the former PPFC.

I stress my pro-choice credentials because I think I’m often suspected of being anti-choice. Surely any woman who advocates for healthy, ovulatory menstruation and speaks out against the health concerns inherent in hormonal birth control methods must be anti-contraception and anti-choice. I am neither. More broadly, I’ve written and talked a lot about the value of body literacy for women’s health and well-being.

I wonder sometimes why I’ve stuck it out with the pro-choice sexual health community. While many have been open to my ideas, I have seen little effort to learn about the health benefits of ovulatory menstruation or acknowledge the need – let alone act – to better serve women who want to use non-hormonal contraception. It’s frustrating to be a lone voice, but I keep talking.

It took me over 20 years to find the community that serves and appreciates my menstrual cycle advocacy. I attended my first Society for Menstrual Cycle Research conference in 2005, and that’s how I came to belong to this diverse group of academics, medical professionals, researchers, activists and artists committed to advancing knowledge and awareness of the menstrual cycle. We come from different perspectives, we ask different questions and we focus on different aspects of women’s menstrual lives. But we all hold true to the same idea: #menstruationmatters.

Menstrual cycle advocacy can be lonely and oh so frustrating. Chris Bobel’s recent post about how difficult it can be to help others make the menstrual connection included this quote from me:

Caring about menstruation and the menstrual cycle makes me almost a freak in the pro-choice world. I get ignored or criticized a lot because people don’t want to ask or answer some of the questions I keep trying to pose about choice around non-hormonal contraceptive methods. 

Thanks to SMCR and re:Cycling, I’m not going to stop asking hard questions, or challenging the ignorance and avoidance that many in the mainstream sexual health-care community demonstrate when it comes to ovulation, the menstrual cycle and fertility awareness. I’ll keep chirping and chipping away.

Coming Off The Pill: A Mind Map Guide

March 7th, 2012 by Laura Wershler

Everybody can use a good map to help them get to where they’re going. Why not women heading to the land of non-hormonal contraception?

In my post on January 11, 2012 I asked if coming off the pill was a growing trend. I proposed to write a series of posts about the issues associated with the decision to stop using hormonal birth control.  For the purposes of this discussion assume that “coming off the pill” refers to quitting any method of hormonal contraception including the pill, patch, ring, shot, implant or Mirena intrauterine system.

As I was preparing a list of possible topics, I realized that one way to represent the complexity of issues involved in this decision is with a mind map: “a diagram used to represent words, ideas, tasks, or other items linked to and arranged around a central key word or idea.” It also occurred to me that readers could then add to this schematic, filling in important points based on personal or professional experience. So I got out my colored markers, did a little brainstorming and came up with Coming Off the Pill: Mind Map 1.0. I invite readers to comment, offering additions under the key headings I’ve noted and suggesting other categories that should be included.  Could this become a talking, planning or process guide for women considering the transition to non-hormonal birth control methods?

If you’ve thought about or been through the experience of quitting hormonal contraception, or if you’ve helped others through the experience, please contribute to the development of Coming Off The Pill: Mind Map 2.0 by posting your comments and suggestions. (I’ve already thought about other headings I could have included.) Besides providing me with a guide for writing future posts, what other ways can you imagine this mind map might be used?

Figure Girl Fertility

January 18th, 2012 by David Linton

Guest Post by Lianne McTavish — University of Alberta

(aka Feminist Figure Girl)

While working out at the gym yesterday—something I do on a daily basis—I felt a strangely familiar pressure in my lower abdomen and noticed that it was protruding, despite the strong elastic of my Lululemon pants. ‘Oh I know what is going on,’ I said to my fit workout partner. ‘I am getting my period!’ She too was bloated and crampy, and we wondered if our cycles had synchronized during strenuous sets of wide grip chin ups and heavy dead lifts. Deciding that we were probably romanticizing our ovarian activity, we stopped talking and returned to our tabata-inspired drills, grunting out 50 burpees. Life was good.

Feminist Figure Girl poses in competition (Used with permission)

I was pleased with my body and its potential fertility, which made me feel younger than my 44 years. Just a few months ago I thought I might have entered menopause, though without any accompanying symptoms, except for amenorrhea. I had stopped menstruating while training and dieting for a bodybuilding competition. After being promoted to full professor at the University of Alberta, writing a couple of books, and publishing numerous articles, I needed a new challenge. Already a dedicated gym rat, I decided to enter a bodybuilding competition, doing so as a form of research. I began reading feminist theories of embodiment and cultural accounts of weight lifting, hired an established diet coach, took posing lessons, and learned how to walk in high heels. I entered a local contest in the category called ‘Figure,’ which favours muscular physiques with wide, capped shoulders, broad upper backs, and well defined quads, but requires a softer appearance than traditional forms of bodybuilding. Adopting a beauty pageant aesthetic, the exclusively female participants in Figure—known colloquially as ‘Figure girls’—wear blinged out bikinis and four-inch high plastic shoes while performing mandatory four-quarter turns to display every angle of their bodies to a panel of judges. I wanted to know why women found such contests empowering, even though these events might initially seem both oppressive and sexist. I also wanted to experience what it felt like to compete.

One physical result was the loss of my period. Six months before my show I had weighed 145 pounds and had my body fat carefully measured at 17%, but when I hit the stage at the Northern Alberta Bodybuilding Championships on June 4, 2011, I was 118 pounds and had only about 6% body fat. During that diet-down phase I had ceased taking birth control pills because the estrogen could soften my body, at odds with my goals. Although I used alternative forms of contraception, I feared that they would be less effective and began taking monthly pregnancy tests. The single blue line on the plastic stick was a relief to me, replacing the role of menstrual blood by providing visual evidence of my non-pregnant state.

My period had not returned three months after my competition, though I had gained about 15 pounds by eating larger amounts of healthy, high protein food. I was training just as hard at the gym; indeed I was lifting much heavier weights. During a routine physical in September, I reluctantly told my sensible-shoes doctor that I had not had a period in quite some time. ‘If I have already gone through menopause,’ I exclaimed, ‘it’s the bomb and I say bring it!’ ‘Oh no,’ she chuckled, ‘most of my athletic female patients no longer menstruate. Plus, you are only 44 and can probably squeeze out a few more eggs.’  Horrified by this news I cried out: ‘No, no more eggs!’ I had been hoping to wear the crown of sterility for the rest of my life.

Still, I was happy when my period finally returned a few months ago. In part, this response was related to my fear of aging, or ‘drying up.’ This conception of growing older stems from the early modern period (1350–1750), when blood was the most important bodily humour and its fluid movement was valued. As a specialist in seventeenth-century French visual culture and medical history, I knew that during the early modern period menstruation had been considered integral to being a woman, and to sexual desire. It was positively linked with fecundity, health, and youth. Periodic bleeding was understood as a necessary expulsion of corrupted blood, providing women with health benefits that men sadly lacked. Male bodies had to resort to random nose bleeds or swollen hemorrhoids to achieve cleanliness. The overwhelmingly negative connotations of les règles are modern, but the early modern response to menstrual blood was in fact ambivalent, with the womb sometimes described as a sewer that collected and expelled dirt.

Are You Too Physically Fit for Motherhood?

September 2nd, 2010 by Elizabeth Kissling

Image of slender white woman doing bicep curls with small barbell.The headline of a story at ABC news about infertility among female athletes is “Female Athletes Are Too Fit To Get Pregnant“. Many women athletes in their 20s, at peak performance levels and peak physical fitness by most measures, may find themselves unable to conceive. This is attributed to low percentages of body fat, which essentially shut down the hypothalamus, which then fails to trigger the H-P-O (hypothalamus, pituitary, ovary) hormone sequence necessary for regular menstrual cycles. About 12% of infertile women seeking treatment are athletes.

According to the article, even women who are not professional athletes (or training at that level) can experience infertility due to physical fitness:

It noted that recreational jogging — only 12 to 18 miles a week — can result in poor follicular development, decreased estrogen and progesterone secretion and absent ovulation.

Setting aside the seriousness of infertility, I’m intrigued by the tone of the article, and especially the language of the headline. In North America today, there is a strong emphasis socially and in mass media on the importance of exercise and being physically fit, and corresponding demonization of fatness as a personal moral failing. But amenorrhea and infertility as a result of thinness is reported without judgment and body-shaming. There are no quotations from experts about women exercising too much or advice to stop working out; instead, professional athletes are advised to freeze their eggs in their early 20s. When fat* women have trouble conceiving or have difficult pregnancies, it is frequently attributed to their weight, which is presumed to be a behavioral a matter of choice.


*I am following the practice of other advocates of fat acceptance and Health At Every Size (HAES) in using the term fat as a descriptive adjective, not a pejorative.

Bravery and Intellect Over Easy: Scrambled

March 12th, 2010 by Giovanna Chesler

(This post also published at the blog g6pix.)

I’ll try not to sound too fan-girlish here as I write about the documentary Scrambled: A Journey through PCOS by Randi Cecchine, but admittedly, it is a difficult task. For in this film, which chronicles Cecchine’s struggle with Polycystic Ovarian Syndrome, we meet a filmmaker brave enough to show us, wart-hairs and all, the challenges inherent in this disease embodied. She does so with humor, with information, and with space for personal reflection.

As Cecchine and the health practitioners she speaks with share, PCOS is a condition that affects 8% of women but that goes under-diagnosed. Though largely undetected in the women who have PCOS, the first sign of something wrong is the absence or change in the menstrual period. According to Cecchine’s participant Dr. Geoffrey Redmond, an endocrinologist who has studied female hormone problems for over twenty years, PCOS generally shows up during puberty or shortly during the menarche period. In his interview, he argues that a delay of fifteen years in diagnosis typically occurs because “people who care for teenagers are typically not clued into this condition.”

In popular rhetoric on menstruation and menstrual suppression, there are many voices who have argued that having a menstrual period is unnecessary and should be done away with through hormonal birth control regimens (for example, Lybrel, Depo-Provera and Seasonale.) These drugs are often presented as choices to girls and young women close to menarche. Scrambled serves to intercept this discourse by demonstrating how the cycle becomes a sign of imbalance and illness. This film reminds us of the value of attending to the menstrual cycle. In Cecchine’s case, as in the case of the many women she interviews in her film, the lack of a period is a personal introduction to the disease.

Cecchine works with a light yet serious tone. A visit to Harry Finley’s Museum of Menstruation underscores the connections between menstruation, body awareness and PCOS. Yet we are able to marvel and smirk at Finley’s collection of menstrual advertising and decades old menstrual protection products which now live in his basement. As her lived investigation continues, Cecchine meets up with the Polycystic Ovarian Association (PCOSA) at their conference. There her film does remarkable work, as it invites the viewer to join in the conversation. In the scenes around the conference, we see how this film works to invite fellow PCOS women into the information Cecchine has gleaned. Though knowledge will not cure one from the illness, certain techniques shared in the film (like limiting carbohydrate intake) will result in reduced symptoms.

In the recent release of the film, which is self distributed, Scrambled is a two disc set. The first disc includes the documentary, but the second disc is chock-full of informative interviews on a variety of topics. Cecchine profiles Redmond along with many other health workers practicing western, eastern and alternative medicine who speak of the options for treatment. These include diet alterations, drug regimens, psychotherapy, acupuncture and others. In this disc, Cecchine provides the tools for a viewer with PCOS to address her syndrome through many methods. By providing information in this manner, Scrambled becomes a guide and a tool for holistic health on a personal level.

But these treatments comes at an expense. Here Cecchine’s humor bubbles up again when she shares the different techniques, like hair removal, pills, acupuncture treatments and their resulting costs. Yet, the feeling that comes afterward: “Priceless!” Bitingly Cecchine reminds us that being a patient also involves being a consumer. Therein she complicates these treatments as choices and necessities simultaneously.

Cecchine’s work follows in the tradition of Judith Helfand’s Healthy Baby Girl (1997) which, also in the first person and with humor, tells the story of Helfand’s illness with cervical cancer at the age of 25 (Helfand’s illness was the result of her mother, and mothers like her, taking the drug DES.) But Cecchine’s work also maintains experimental qualities, akin to those in the tradition of Su Friedrich’s similarly themed The Odds of Recovery (2002) which leave space for reflection by the viewer. In Scrambled, a score of tonal hums and drones, clicks and zaps create these necessary moments for reflection. In these spaces a viewer may consider her own wellness or wonder whether she knows her body enough to identify the signs of PCOS. Cecchine encourages an empowered understanding of one’s body, making Scrambled a tool for education and insight. Be sure to (order and then) watch with your notebook in one hand and the pause button in the other. There is much to take away here, but no better lesson than the importance of listening to one’s body.

Readers should note that statements published in re: Cycling are those of individual authors and do not necessarily reflect the positions of the Society as a whole.