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?