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Query: UMLS:C0745411 (irregular bleeding)
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More than 300 subscribers of Contraceptive Technology Update (CTU) completed the questionnaire for the 1994 Pill Survey. Most respondents (68%) were nurse practitioners followed by physicians (11%), registered nurses (9%), and physician assistants (4%). 92% of respondents considered oral contraceptives (OCs) (especially Ortho-Cept and Ortho Novum 7/7/7) as the leading hormonal contraceptive choice among adolescents and adults. Among teens, Depo-Provera was the second choice (4%). Among adults, Depo-Provera and the contraceptive implant, Norplant, fared equally as well (2% each). Headaches, mood swings, and weight gain continued to be complaints for all hormonal contraceptives. Progestins are potent depressants. Norplant produced the most complaints. About 20% of providers reported that at least 20% of their patients wanted Norplant implants removed because of significant side effects, especially irregular bleeding. Most Norplant users had the implants for no more than 12 months. The providers realized that they were providing insufficient counseling to Norplant users about irregular bleeding before insertion. A physician noted that some women experience infertility for as long as two to three years after their last Depo-Provera injection. Some providers discourage women from using Norplant based on the many complaints they have received from past users.
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PMID:Depo-Provera and Norplant implants prove no competition for no. 1 choice, OCs. The 1994 pill survey. 1228 3

A study conducted by the World Health Organization (WHO) Special Programme of Research, Development and Research Training in Human Reproduction with the collaboration with the University of Otago Medical School in Dunedin, New Zealand, and the Fred Hutchinson Cancer Research Center in Seattle, Washington, reveals that the injectable contraceptive DMPA (depot-medroxyprogesterone acetate) does not increase the overall risk of developing breast cancer, especially in women who have used DMPA for long periods in the past. Women who began using DMPA within the last 5 years may face a 2-fold increased risk of developing breast cancer, however. Enhanced detection of breast tumors or an acceleration of the growth of pre-existing tumors may explain this increased risk in recent or current users of DMPA. The researchers concluded that providers should not restrict DMPA on the grounds of breast cancer risk. The study reaffirmed the known link of increased risk of breast cancer with early menarche, being single, late age at birth of first child, nulliparity, family history of breast cancer, and history of benign breast disease. The study data originated from New Zealand, the US, Kenya, Mexico, and Thailand. Disadvantages of DMPA include: irregular bleeding, that it is provider-dependent, and slow return to fertility after DMPA use ceases. Advantages include high contraceptive effectiveness, no effect on blood clotting factors, and a protective effect against endometrial cancer.
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PMID:Long-term use of hormonal contraceptive DMPA not linked to breast cancer. 1228 77

To ensure that Depo-Provera acceptors return after three months for follow-up injections, counseling is essential. Women should be informed about the potential for menstrual irregularities, particularly irregular bleeding and missed periods. Amenorrhea has been reported by 57% of Depo-Provera users in the first year and by 68% in the second year. In some cases, women will mistake this side effect for pregnancy and not return for the next injection. In addition, acceptors should be advised that it can take as long as six months after the last injection for conception to occur.
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PMID:Counseling for Depo a must. 1229 Aug 13

The author describes a range of contraceptive methods, and their side effects, which may be acceptable for new parents. The methods are the oral contraceptive pill, Norplant, Depo-Provera, and intrauterine devices (IUD). Natural methods and permanent contraception are options described in insets. The author notes that differences in the effectiveness rates among available types of oral contraceptive pills are small enough not to merit consideration when deciding which kind of pill may be appropriate. Combination birth control pills are taken daily at the same time for 21 out of 28 days. Combination pills are not recommended for women with a history of hypertension or other cardiovascular diseases, thrombophlebitis, migraine headaches, diabetes, active gallbladder disease, or mononucleosis. Any hormonal method may be particularly risky for smokers over age 35. The mini-pill, containing a smaller amount of progesterone and no estrogen, is taken every day and is also on a 28-day cycle. Containing no estrogen, the mini-pill is often recommended for women who are nursing, who are over age 35, or who suffer from hypertension or migraines. Both adverse and positive side effects may be experienced from use. Norplant is the brand name of a contraceptive system which releases progesterone from under the skin of a woman's upper arm over the course of a five-year period. The system has a theoretical effectiveness rate of more than 99%, although the duration of effectiveness may be less than five years in overweight women. The most common side effect is irregular bleeding, and removal is often a longer and more difficult procedure than insertion. The most commonly used injectable hormonal contraceptive is Depo-Provera, a progesterone solution which works for up to three months. The majority of users experience some side effects. Finally, IUDs are highly effective and need to be replaced only every 1-10 years depending upon how they are made. Women typically experience discomfort during IUD insertion, and they should not be used by women under age 20 years, who have never had children, or who have ever had a pelvic infection.
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PMID:Birth control for new parents. 1229 Aug 91

Among 30-40 year old women, 40% of pregnancies are unplanned, which is indicative of the unreliability of the birth control methods they are using. The 1992 Ortho Birth Control Study interviewed almost 7000 women, of whom 8% listed withdrawal and 4% listed the rhythm method. These two methods have failure rates of 24% and 19%, respectively. Birth control methods often disappoint the users and increasingly they turn to sterilization. 48% of married women aged 15-44 had themselves been sterilized or had a sterilized partner in the Ortho survey. Although reversal of tubal ligation succeeds in 43-88% of cases, conception cannot be guaranteed. For women over the age of 30 who are healthy and do not smoke, low-estrogen or no-estrogen oral contraceptive pills are considered safe. Taking the pill also helps prevent ovarian and endometrial cancer. The failure rate is 6%. Barrier methods also offer protection from sexually transmitted diseases including HIV. Condoms are favored by 33% of unmarried women and 19% of married women. Sexually active 40-44 year old unmarried women run a 14-19% risk of contracting a sexually transmitted disease (STD) in a 12-month period. Diaphragms offer some protection against STDs, but their failure rate is 18%. IUDs are regaining popularity, but only 1% of women use them (ParaGard T380A or Progestasert). Pelvic inflammatory disease is the reason: a 1992 study showed that 0.97% of women developed it within 20 days of use. Norplant is a long-term implant containing levonorgestrel with a failure rate of 0.5%. A 1993 study followed 1253 implant users over 12 months and found a very low rate of pregnancy, but 75% experienced some side effects during the first year. About half of the women using Norplant removed it after 2.5 years because of irregular bleeding. Depo-Provera is an injectable administered every 3 months, but after removal it can take up to a year for ovulation to return. Side effects may include hair loss and weight gain; and links to breast cancer have also been suggested.
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PMID:Birth control over 30. 1229 85

The Norplant System of levonorgestrel implants and the Depo Provera contraceptive Injection of sterile medroxy progesterone acetate suspension (DMPA) are longterm, progestagen-based contraceptive delivery systems designed to overcome noncompliance which are under review for use in Canada. 150 mg of DMPA, a pregnane compound derived from progesterone, is injected every 3 months. Peak plasma concentrations are reached in 24 hours and plateau for 3-4 months before gradually declining. After termination, ovulation returns on average in 4.5 months, and conception occurs at a median time of 10 months. 90% conceive by 24 months. In the Norplant system, a steady daily supply of 50-80 mcg of levonorgestrel, a gonane progestin derived from the testosterone nucleus which has both progestogenic and androgenic receptor affinity, diffuses from 5 Silastic implants, which must be replaced every 5 years. Ovulation and fertility return rapidly after rod removal. The actual and lowest expected failure rates are equal for both systems. The failure rate for DMPA is .3 pregnancies per 100 women years, while that for levonorgestrel is .4% in 1 year. Although neither method affects blood pressure, DMPA appears to affect carbohydrate metabolism by impairing glucose tolerance and increasing insulin production. Lipid metabolism is also affected. 5% of those who use levonorgestrel discontinue it because of side effects, including headache, mastodynia, and acne; 19.1% of DMPA users did so, especially for weight gain and menstrual cycle abnormalities. Both methods have a higher frequency of menstrual abnormalities than normal. 27.7% of levonorgestrel users experienced prolonged bleeding, while 17% experienced spotting during the first 6 months. However, normal menses usually returned within a year, and only 7.9% discontinued use because of cycle abnormalities. In 1 study, less than 10% of DMPA users experienced normal cycles, and in another study 35% experienced amenorrhea (500/700 discontinued use). Amenorrhea replaced irregular bleeding with continued use, occurring in 68% of users by 2 years. There is also some concern about DMPA and breast cancer and bone loss. Based on 1 case-control study of 110 women with breast cancer who had taken DMPA, the relative risk is highest for those between ages 25 and 34 who use DMPA longer than 6 years. A WHO study concluded that the relative risk of developing breast cancer, because of DMPA, is inversely related to duration of use. A Phase IV study on DMPA and bone mineral density has been undertaken.
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PMID:A comparison of levonorgestrel implants with depo-medroxyprogesterone acetate injections for contraception. 1231 30

Side effects of Depo-Provera (depot medroxyprogesterone) use, such as irregular bleeding and weight gain, can cause many Depo-Provera users to stop using the injectable contraceptive method. The best way to ensure method continuation is to make sure that clients understand the common side effects associated with the method before they receive their first injection. It is common for users of Depo-Provera to experience weight gain and changes in vaginal bleeding. Potential annual average weight gain associated with method use is on the order of 2-4 pounds. Food and exercise diaries, as well as a review of healthy food choices, can help patients manage their weight. Katherine Jensen, a nurse midwife at Roseburg Women's Health Center, currently sees about 120 Depo-Provera clients annually. She has found that women who are naturally thin and typically do not have weight problems seem to have no problem using Depo-Provera.
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PMID:Pretreatment counseling keeps patients on Depo. 1232 Dec 12

This study presents findings on the socio-demographic and health characteristics, continuation rates, menstrual disturbances, and changes in menstrual patterns as well as other side effects among a sample of 952 1st time acceptors of the injectable contraceptive Depo-Provera during 1978-1980 in Colombo, Sri Lanka. Those continuing to use the method were observed for 24 months. The reasons for discontinuation are discussed based on another study that focused on 321 discontinuers who received Depo-Provera from the same clinic. The overall continuation rates at 12 and 24 months were 58% and 29%, respectively. Relatively older and higher parity women had lower continuation rates than younger and lower parity women. The occurrence of amenorrhea rose sharply foloowing the 1st dose and stabilized such that about 1/3 of those continuing with Depo-Provera became amenorrheic. 1/4 of the women experienced menstrual disturbances such as spotting and irregular bleeding. Other side effects, including vomiting, headache, and dizziness, affected 6% of the women following the 1st dose, but declined gradually over time. Over the course of the observation, 41-66% of the women appeared to gain weight. The 2 primary reasons for discontinuing Depo-Provera were non-medical: 1) the desire to have another child and 2) the decision to be sterilized. The findings suggest that Depo-Provera has played a signinficant role in Sri Lanka in 2 ways: 1) its use has provided desired pregnancy spacing for those who wished to have another child and 2) it has assisted couples by providing them with time (without the fear of pregnancy) to decide to stop having children and then get sterilized.
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PMID:Depo-Provera use in Sri Lanka: acceptor characteristics, continuation and side effects. 1234 Nov 88

Even though the Food and Drug Administration (FDA) does not label Depo-Provera as a contraceptive, this fact should not preclude clinicians from prescribing it as such. The lack of FDA approval may deter clinicians from prescribing Depo-Provera as a contraceptive, but legal precedents for prescribing the drug as a contraceptive do exist. As Dr. Andrew M. Kaunitz of the University of Florida Health Sciences Center explains, it is not uncommon for physicians to prescribe drugs for unlabeled indications. Moreover, the American Medical Association (AMA) maintains that such a practice is entirely proper, as long as it is based on "rational scientific theory, reliable medical opinion, or controlled clinical studies," and as long as the FDA does not mandate that physicians may only prescribe the drug for an officially labeled use. Drug labeling, says the AMA, does not necessarily set the standard for what is good medical practice. Clinicians, however, must take the necessary steps to protect themselves from liability when using Depo-Provera. The AMA warns that official drug labeling may be used as evidence in a liability lawsuit. Through computerized search programs, Kaunitz has investigated US court decisions concerning the use of Depo-Provera as a contraceptive. He found no litigation cases resulting from Depo-Provera's official status with the FDA. He did, however, find lawsuits resulting from physician failure to diagnose pregnancy at the time the patient received Depo-Provera and physician failure to advise the patient about Depo-Provera's side effects--especially the irregular bleeding patterns. Kaunitz advises that informed consent forms should indicate that Depo-Provera is not labeled as a contraceptive in the US and should point out the major side effects.
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PMID:Medicolegal issues surrounding Depo-Provera easily overcome. 1234 60

Irregular menstrual bleeding, the most common side effect of Depo-Provera use, is being managed by some physicians through administration of estrogen and/or ibuprofen. A practitioner from the Jones Institute for Reproductive Medicine in Norfolk, Virginia, reported that women with 8-10 days of bleeding over 2 weeks are administered 0.02 mg of ethinyl estradiol for 10 days; bleeding generally stops in 5 days. Other physicians prescribe an estrogen patch. If estrogen is contraindicated, patients are given 800 mg of ibuprofen 3 times a day for 5 days. In all cases of heavy bleeding apparently related to Depo-Provera use, other causes (e.g., cervical malignancy, uterine fibroids, sexually transmitted diseases) should be ruled out before treatment is initiated. Finally, several clinicians noted that counseling Depo-Provera acceptors to anticipate irregular bleeding for as long as a year is perhaps the most effective management strategy.
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PMID:Dealing with Depo: you can manage bleeding with estrogen, ibuprofen. 1234 32


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