Depo-Provera, the controversial contraceptive-abortifacient drug, has been given the green light for use in Canada by an advisory committee to the Department of Health and Welfare. However, the Minister of Health, Jake Epp, has said that government approval for the drug is not likely “for some months.”
Depo-Provera, manufactured by the Upjohn Company, is a progesterone steroid. It is legally used in Canada now to treat endometriosis and certain types of cancer. It has been sued contraceptively for teenagers in group homes in Winnipeg and in Ontario homes for the mentally retarded. Although such use is not authorized, doctors have prescribed Depo-Provera by following a legal loophole, which allows them to prescribe if they feel benefits to a patient outweigh the rise.
For contraceptive use, the drug is injected every three months. It works by suppressing ovulation and by causing changes in the cervical mucus and the uterine lining. Changing the uterine lining causes an early abortion, by preventing implantation of the tiny embryo.
While the committee advising the Minister of Health, the Committee on Female Reproductive Physiology, has based its current recommendations on studies done by the World Health Organization (WHO), the International Planned Parenthood Federation, and the U.S. Centres for Disease Control, the drug’s safety has not been clearly established.
Animal tests have shown the Depo use increases the incidence of cancerous tumors. Indeed, one test using rhesus monkeys resulted in the first-ever reports of uterine cancer in these animals. Champions of the drug, however, argue that such trials are not conclusive since a similar increase in cancer has not been found in women using Depo.
Those opposed to Depo are concerned that the drug may lead to another DES tragedy if it is administered to women who are already unknowingly pregnant, or who become pregnant despite the injection, or who use the drug while breastfeeding. (DES is a drug used in the 40s and 50s to prevent miscarriage. It has since been proved to cause cancer in the children of women who took it.)
Since the estimated pregnancy rate for Depo is less than one per 100, WHO believes that the risk for pregnant women and their children is small and states that: “this is not likely to be a major public health problem.” The same report admits that there have been no studies to “systematically” follow the health and development of a large number of infants exposed in utero to Depo. Nevertheless, reports on three cases of clitoral enlargement among daughters of women who received Depo during the first trimester of pregnancy.
Potential hazards to breast-fed children of Depo mothers are similarly dismissed as unimportant since there are not enough studies on which to base an informed conclusion. Some children have been studied up to 13 years of age; their “growth and development appear normal.”
There is one animal study, cited by WHO, which suggests there may be “a possible effect on reproductive development.” Such vague assurance is not likely to impress those who have followed the DES story. The effects of this drug were not discovered until the children reached adulthood.
The side effects of Depo are considered acceptable by those who favour the drug. They are, however, not an acceptable to many women who have tried and discontinued the injection. Depo severely disrupts the menstrual cycle, and fewer than one third of women report normal menstrual cycles during the first year of use. Approximately 15 per cent of women discontinue the drug because of “bleeding irregularities” and another 12 per cent gave it up because of amenorrhoea (complete absence of monthly periods.)
“Bleeding irregularities” are defined by WHO as “unpredictable bleeding or spotting [that] can be inconvenient and of concern to the woman, and heavy or prolonged bleeding may lead to depletion of iron stores. “The WHO report regarded favourably by the Canadian committee, states that severe bleeding in Depo users is “uncommon.” However, Germain Greer in her book Sex and Destiny refers to a British study which concluded that Depo led to “menstrual chaos.” She further reports on a Bangladeshi organization which ceased using Depo after 11 cases of severe bleeding in eight months required hospital treatment.
Other side effects reported by Depo users are weight gain, raised blood-glucose levels, nausea, dizziness, headaches, skin pigmentation changes, painful menstruation and loss of libido. After discontinuing Depo, fertility returns in about eight months. (Other estimates are that it may take up to 18 months.) Even these figures may not be correct, as WHO notes that “subsequent fertility” has not been studied after Depo use. WHO cautions that women who have not had children “might be advised to use other methods.”
Depo-Provera has been extensively tested on Third World women. More than 10 million women have used the drug in the past, and estimates are that 1.5 million women world-wide are currently using it. Because each dosage lasts so long, it is considered a perfect contraceptive for poor women in cultures where contraception is not widely accepted.
Field health workers in the third world have already been trained to administer injections and a “once every three months” needle does not require the follow up required by the IUD, nor the discipline required to take the Pill daily. In addition, vaccinations are well regarded in many developing countries, because they are connected with health. Therefore, suspicion is minimal.
Despite such “advantages,” Depo continues to be banned as a contraceptive in the United States and in Britain. An independent board of inquiry in the U.S. recently upheld the earlier ban, stating that there is not enough evidence to prove the drug is safe.
Dr. Jack Walters, head of the Canadian advisory committee, dismissed the U.S. decision in recent media interviews. He called it a “political rather than scientific” decision, taken on “election-year pressure.” He prefers to follow the recommendations of the WHO report, saying it is “high” on Depo. He sees it as perfect contraceptive choice for a woman over 35, who is a smoker, and who doesn’t want any ore children.
Dr. Ian Henderson, director of the Human Prescription Drug branch of the Department of Health, supports Dr. Walters and the Committee on Female Reproductive Physiology’s recommendations. He believes Depo is safer than the Pill. In a Globe and Mail interview, Dr. Henderson said that one factor in his support of the drug was “an examination of the records of over 10 million women who have used Depo-Provera for a year.” Interviewer Anne Pappert comments on this statement that most scientific studies “generally stipulate a minimum five years as essential in obtaining meaningful data.”
Pappert reported that one “only area of concern” noted by the Committee is whether the drug is suitable for use by teenagers. Dr Henderson said that the committee will be making specific recommendations in this area. These recommendations, he said, will be drafted by Dr. Walters who “was instruments” in setting up a Depo programme for teens in Jamaica. “We’ve decided that Depo-Provera is safe enough for teen-age women in Jamaica.” Henderson said “How can we say it not safe for Canadian teenagers?”
Depo’s action is preventing menstruation is beneficial, according to Dr. Henderson. He said that athletes and astronauts are using it and added that it is “now culturally acceptable to say that menstruation is a nuisance.” He thinks that eliminating menstruation will be welcomed by many women.
“Our job at Health and Welfare after Depo is approved will be to educate women that the fact they have stopped menstruating is a natural side effect of this drug and that it is not unhealthy for their genitals to be in a dormant state. Their genitals will be just like they were when they were nine or ten years old.”
In his view, the only woman who still “choose to menstruate” by the year 2000 will be the women who are trying to conceive.
When the Advisory Committee’s recommendation to approve Depo were made public last November, women’s health activists immediately formed the Canadian Coalition Against Depo-Provera and called for public hearings into the drug. Coalition spokesperson Connie Clement charges that the drug’s safety has not been proved and that researchers have downplayed the so-called “nuisance side-effects.”
Health Minister Epp has rejected the need for a public hearing but he has said that department official’s will pay careful attention to the public’s views.
Alliance for Life executive director, Anna Desilets, has written to Mr. Epp, expressing Alliance’s displeasure at the possible approval of another drug which can be harmful to women and children in the short or long term. She notes that Depo can be used properly to treat certain life and health threatening conditions (such as endometriosis or certain types of cancer), a use with which Alliance has no quarrel. Alliance is urging pro-lifers to send letters and telegrams to minister Epp and to Health Department officials.
Strangely enough, the dispute over Depo is one issue on which pro-life and women’s health activists, most of whom use a feminist perspective, can agree. Mrs. Desilets assured The Interim that she would be happy to work with the Canadian Coalition on Depo-Provera. However, we have not yet been able to get in touch with Ms. Clements of the Coalition, so we don’t yet now whether the feeling is mutual.