Injectable long-acting progestogen contraception: a neglected modality

Long acting contraceptives. Present status

Long acting injectable hormonal contraceptives are among the most effective fertility regulating agents developed; yet they are also among the most controversial because of animal data indicating a possible carcinogenic potential in several species. A critical analysis of these animal findings has revealed, in all instances, the existence of specific mechanisms not occurring in the human. For this reason, most national and international scientific bodies who have reviewed this issue have concluded that there are no toxicological reasons for not using long acting hormonal contraceptives. Long acting agents can be divided into 2 separate groups: those having a duration of action of one month, which are composed of a long acting oestrogen and a progestagen, and those lasting for several months which consist of only a progestagen. Among the injectable progestagen-only contraceptives tested, only 2 have so far reached the international market: depot medroxyprogesterone acetate (DMPA), which has been administered at 3- or 6-month intervals and norethisterone enanthate, which has been injected at intervals ranging between 2 and 3 months. The most important side effect observed with these 2 agents is a complete disruption of the menstrual bleeding pattern, leading - in some cases - to total amenorrhoea, which is more frequent with depot medroxyprogesterone acetate than with norethisterone enanthate. The latter, however, has a shorter duration of action with a higher pregnancy rate than the former. Other adverse reactions are rare and of no real importance. Metabolic effects with progestagen-only injectable preparations are, in general, mild and less marked than with combined oestrogen-progestagen formulations. Recent investigations have shown that the return of fertility following their use is delayed but in no way impaired. Monthly injectable oestrogen-progestagen combinations have been tested to a more limited extent and these agents are available only in a very few countries. Their main advantage over progestagen-only preparations is that they allow a reasonable menstrual bleeding pattern in the majority of cases. Their obvious disadvantage is that they contain a long acting oestrogen.

Effects of medroxyprogesterone acetate on socio-sexual behavior of stumptail macaques

Two studies assessed (1) the effect of medroxyprogesterone acetate (MPA), Depo-Provera, on socio-sexual behaviors, and (2) the interaction between socio-environmental conditions and MPA treatment effects. Study One utilized two males and eight female members of a semi-free-ranging island colony. Females received 30 or 100 MPA IM or were untreated. Study Two used three laboratory-housed pairs of tubal-ligated females, observed during 30 min behavior tests with one of three males. Sexually preferred females received 30 mg MPA IM. Semi-free-ranging treated females received fewer ejaculations than untreated females and did not copulate for up to 68 days post-treatment. Rates of grooming were not affected. In the laboratory tests, mean rates of ejaculations per test were reduced for treated females but increased for untreated females, and untreated females groomed males more than did treated females. Contrary to previous studies, these results suggest that stumptail macaque sexual behavior can be influenced by hormones but this influence is modulated by socio-environmental factors.

The Depo-Provera debate. Commentary on the article "Depo-Provera, a critical analysis"

A widely publicized article has in recent months caused a great deal of concern among individuals interested in responsible promotion of family planning. The article contains a long series of factual errors, distortions and biased quotations. This commentary presents evidence, based on current knowledge, that Depo-Provera is a satisfactory contraceptive with several advantages and some disadvantages, and poses no more unresolved problems than oral contraceptives. There is no evidence that, at contraceptive doses, it increases the risk of cancer, impairs bone mineralization, "shocks" the hypothalamus, damages the liver or the immune system, or causes premature aging. Studies to date have not shown damaging effects on infants exposed to the drug in utero or via breast milk. To most women, disruption of the menstrual cycle, the major side effect, is not a health hazard. Finally, women in various parts of the world have shown to be quite capable of choosing for themselves whether or not the advantages of the drug can overcome the disadvantage of almost certain menstrual disturbance.

The adolescent and contraception: issues and controversies

Issues relating to adolescent sexuality and high fertility in the U.S. are reviewed briefly. Similar issues in the developing world are discussed, with emphasis placed on the limited data on the subject currently available in most developing countries. The contraceptive options available for the sexually active teenager are presented, together with a discussion of the very difficult decisions and controversies that result from the lack of an ideal or even preferable method of contraception at present.

Injectable contraception (medroxyprogesterone acetate) in rural Bangladesh

1601 women used the injectable contraceptive agent medroxyprogesterone acetate for up to 3 years. The programme was conducted by a rural health centre with detailed follow-up. While the continuation-rate, 56% after 1 year, compared favourably with that of other contraceptive methods in Bangladesh, at least half the women experienced troublesome menstrual side-effects and there were indications that milk yield was adversely affected in 147 out of the 1020 women who received the first injection while lactating.