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Amid the excitement engendered by the four new birth control methods available this year, it would be easy to overlook the fact that the US Food and Drug Administration-approved Depo-Provera for contraception 10 years ago. But we need to take a moment and recognize that in the past decade the people of the United States have benefited greatly from this extremely effective, convenient, reversible method. Depot medroxyprogesterone acetate (DMPA, a progestin-only injectable administered every 3 months) has made very significant contributions to the goals of reducing unplanned pregnancy. One study calculated that the lion's share of the reduction in teen pregnancy in the United States in the 1990s was due to Depo-Provera and Norplant.1
However, reviewing the past decade, we can see a curious pattern of use. In general practice, DMPA tends to be offered primarily to special niches of contracepting women: primarily to indigent women, adolescents, and mentally challenged women. One professional woman at a meeting recently volunteered that when she asked for DMPA at her postpartum visit, her doctor told her that she "didn't fit the profile." This practice is concerning, because clinical experience has taught that DMPA is a first-line contraceptive choice. From a narrow medical perspective, DMPA is one of the best contraceptives for women with many medical conditions. Women with seizure disorders are a prime example. Not only does progestin have mild anticonvulsant activity, there are no drug-drug interactions between DMPA and phenobarbital, phenytoin, or carbamazepine as might be expected with other lowdose progestin-only methods (eg, implants or mini-pills) or with estrogen-containing hormonal methods. Women on phenytoin or phenobarbital have alterations in vitamin K synthesis and, as a result, may suffer menorrhagia; DMPA reduces the woman's monthly blood loss. Similarly, women with sickle cell anemia also benefit from reduction of menstrual blood loss. In addition, one Egyptian study has demonstrated that women with sickle cell disease enjoyed a 70% reduction in the number of acute crises they suffered when they used DMPA.2 And, of course, the DMPA-associated reduction in menses is important for women who must routinely cope with menorrhagia from adenomyosis or pain from primary or secondary dysmenorrhea. The toll that this latter problem inflicts is legend; dysmenorrhea is the leading cause of lost days of school and work...