One of our readers contacted us noting that she developed a severe episode of postpartum depression after receiving an injection of the contraceptive, Depo-Provera. She is pregnant again and now wonders if she should avoid Depo-Provera given her previous experience.
Depo-Provera (DMPA), also known as the birth control shot, is a highly effective form of contraception that lasts for 3 months, and thus requires only 4 injections per year. DMPA contains a long-lasting form of depot medroxyprogesterone acetate that works as a contraceptive agent by suppressing ovulation. Potential side effects of DMPA include decreased bone density, weight gain, and mood worsening. Although depression is listed in the package insert as a side effect of the injection, available research addressing this side effect are limited and contradictory. Although some women report mood worsening on DMPA, more research is needed to determine how common this side effect is observed.
Because estrogen-containing contraceptives may affect lactation, Depo-Provera (DMPA) is frequently used during the immediate postpartum period in women who are breastfeeding and are interested in efficacious, long-term contraception. (The minipill is another type of progestin-only contraceptive which is used in this setting. It contains a different type of progestin called norethindrone.)
Because some studies have associated DMPA with worsening of mood, one important question is whether DMPA and other progestin-only contraceptives increase the risk for depression when administered during the postpartum period, a time when women are more vulnerable to depression.
A single-blind randomized controlled trial examined whether DMPA increases the risk of postpartum depression compared to a copper-containing (hormone-free) intrauterine device (IUD) when administered after delivery. Eligible women (N=242) requiring postpartum contraception were randomised to receive DMPA or an IUD within 48?hours of childbirth and were interviewed at 1 and 3 months postpartum.
Depression scores on the Edinburgh Postnatal Depression Scale (EPDS) were statistically significantly higher in the women using DMPA compared to the women with an IUD at one month. While EPDS scores were not different between the two groups at three months postpartum, Beck Depression Inventory (BDI) scores were significantly higher in the DMPA users than in the IUD users. In addition, more women in the DMPA group had major depression at this time-point than women with an IUD (8 vs. 2; p=0.05).
In our community, the mini-pill (containing a different type of progestin, norethindrone) is used more commonly than Depo-Provera. Somewhat surprisingly given how commonly the mini-pill is used, I did not find any studies examining the effect of the mini-pill on mood in postpartum women. There was one study which examined the impact of an injectable form of norethindrone on mood when administered during the postpartum period. Similar to the DMPA study, women receiving the norethindrone experienced more depressive symptoms than women in the control group.
While information related to the risk for postpartum depression in women taking progestin-only contraceptives is sparse, the data suggest that depression may be more common among women treated with DMPA and norethindrone. Another important issue with the depo preparation is that once the injection is given, it is irreversible and its effects will last for 3-4 months. Thus, we typically recommend that women with histories of postpartum depression or histories of mood disorder avoid using progestin-only contraception during the postpartum period.
Ruta Nonacs, MD PhD
Tsai R, Schaffir J. Effect of depot medroxyprogesterone acetate on postpartum depression. Contraception. 2010 Aug;82(2):174-7.
Lawrie TA, Hofmeyr GJ, De Jager M, Berk M, Paiker J, Viljoen E. A double-blind randomised placebo controlled trial of postnatal norethisterone enanthate: the effect on postnatal depression and serum hormones. Br J Obstet Gynaecol. 1998 Oct;105(10):1082-90.