At the beginning of 2017, I sat opposite a nurse discussing options for long-acting reversible contraception (LARC) from the list she waved at me . I was in the process of having a medical abortion, and highly aware of not wanting to be in this position again any time soon. The nurse was schooling me on the possibility of conception after abortion; that an egg could be released from the ovary as soon as 8 days after treatment (1). This information left me feeling nervous and adamant to prevent any risk. Little did I know that the choice I was about to make would lead to my periods disappearing for the next twenty-two months.
The method I was sold that day was the most popular injectable contraceptive, a progestin based injection into the muscles (most commonly the bottom) every 3 months. The steady release of progestin acts on the HPA axis (hypothalamic-pituitary-adrenal) and suppresses the surge of luteinizing hormone (LH) normally seen prior to ovulation. The increase in progestin thickens the cervical mucus making it difficult for sperm to move through the cervix. It thins the lining of the womb so that a fertilised egg is less likely to implant itself (2). These internal changes often coincide with the disappearance of a menstrual bleed. This I saw almost instantly. Apart from the dribs and drabs of my post-abortion blood clots, my period never arrived.
Over the next 12 months, each time I was injected with the electric shock of hormones I steadily grew more aware of the shifts in my mood, libido, appetite, and physical body. My boobs would swell, I’d lose all desire to eat, my sex drive soared, and there was a general sense of hyperactivity buzzing around my brain. This progestin spurt would last for a week or two before I felt myself mellow out, body relaxing, fingers finding food again. It was on my fourth visit to the nurse when I displayed some concern about these effects. I was encouraged to switch to another progestin contraceptive injection lasting 12 weeks, with a lower concentration of progestin. This one I could self-administer by injecting it beneath the skin, into my tummy or top of the thigh.
The first time I injected myself was also the last time. It took 5 solo stabs into the belly followed by a dizzyingly hot fainting episode for me to know I didn’t want to be on this contraception anymore. The fear of what had caused this reaction led to me refusing another dose, deciding it was time to navigate my way back to a natural cycle. I bought myself a menstrual cup and began counting down the three months until I would be free of these injected hormones.
I waited for my period to arrive for 8 more months in 4 different countries. I waited whilst attending menstrual cycle workshops, love blood ceremonies, period power podcasts and more.
By April, my eyes were glued to my knickers. Checking for the first spots of blood to appear. Eager and ready. I waited for my period to arrive for 8 more months in 4 different countries. I waited whilst attending menstrual cycle workshops, love blood ceremonies, period power podcasts and more. I found that the longer my period took to arrive, the more attention I was giving it. I began speaking to my womb, massaging my stomach and vaginal canal, praying to the moon. All of these personal rituals ran alongside the continual research I was doing on how contraception methods impact the female reproductive system.
Studies showed me how common it was for women coming off the contraceptive injection to experience secondary amenorrhea (3); the term used to describe symptoms of someone who has had periods in the past but for some reason, they have stopped for 3 months or more (4). I learnt that, on average, fertility in women coming off the contraceptive injection was expected to resume 10 months after the last dose of hormones. However, occasionally the suppression of ovulation would persist for 22 months (5). These facts and figures all correlated with my own experience, begging the question of why a nurse hadn’t told me this prior to the first injection.
Finally, in November ‘18 I was joyfully reacquainted with my menstrual blood. Singing my cycle back in and adamant to engage with my own natural body, I stocked up on condoms and started paying close attention to my body's ever-changing form. Over the course of a year, my periods grew heavier and more regular. The blood collected in my menstrual cup changed from light bright red to stewed dark browns. I committed to tracking my cycle and now enjoy every tell-tale sign that indicates when I’m ovulating, when I’m due to start my period, and all the stages in between. Though it was disconcerting having to wait so long, it seems that the distance from my menstrual cycle really did make my heart grow fonder.
References
1. Stoddard A, Eisenberg DL. Controversies in family planning: timing of ovulation after abortion and the conundrum of post-abortion intrauterine device insertion. Contraception. 2011;84(2): pages 119-121.
2. Smith M. Depo-Provera (Injectable Contraceptive)—A Review. Scottish Medical Journal. 1978;23(3):pages 223-226.
3. Lord M, Sahni M. Amenorrhea, Secondary. (Updated 2020 Jul 17), StatPearls Publishing; Jan2020
4. Depot-medroxyprogesterone acetate (DMPA-SC) (Sayana® Press) Application for Inclusion in the WHO Essential Medicines List December 2016, paper referred to September 2020
5. Kaunitz AM. Injectable depot medroxyprogesterone acetate contraception: an update for U.S. clinicians. Int J Fertil Womens Med. 1998;43(2):pages 73-83.
