Some comments from other NFP professionals:

" ...I had one client back in 99 who had been on Depo. She had 2 Depo shots, last one in Feb 99.  She came to my class in June of 99 and her temps were constantly high -- waking temps of 98.6 to 99. I don't remember what her mucus was showing, vaguely remember that she was having different types including stretchy, but at the time, I think she thought she might have a vaginal infection.  Temps stayed up till around Jan of 2000 and then dropped and stayed down I think.

Following the next menstruation, she had mittleschmertz and decided to try for pregnancy. She conceived. She says this was the first ovulation after depo according to the signs.  So it took her about a year after the last shot to ovulate.  The interesting thing is that the temps were very helpful to her in this situation, CCL conferred with a doc who instructed us to consider her infertile until the temps dropped which is exactly what she experienced.  Those temps stayed up in the post-ovulatory area for almost a whole year.

I just gave a conference to public health nurses who told me they counsel women that it takes an average of 18 months for fertility to return.

Kristina J."


"I have had only one client coming off Depo in April 2001. Her chart until July 2001 was completely infertile, no bleeding, just green stamps indicating dryness, or infertility. I have instructed her to remain on the Early Days Rules, intercourse every other night, and watch for a change in sensation or beginning of mucus...

Mary M."



"Worked with a client who had had 3 - 4 depo shots, about a year.  Her husband complained how ornery she was and how violent she could be with
their children.  I teach the Creighton Model Ovulation System, and she was totally dry.  After three months of charting she became complacent
and discontinued follow-ups.  Since she was so young I felt her fertility would return and tried to encourage her to continue making and
charting her observations but she didn't want to bother.  She became pregnant about 2 yr. after discontinuing depo and was very upset.  After
having the baby, which, thankfully they fully enjoy, she had a tubal. I was so shocked she made such a radical decision. Guess all I can say is keep in touch with these women as they most often return to fertility.  I have always felt I failed with this client.
 
Kathy D."


Just a few more Footnotes:




 From the NWFS book, the Basic Instructional Approach on post-hormonal (reproductive category #6):

When is a woman "post-Depo-Provera"?
The post-Depo-Provera phase begins three months from the date of her last shot, so charting is in order by then.  Some women, however, may experience a
delay of one years or more in the return of the menstrual periods.  The temperature level may be somewhat elevated for several months because of
the synthetic progesterone.  The most common occurrence is prolonged dry days with a gradual return of cycling.

Background on Post-Hormone Possibilities:
 
There may be a delayed return of bleeding and temperature rise, perhaps as long as a year, especially with post-Norplant or
post-Depo-Provera.  Sometimes the woman will have bleeding episodes but no temperature rise.  She may experience a "dry" cycle with a temperature rise
and menstrual bleeding.  If after 6-12 months the woman does not experience a true menstruation, she should be referred to her health care provider.

  There may be a variable return of fertility, with sporadic mucus and bleeding.

Generally, the younger the woman is when she first takes the hormone and the less established are her cycles, the more likely it is for her to have
problems with recovery.  Women seem to experience more breakthrough bleeding with progesterone-only pills.

Lorincz reported (International Review of NFP, I/3, 1977) that "...after cessation of oral 'contraceptive steroids', amenorrhea persists for six
months or longer.  This phenomenon simulates the occasional period of extended anovulation that may follow pregnancy or lactation.  Recover after
long-term suppression usually does occur; the pituitary recovers first (FSH first, then LH), followed by the ovary, and the endometrium, which may
require three months to regain its normal histologic appearance and enzymatic activity.  In any event, when significant suppression of the
hypothalamic-pituitary system has occurred through the use of oral 'contraceptives' it cannot be expected that ovulation will subsequently
become enhanced when the drugs are discontinued."

Furthermore, Erik Odeblad found in his investigation of cervical mucus that the Pill accelerates aging of the cervix.  He says, "a pregnancy
rejuvenates the cervix by 2-3 years, but for each year the Pill is taken, the cervix ages by an extra year.  If a woman takes the Pill for 10-15
years and then ceases taking it in order to achieve pregnancy, she may encounter some difficulties.  Studies indicate that the number of S crypts
are very few and, as well, the cervical canal will be very narrow.."

Needless to say, Lorincz's interpretation gives an explanation for the phenomenon that is observed, such as an increase in miscarriages the first
3-6 months postpill (we don't know if the same will occur post-Norplant or post-Depo-Provera).  Odeblad's research clarifies the temporary or even
permanent infertility some women experience postpill.  But for the purposes of NFP, we need to always remember that the bottom line is making
judgements on the basis of the charts.

Persistent mucus is a common post-hormone problem.  When cervical cells are infected, exposed, or damaged (cervicitis, cervical eversion, or cervical
erosion), there may be a constant secretion of mucus.  "Dry" cycles post another problem, with some women noticing persistent dryness. They should
be encouraged to be very conscientious in their observations and advised that the cervical examination may help.  Once cycling begins, "dry" cycles should use the  Day 6 rule (as usual, use evenings only, and watch for mucus), and a temperature-only rule for Phase 3.

The Basic Instructional Approach for Posthormone is
*  Abstain and chart.  Then...
*  Use the Basic S-T Rules for Phase 3  (or the just-off-the-pill temperature rule, if  the mucus pattern is ambiguous or absent).
*  For Phase 1: if no temperature-rise occurs by four weeks, apply the End of Phase 1 Rules to any change from a continuous pattern of otherwise unchanging discharge.  Don't use "Patch Rules" as for post-partum.
*  Once cycling resumes,  assume you are in your normal cycles.
--------------------------------------------




Depo-Provera Impairs Arterial Endothelial Function 

 Sept. 5, 2002 — Long-term use of Depomedroxyprogesterone acetate (DMPA [Depo-Provera]) impairs arterial endothelial function measured by cardiovascular magnetic resonance (CMR), according to research published Sept. 3 in Circulation.  DMPA affects arterial ability to "respond to different stimuli and particularly affects the ability of the artery to dilate,"  senior author Dudley J. Pennell, MD, from the Imperial College School of Medicine in London, U.K., said in a news release.

 Endothelium-dependent, hyperemia-induced flow-mediated dilatation, an indicator of endothelial function, was significantly reduced in the DMPA users to 1.1%, compared with  8.0% in controls during menstruation (P<.01). By inhibiting proliferation of ovarian follicles, DMPA prevents ovulation and decreases  circulating estrogen, which may be potentially harmful to cardiovascular health.

 Although DMPA had been considered a good drug for women with some cardiac risk factors such as smoking, hypertension, or a family history of heart disease, Pennell says that  these findings suggest that women with risk factors for cardiovascular disease "would be wise to review that decision with their physician."




Subject: More on Provera
24 Feb 2002

After some reflection and looking some things up this is what I found.

1. In Lobo, PA "Progestogen Metabolism" in Journal of Reproductive Medicine in 1999: "Progestagens are metabolized differently fromm endogenous progesterone". The metabolities are dependent on the route of administration, show significant variation among individuals, and are
metabolized differnetly by different organs. The metabolities of progestagens have different biologic potencies. Included in this are the C-6
progestins (Provera and Depo-Provera).

2.From numerous studies provera and micronized progesterone have differing effects on the heart - provera having a more adverse effect on cholesterol
(like androgens) .

3.The Depo form of provera (Depo-Provera) binds to androgen receptors, which is useful in treating sex criminals who are testosterone-laden

4. Provera has 15 times the potency of progesterone.  So I think we should be cautious about provera and its effects on the endometrium. The differences between the C-6 and C-19 progestins (provera and norethindrone/norgesrel ) definitely work better than progesterone for controlling abnormal bleeding, because they are more efficient at making a thinner endometrium, but in ovulatory women they might make the endometrium too thin for implantation.

Mary D