What alternative contraceptive methods are appropriate for a 30‑year‑old woman with four children who experiences mood disturbances while using depot medroxyprogesterone acetate (Depo‑Provera) and desires reliable birth control?

Alternative Contraceptive Options for a 30-Year-Old Woman with Mood Disturbances on Depo-Provera

Switch to a long-acting reversible contraceptive (LARC) such as a copper IUD or levonorgestrel IUD, or consider the etonogestrel subdermal implant, as these methods provide highly effective contraception without the systemic progestin levels associated with Depo-Provera's mood effects. 1

Understanding the Problem with Depo-Provera

Depot medroxyprogesterone acetate (DMPA) is associated with mood disturbances in some women, including depression and emotional changes. 2, 3, 4 A randomized controlled trial demonstrated statistically significant increases in depression scores among women using DMPA compared to copper IUD users, with higher rates of major depression at 3 months postpartum. 2 These mood effects are well-documented side effects that can significantly impact quality of life and lead to method discontinuation. 3, 5, 4

First-Line Alternative: Long-Acting Reversible Contraceptives (LARCs)

Copper Intrauterine Device (Cu-IUD)

• The copper IUD is the optimal choice for this patient because it provides highly effective contraception (failure rate <1%) without any hormonal component, completely eliminating concerns about progestin-related mood effects. 1
• Offers 10-12 years of continuous protection without requiring user adherence beyond initial placement. 1
• Particularly appropriate for women who have completed childbearing or desire long intervals between pregnancies. 1
• The copper IUD is rated Category 1 (no restriction) by CDC Medical Eligibility Criteria for parous women. 6

Levonorgestrel Intrauterine Device (LNG-IUD)

• Delivers very low systemic progestin levels compared to DMPA, with primarily local endometrial effects. 6
• May be better tolerated than systemic progestin methods in terms of mood effects due to minimal systemic absorption. 6
• However, there is some controversy: while epidemiological data suggest a possible increased breast cancer risk, clinical trials in breast cancer patients showed no increased recurrence rates. 6
• For women specifically concerned about hormonal mood effects, the copper IUD remains preferable to the LNG-IUD. 6
• Provides additional benefits of reduced menstrual bleeding and dysmenorrhea. 1

Etonogestrel Subdermal Implant

• Another highly effective LARC option with <1% failure rate and 3-year duration. 1, 7
• Contains a different progestin (etonogestrel) than DMPA, which may be better tolerated in terms of mood effects. 7
• Provides steady, lower-dose progestin release compared to the high-dose depot injection. 7
• Can be removed at any time if side effects occur, with rapid return to fertility. 7

Second-Line Alternative: Barrier Methods

Non-Hormonal Barrier Options

• Condoms, cervical diaphragm, and cervical cap are completely hormone-free options that avoid any mood-related effects. 6
• These methods are particularly recommended when hormonal contraception is contraindicated or poorly tolerated. 6
• Require consistent use with each act of intercourse, making them less effective than LARCs (typical use failure rates 12-18%). 1
• Should be combined with fertility awareness methods for improved efficacy if LARCs are declined. 6

Third-Line Alternative: Combined Hormonal Contraceptives (If No Contraindications)

Etonogestrel/Ethinyl Estradiol Vaginal Ring

• Contains both estrogen and progestin, which may provide better mood stability than progestin-only methods in some women. 7
• Delivers steady hormone levels with once-monthly insertion. 7
• Critical contraindications to assess: smoking over age 35, history of thromboembolism, migraine with aura, cardiovascular disease, or hypertension. 7
• The vaginal ring is contraindicated in women with high risk of arterial or venous thrombotic diseases. 7

Combined Oral Contraceptives (COCs)

• May be considered if patient has no contraindications to estrogen. 6
• Some women report improved mood stability with combined hormonal methods compared to progestin-only options. 3
• Requires daily adherence, which may be challenging for a busy mother of four children. 1

Critical Counseling Points

Addressing Mood Concerns

• Explicitly validate the patient's experience that mood disturbances are a recognized side effect of DMPA and a legitimate reason to switch methods. 2, 3, 4
• Explain that non-hormonal methods (copper IUD) completely eliminate hormonal mood effects. 6, 2
• If considering the LNG-IUD or implant, counsel that lower systemic progestin levels may result in fewer mood symptoms than DMPA. 6

Efficacy Comparison

• Emphasize that LARCs (IUDs and implants) have failure rates <1%, which is equivalent to or better than DMPA's 0.2-0.3% perfect use failure rate. 1
• Barrier methods are significantly less effective (12-18% typical use failure rate) but appropriate if patient strongly prefers non-hormonal, non-invasive options. 1

Return to Fertility

• Important consideration: DMPA has delayed return to fertility (up to 9 months after last injection), whereas IUDs and implants allow immediate return to fertility upon removal. 8
• This may be relevant even for a woman with four children who may want the option of rapid fertility return if circumstances change. 8

Common Pitfalls to Avoid

• Do not dismiss mood symptoms as unrelated to DMPA – research clearly demonstrates this association. 2, 3, 4
• Do not assume all progestin methods will cause the same mood effects – the high-dose, long-acting nature of DMPA may be uniquely problematic. 2, 8
• Do not overlook the copper IUD as the most straightforward solution for hormone-related mood concerns. 6, 2
• Do not prescribe combined hormonal methods without screening for cardiovascular risk factors including smoking, hypertension, and history of thromboembolism. 7
• Do not limit contraceptive counseling to hormonal options – barrier methods combined with fertility awareness can be effective for motivated users. 6