Talk:Depot medroxyprogesterone acetate

Introduction
Maybe its just me, but it took quite some time to figure out what the drug does. I think in order to make the article clearer, someone needs to revamp the introduction and make it clearer. I would offer to, but this is way outside my knowledge. Sovereignlance (talk) 07:07, 21 December 2011 (UTC)

Lacroix studies
I've noticed that the two "LaCroix" studies (probably more accurately Scholes studies, as Scholes is the lead author) are billed as being essentially one study on the talk page and in the article. I'm not clear why this is. Looking at the studies, they describe two different patient populations. One study looked at a group of 170 women aged 14-18, enrolled in 1999-2000. The other study looked at 457 women aged 18-39, enrolled 1994-1999. There's no overlap in the cohorts (see their ages), and they were enrolled separately (not as part of the same project). So these would appear to be two separate studies, which reached similar conclusions. I think the confusion may arise from a third study, in which Scholes et al. "pre-published" their results from the adolescent cohort, but that study is not referenced in the article. The bottom line is that there appear to be two separate studies (one in adolescents, one in adult women) which reached similar conclusions about reversibility of BMD after discontinuation of Depo (in addition to the small New Zealand study). I'll make an adjustment to the text to reflect this. MastCell 03:29, 5 November 2006 (UTC)

Pfizer consultant
Thank you, David. Points taken. Apologies to Cindery for being unnecessarily argumentative. To refocus on content issues, I'm curious to hear other opinions about labeling Lacroix a "Pfizer consultant" in the context of this article, as I notice I'm not the only editor to raise this concern. My own feeling is that it represents OR, as I mentioned above, again in needlessly incivil language for which I apologize. MastCell 03:35, 5 November 2006 (UTC)

pov
i must add to this discussion since my mother was tricked into being injected with depo provera 28 years ago, in britain there where many foreign women also coerced and some even FORCED into being injected with provera - non of them knew depo would have such an awful affect to their health and neither i believe do all those pour women in thailand.

...i was breast fed soon after i was born so i too have had serious health problems since childhood ..some of these issues include low bone density since the age of about 6 ,my mother developed osteoarthritis soon after being given the depo injection ,however she was not on depo for a long time but still she developed these problems and so did i and many of the women also on depo-provera and the children born soon after to mothers on this drug....this is no mere coincidence and the medical world has consistently LIED about the dangers. there are thousands of women here in the u.k who have attempted to sue the drug company's ..my mother is one of them. whoever created this drug has a lot to answer for.

suggestion: cancer section
I suggest that this article have a section just for evidence about cancer risks. Why is item #9 in the "Footnotes" section blank? --JWSchmidt 04:24, 5 November 2006 (UTC)

Just a question (from a random reader of course), when the trials were taking place for the Depo-Provera were any other variables taken into consideration? Such as other contraceptives being used with the depo-provera, surroundings, and the people being tested of course. Because if the first-year failure rate results were tested by only using the depo and nothing else, that would be quite impressive. — Preceding unsigned comment added by 99.161.161.167 (talk) 18:03, 6 August 2011 (UTC)

Just a question (from a random reader of course), when the trials were taking place for the Depo-Provera were any other variables taken into consideration? Such as other contraceptives being used with the depo-provera, surroundings, and the people being tested of course. Because if the first-year failure rate results were tested by only using the depo and nothing else, that would be quite impressive. — Preceding unsigned comment added by 99.161.161.167 (talk) 18:03, 6 August 2011 (UTC) — Preceding unsigned comment added by 99.161.161.167 (talk)

Content Deleted

 * Use of Depo may offer more privacy to some users than other forms of contraception, such as pills, condoms, and diaphragms, as there are no material objects which must be kept at home to continuously provide contraceptive protection.


 * Depo is not immediately reversible. Because Depo Provera is administered once every 3 months, treatment can only be stopped 3 months after the last injection.

i can only assume the following claim is nonsense: .
 * Infants born to women exposed to Depo during pregnancy in one study had an 80% greater chance of dying in the first year of life. —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs)

inaccurate inoformation
"The majority of this article has been written by a single editor who persistently and blatantly violates WP:NPOV, WP:NOR, and restores inaccurate information, using Wikipedia as a soapbox to push their POV that Depo-Provera (and most other contraceptives) are dangerous products foisted on women by a conspiracy of greedy and malevolent corporations, public health organizations and physicians. 68.255.20.88 08:05, 3 November 2006 (UTC)"

actually i would like to see that 'inaccurate inoformation' - at least in the discussion section - as well as Pfizers' completely accurate and neutral information —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

Depo during pregnancy
'Infants born to women exposed to Depo during pregnancy in one study had an 80% greater chance of dying in the first year of life'

does this mean something along the lines of: "while Depo is not injected during pregnancy, if it WERE injected due to error the consequences would be............"

or does it mean something else entirely????????? also the citataion does not re-direct to an actual article —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

effectiveness of Depo
is it reasonable to suggest in the article that while other contraceptives are only partially effective Depo is near 100% effective or is that not accurate? —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

deliberate misinformation?
'Infants born to women exposed to Depo during pregnancy in one study had an 80% greater chance of dying in the first year of life' and here is the citation:

Exposure to DMPA in pregnancy may cause low birth weight.

[No authors listed]

PIP: A study sponsored by the Special Program of Research, Development and Research Training in Human Reproduction of the World Health Organization was carried out in Thailand involving groups of women with 1573 accidental pregnancies. There were 830 accidental pregnancies while using the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), while 743 women had become pregnant before use. There were also 601 accidental pregnancies in oral contraceptive (OC) users. The comparison group of a total of 2587 controls comprised women whose pregnancies were planned as opposed to the exposed group. Women using DMPA had more pregnancy risk factors compared to other groups owing to low socioeconomic status, lower maternal weight and height, smoking and alcohol use during pregnancy, and unplanned pregnancy. However, even after adjusting for these factors, DMPA users had a 50% higher than normal risk of having a low-birth-weight child. The same level of statistically not significant risk was also found among the OC users. Among those who had had accidental pregnancies during DMPA use, and in whom conception was estimated to have occurred within 4 weeks of a DMPA injection, the risk of low birth weight was 90% higher than that in the control group. The increase in risk appeared to decline to 50% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval between conception and DMPA injection was 5-8 weeks, and to 20% when the interval was or= 9 weeks. This trend was highly significant. Early, high-dose exposure in utero to DMPA seemed to affect fetal growth. There was no increase in the risk of mortality in the 1st year of life for infants exposed to OCs as compared to infants not exposed. However, infants from DMPA-exposed pregnancies had an 80% higher than normal risk of dying during the 1st year of life. Therefore, some infants born out of accidental pregnancies that occur during DMPA use may be at an increased risk of infant death.

—The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

content deleted
according to Pfizers' site, which the section on Warnings and precautions is purportedly referfing to: 'You should use Depo-Provera Contraceptive Injection long term (for example, more than 2 years) only if other methods of birth control are not right for you.'

i have deleted those items which appear to be either gibberish or deliberate misinformation —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

gibberish?
how is the following NOT gibberish? 'Use of Depo may offer more privacy to some users than other forms of contraception, such as pills, condoms, and diaphragms, as there are no material objects which must be kept at home to continuously provide contraceptive protection.' —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

It's not really possible to quantify that, but it seems pretty obvious. How IS that gibberish? If you're using the normal use of gibberish to mean something that doesn't make any sense, I don't see your point.71.63.119.49 01:13, 18 August 2007 (UTC)

content deleted

 * 'This loss of BMD is of particular concern during adolescence and early adulthood, a critical period of bone accretion.'

sounds good however what is BMD and what is 'bone accretion'...... and who is the target audience?


 * Long-term studies of users of Depo-Provera have found slight or no increased overall risk of breast cancer. However, one subset of the study population did show an increased risk of breast cancer in recent users (Depo use in the last four years) under age 35. ........... the reference appears to be about Pfizers' disclaimers RE loss of bone calcium —The preceding unsigned comment was added by 202.0.106.130 (talk • contribs).

WOAH!
Many parts of this article are good and NPOV, but other parts of it read like a scathing review. I'm sorry I don't have any better critcism at this time, but wow... this article seems to be highly POVed against use of Depo. I don't want to start disputing facts, or quotes, like where there's that quote that (paraphrased) Depo is by far the most dangerous drug on the market (/paraphrased). But it would be nice if the content outside of facts and quotes were more straight forward, honest, and neutral. I mean, the dangers that are inherent in use of Depo are pretty clear given the facts, I don't think we need to bolster that with our own personal opinions. --Puellanivis 22:16, 4 December 2006 (UTC)


 * You've probably seen on the talk page that issues of POV have been debated pretty heavily. I tend to agree with you. If you have some suggestions on how the page can be improved, please go for it. Don't worry - if others disagree with your edits, you'll hear about it. MastCell 00:36, 5 December 2006 (UTC)


 * I completely agree. Mifepristone is in a similar state. -Severa (!!!) 11:55, 19 December 2006 (UTC)


 * I also agree (except few not many parts of this article are accurate and NPOV). Mifepristone (and Emergency contraception) are in similar states. All three articles should be flagged to warn readers that the neutrality and factual accuracy of the articles are disputed.68.255.23.152 18:10, 20 December 2006 (UTC)

In general, I think the template and its ilk should be reserved for instances where no agreement or consensus can be reached on NPOV, despite the efforts of a number of editors. I don't think we're at that point yet - I'd suggest, instead, editing the three articles to try to remove what appears to be POV. It may be possible to do so and maintain a reasonable consensus. If not, and an impasse is reached, then the NPOV tags would be more appropriate - I just don't like to use them first-line, before we've made efforts to address the POV issues. So I guess what I'm saying is, be bold and edit the articles (or propose edits on the talk page) to address the POV issues. MastCell 18:21, 20 December 2006 (UTC)


 * I think it is perfectly appropriate to flag articles that have been made extensively and pervasively biased and factually inaccurate as a result of hundreds and hundreds of edits by a single editor in a short period of time.68.255.23.152 20:20, 20 December 2006 (UTC)

Well, I guess whether you add the tag is up to you. I would say that if you add the tag, it would be best to list here on the talk page specific areas/issues which you believe are factually inaccurate or POV. Best of all is to also propose edits to resolve those issues). My experience has been that just tagging an article as POV, without specifying the reasons and particulars, is not as constructive. MastCell 21:57, 20 December 2006 (UTC)

Recent edits
I've removed the following from "Warnings and Precautions": "Some women may prefer amenorrhea. According to Jerilynn Prior, M.D., professor of endocrinology and metabolism at the University of British Columbia in Vancouver, and board member for the Society for Menstrual Cycle Research,'the most important thing to emphasize about menstrual suppression is that the long-term effects are simply unknown,' and 'allowing the one vital sign unique to women to go unmonitored...could ultimately lead to an enormous uncontrolled experiment with a woman's health.'" The "some women may prefer..." sentence is unsourced, and the quote on the importance of a menstrual cycle and the possbile risks of amenorrhea is in no way specific to Depo (it would apply equally to all forms of hormonal contraception) and is more appropriate for the hormonal contraception or amenorrhea articles. MastCell 18:32, 20 December 2006 (UTC)


 * Also removed, from "Black Box Warning", the clause about WHO distribution vs. FDA approval. This has little to do with the black box warning on bone loss, and the controversy is already covered under the "Controversies" section, which is the more appropriate place for it. The removed source is here for archival purposes: . MastCell 18:43, 20 December 2006 (UTC)


 * I know we've gone back and forth about LaCroix being a consultant to Pfizer, but to recap: in the studies cited here, a) no conflicts of interest are disclosed, and b) LaCroix is neither the lead nor senior author. The Pfizer consultancy thing is apparently based on a separate, unrelated article authored by LaCroix in 2003 in which she notes receiving consultancy fees from Pfizer. There are several issues here: a) the papers cited here do not disclose a conflict of interest; b) the potential conflict noted in the 2003 paper comes after one of the studies cited here - there's no indication whether LaCroix had received fees at the time of the relevant article's publication; c) joining fact A (LaCroix wrote a paper on Depo) with Fact B (LaCroix elsewhere disclosed a Pfizer consultancy fee in a different article) to advance Position C (that LaCroix had an undisclosed conflict relevant to the Depo paper) is the defintion of original research. Finally, the way it's phrased now, it seems to totally discount the results of two peer-reviewed studies based on an OR assertion of an undisclosed conflict of interest which no citable source seems to be alleging. Therefore I've removed it. MastCell 18:58, 20 December 2006 (UTC)
 * Well thought out comments.  DPeterson talk 03:33, 15 January 2007 (UTC)

Contraindications
The Contraindications section of this Wikipedia article used to only say:
 * Women with the following conditions should not use Depo Provera:
 * * stroke
 * * currently pregnant
 * * current or past breast cancer
 * * liver problems or liver disease
 * * blood clots

The full prescribing information from Pfizer for Depo-Provera in the United States lists the following in its Contraindications section:
 * 1. Known or suspected pregnancy or as a diagnostic test for pregnancy
 * 2. Undiagnosed vaginal bleeding
 * 3. Known or suspected malignancy of the breast
 * 4. Active thrombophlebitis, or a current or past history of thromboembolic disorders, or cerebrovascular disease.
 * 5. Significant liver disease
 * 6. Known hypersensitivity to Depo-Provera CI (medroxyprogesterone acetate or any of its other ingredients.

The summary of product characteristics (SPC) from Pharmacia (Pfizer) for Depo-Provera in the United Kingdom and Europe says the following its Contraindications section:
 * Depo-Provera is contra-indicated in patients with a known sensitivity to medroxyprogesterone acetate or any ingredient of the vehicle.
 * Depo-Provera should not be used during pregnancy, either for diagnosis or therapy.
 * Depo-Provera is contra-indicated as a contraceptive at the above dosage in known or suspected hormone-dependent malignancy of breast or genital organs.
 * Whether administered alone or in combination with oestrogen, Depo-Provera should not be employed in patients with abnormal uterine bleeding until a definite diagnosis has been established and the possibility of genital tract malignancy eliminated.

The WHO Medical Eligibility Criteria for Contraception and the RCOG FFPRHC UK Medical Eligibility Criteria for Contraception have more informative annotated tables of relative (category 3) and absolute (category 4) contraindications for Depo-Provera than the list drawn from Pfizer's US-only full prescribing information and patient package insert.

Significantly, Pfizer's US-only label information lists "past history of thromboembolic disorders" as a contraindication to using Depo-Provera, whereas the UK and European SPC, the WHO and FFPRHC Medical Eligibility Criteria for Contraception, and current medical reference textbooks do not and even suggest progestogen-only contraceptives including Depo-Provera as alternatives to combined oral contraceptives containing estrogen for which a "past history of thromboembolic disorders" is an absolute (category 4) contraindication.

It is also useful to distinguish contraceptive methods like Depo-Provera and other hormonal contraceptives where use during pregnancy is not indicated but accidental use has not been found to be harmful, from contraceptive methods like the IUD where use during pregnancy is an absolute (category 4) contraindication (because of the risk of serious pelvic infection and septic spontaneous abortion).

The link to the WHO and FFPRHC Medical Eligibility Criteria for Contraception Progestogen-only contraceptive tables also provides easy comparison of injectable progestogen-only contraceptives including Depo-Provera with oral progestogen-only contraceptives (minipills) and progestogen-only implants (Norplant, Jadelle, Implanon) that explain why Depo-Provera has more relative (category 3) contraindications than progestogen-only minipills or implants: 1) Depo-Provera is long-acting and not rapidly reversible 2) Depo-Provera's relatively high progestogen dose suppressing follicular development and ovulation leads to a hypo-estrogenic state which may decrease protective HDL and could theoretically increase cardiovascular risk (though it has not been shown to do so)--which would be of most concern with women already at very high cardiovascular risk (such as those with a history of ischemic heart disease, stroke, complications of hypertension, or complications of diabetes).

If this Wikipedia article's Contraindication section is too long, perhaps: 69.208.162.137 20:54, 16 January 2007 (UTC)
 * a stub article defining the FFPRHC could help shorten the introductory sentence?
 * "breastfeeding < 6 weeks postpartum" should be deleted? (since the FFPRHC does not consider it to be a relative contraindication)


 * Apologies for the perhaps too-hasty reversion. I think the expansion is a good idea - although perhaps we could find a way to make it a little more user-friendly (move away from Category 3, Category 4, etc to just a description of what those terms mean)? MastCell 21:31, 16 January 2007 (UTC)

I agree that the category numbers were superfluous, so I have removed them. I also removed "breastfeeding < 6 weeks postpartum" which is listed as a relative contraindication in the WHO MEC but not in the FFPRHC MEC, and is not listed as a contraindiction in the US prescribing information nor in the UK SPC. 69.208.162.137 04:54, 17 January 2007 (UTC)

NPOV tag
I'm sorry, what were the grounds for attaching the "neutrality disputed" tag? Usually if there are issues, they're addressed here on the talk page and via edits. If they can't be resolved here, then the tag is attached. Could the placer of the tag comment on the POV issues, so that we can work on them? MastCell 21:31, 18 January 2007 (UTC)


 * This Wikipedia article shamefully, intentionally, totally misrepresents the advantages, disadvantages and history of Depo-Provera as found in current, authoritative medical reference textbooks.
 * Any and all good faith efforts to add any balance to this article are immediately reverted or altered.
 * The NPOV flag should apply to the article as a whole because the bias and misinformation is pervasive throughout the article and will take a long time to resolve.
 * 69.208.168.135 21:50, 18 January 2007 (UTC)


 * I know you said the whole article is biased, but it would help other editors to contribute to fixing the problems, if you tried your best to list specific problems here on talk.-Andrew c 21:53, 18 January 2007 (UTC)

Yes, please calm down and talk to us. Which parts do you consider shameful, intentional misrepresentations? We're reasonable folk. I don't think any of the regular editors here have a major pro- or anti-Depo axe to grind. Please assume the best, at least until proven otherwise. MastCell 22:36, 18 January 2007 (UTC)


 * Some problems with this article include:


 * Infobox
 * Misrepresents, overemphasizes, and overstates breast cancer risk
 * Misrepresents, overemphasizes, and overstates cervical cancer risk
 * Benefits
 * Misrepresents and understates the duration of the reduced endometrial cancer risk
 * Misrepresents and understates the significance and importance of the reduced risk of seizures in women with epilepsy
 * Misrepresents and understates the significance and importance of the reduced risk of sickle cell crises in women with sickle-cell disease
 * Pregnancy and breastfeeding
 * Misrepresents the risk of Depo-Provera during pregnancy and breastfeeding
 * Warning and precautions
 * Misrepresents and overstates breast cancer risk
 * Misrepresents and overstates risk of Depo-Provera during pregnancy
 * Black box warning
 * Overemphasizes BLACK BOX WARNING about the risk of reduced bone density in Depo-Provera users
 * Side effects
 * Misrepresents rare adverse effects that have occurred while using Depo-Provera (but have not been postulated to be caused by Depo-Provera) such as DVT & PE and lack of return to fertility (no increased risk found in trials), convulsions (studies have found reduced risk)
 * "Related studies"
 * Misrepresents the significance of primate studies of SIV and Depo-Provera which did not correspond with studies in humans
 * Misrepresents the significance and notability (WP:NN) of "a study in mice" of Depo-Provera and herpes
 * Misrepresents the significance and notability (WP:NN) of "an in vitro study of glutamate excitotoxicty" that Cindery thinks "may render users more vulnerable to neurodegeneration"
 * Controversy over Approval of Depo-Provera in the United States
 * Misrepresents the history of the "Controversy over Approval of Depo-Provera in the United States" and its "Aftermath"--could more accurately be titled "Misleading and Inaccurate Arguments Made Three Decades Ago by Opponents of the Approval of Depo-Provera in the United States" (before the FDA approved Depo-Provera 15 years ago, finally agreeing with the WHO, IPPF, AMA, ACOG, and the drug regulatory agencies of over 90 other countries that Depo-Provera is a safe and effective contraceptive--and stopped requiring long-term carcinogencity tests of contraceptives in beagles and monkeys because they do not predict carcingencity in women).
 * 69.208.168.135 00:11, 19 January 2007 (UTC)


 * Thank you very much for this. When I have more time I will review more closely and comment further.-Andrew c 01:09, 19 January 2007 (UTC)
 * Likewise... heading out the door now, but thanks for listing them and I'll comment soon. MastCell 02:28, 19 January 2007 (UTC)


 * In this Wikipedia article and other Wikipedia articles on contraception, I suggest using secondary sources such as:


 * Current leading medical reference textbooks of contraception, reproductive endocrinology, endocrinology, and gynecology like:
 * Hatcher et al. (2004). Contraceptive Technology, 18th ed. ISBN 0-9664902-5-8 (19th ed. due this month)
 * Speroff & Darney (2005). A Clinical Guide for Contraception, 4th ed. ISBN 0-7817-6488-2
 * Mishell (2004). "Contraception" in Strauss & Barbieri, Yen & Jaffe's Reproductive Endocrinology, 5th ed. ISBN 0-7216-9546-9
 * Glasier (2006). "Contraception" in DeGroot & Jameson, Endocrinology, 5th ed. ISBN 0-7216-0376-9
 * Kafrissen & Adashi (2003). "Fertility Control: Current Approaches and Global Aspects" in Larsen et al. Williams Textbook of Endocrinology, 10th ed. ISBN 0-7216-9184-6
 * Stubblefield et al. (2007). "Family Planning" in Berek, Berek & Novak's Gynecology, 14th ed. ISBN 0-7817-6805-5


 * Review articles in leading peer-reviewed journals of medicine, obstetrics and gynecology, contraception, and reproductive medicine like: New England Journal of Medicine, JAMA, American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, Contraception, and Fertility and Sterility in the United States and The Lancet, BMJ, BJOG, Journal of Family Planning and Reproductive Health Care, and Human Reproduction in the United Kingdom.


 * Guidelines from organizations like: WHO, ACOG, RCOG and its Faculty of Family Planning and Reproductive Health Care (FFPRHC).


 * as guides to the current medical consensus on these subjects.


 * The above are the most authoritative, comprehensive and reliable sources that I am aware of. I do not claim they represent an exclusive or exhaustive list of reliable sources, but are examples of the type of sources that would provide a good basis for this article. I would welcome other editors' suggestions of other similar reliable sources.
 * 69.208.168.135 06:02, 19 January 2007 (UTC)

Duration of reduced endometrial cancer risk
69.208.168.135 17:46, 19 January 2007 (UTC)
 * Benefits
 * Misrepresents and understates the duration of the reduced endometrial cancer risk:
 * "The decrease in risk  may extend even after  Depo Provera is discontinued."
 * citing: Westhoff (2003). "Depot-medroxyprogesterone acetate injection (Depo-Provera®): a highly effective contraceptive option with proven long-term safety". which says:
 * "A number of noncontraceptive health benefits associated with the use of OCs have also been observed among women who use DMPA. Although currently the only FDA-approved indications for DMPA are for contraception and the treatment of metastatic endometrial cancer (with the injectable suspension of 400 mg/mL of medroxyprogesterone acetate), clinical experience has shown that a number of gynecological problems improve or have a reported lower incidence among women who receive this long-acting progestin. It should be noted that these represent off-label uses that have not been approved by the FDA.
 * Similar to OCs, DMPA users have been noted to experience a decreased risk of endometrial cancer, iron deficiency anemia, pelvic inflammatory disease, and ectopic pregnancy. DMPA has demonstrated an 80% risk reduction for endometrial cancer, which may extend beyond the duration of use."
 * citing: Thomas & Ray (1991). "Depot-medroxyprogesterone acetate (DMPA) and risk of endometrial cancer". who concluded:
 * "The relative risk of endometrial cancer was estimated to be 0.21. Although based on small numbers of exposed women, the protective effect of DMPA appeared to last at least 8 years after cessation of use. The reduction in risk of endometrial cancer is at least as great for DMPA as for combined oral contraceptives."
 * Speroff & Darney (2005). A Clinical Guide for Contraception, 4th ed. ISBN 0-7817-6488-2
 * "Oral Contraception
 * Endometrial Cancer, p. 72
 * The use of oral contraception protects against endometrial cancer. Use for at least 12 months reduces the risk of developing endometrial cancer by 50%, with the greatest protective effect gained by use for more than 3 years. This protection persists for at least 20 years after discontinuation (the actual length of duration of protection is unknown) and is greatest in women at highest risk: nulliparous and low parity women."
 * "Injectable Contraception
 * Advantages, p. 205
 * "Other benefits associated with depot-medroxyprogesterone acetate use include a decreased risk of endometrial cancer comparable with that observed with oral contraceptives."
 * Hatcher & Nelson (2004). "Combined Hormonal Contraceptive Methods" in Hatcher et al. Contraceptive Technology, 18th ed. ISBN 0-9664902-5-8
 * "Advantages and Indications
 * General health benefits
 * 1. Endometrial and ovarian cancer risk reductions.
 * OC use for at least 12 months reduces a women's risk of developing endometrial cancer by about 40%. That risk reduction is increased to 80% in women who use OCs for at least a decade. This protection endures for up to 20 years after OC discontinuation."
 * Hatcher (2004). "Depo-Provera Injections, Implants, and Progestin-Only Pills (Minipills)" in Hatcher et al. Contraceptive Technology, 18th ed. ISBN 0-9664902-5-8
 * "Advantages and Indications
 * Advantages of All Progestin-Only Methods, p. 466
 * 2. Noncontraceptive benefits. Implanon, Norplant, Depo-Provera, and minipills may lead to several noncontraceptive benefits, including the following:
 * Decreased risk of endometrial cancer, ovarian cancer, and pelvic inflammatory disease"
 * "Depo-Provera
 * Instructions for Using Depo-Provera, p. 481
 * Depo-Provera injections confer a number of noncontraceptive benefits by decreasing the following:
 * Risk of endometrial cancer"
 * Mishell (2004). "Contraception" in Strauss & Barbieri, Yen & Jaffe's Reproductive Endocrinology, 5th ed. ISBN 0-7216-9546-9
 * "Oral Steroid Contraceptives
 * Neoplastic effects
 * Endometrial Cancer, p. 915
 * Twelve case-control studies and three cohort studies have examined the relation between OCs and endometrial cancer, and all but two of these studies have indicated that the use of these agents has a protective effect against endometrial cancer, the third most common cancer among United States women. Women who use OCs for at least one year have an age-adjusted relative risk of 0.5 for diagnosis of endometrial cancer between the ages of 40 and 55 years compared with nonusers. This protective effect is related to duration of use, increasing from a 20% risk reduction with one year of use to a 40% reduction with two years of use, to about a 60% reduction with four years of use.
 * In the large RCGP prospective study that began in 1968, data obtained through 1995 found that OC users had one third the risk of endometrial cancer as nonusers (RR, 0.34, CI, 0.17 to 0.66) and one third the risk of dying of uterine cancer (RR, 0.3), compared with age-matched non-OC users. Voight and colleagues reported that the protective effect of OCs on endometrial cancer occurred with use of combination formulations containing both high and low doses of progestin."
 * "Long-Acting Contraceptive Steroids
 * Injectable Suspensions
 * Depot Formulation of Medroxyprogesterone Acetate
 * Neoplastic effects
 * Endometrial cancer, p. 925
 * A WHO case-control study found the risk of endometrial cancer to be significantly reduced among DMPA users (RR, 0.21; CI, 0.06 to 0.79). This reduction in risk persisted for at least eight years and was similar in magnitude to the protective effect observed with combination OCs."
 * Kafrissen & Adashi (2003). "Fertility Control: Current Approaches and Global Aspects" in Larsen et al. Williams Textbook of Endocrinology, 10th ed. ISBN 0-7216-9184-6
 * "Technologies of Fertility Control
 * Oral Contraception
 * Benefits of Oral Contraception
 * Noncontraceptive Reproductive Benefits of Oral Contraception
 * Endometrial and Ovarian Carcinoma, p. 684
 * The most impressive noncontraceptive benefit of hormonal contraception is the decreased incidence of endometrial and ovarian carcinomas. In the United States, endometrial carcinoma is the most common pelvic cancer in women. Current estimates indicate that 36,000 new cases are diagnosed yearly with a death rate of 6,500. The 5-year survival rate is 83% when it is diagnosed early; more advanced cases have a survival rate of 65%. For the most part endometrial cancer affects women past reproductive age, although younger women are not immune to the disease.
 * The decreased risk is related to the length of use of OCs. A decrease is evident after only 1 year of use; women who have been practicing hormonal contraception for 4 years or more have risk reduced by more than 50%. It is important to note that hormonal contraception offers long-term protection and that the residual protective effects persist for 20 years or longer. It is also important that the protective effect has been associated with the use of all OCs for which data have been gathered. Data on progestagen-only contraception and preparations with 20 µg of ethinylestradiol are not yet available, but it is likely that they would offer the same protection as the other preparations.'''
 * The mechanism of the protective effect on the endometrium most likely involves the direct antiestrogenic effects of the progestagen component of the OCs. Estrogens stimulate synthesis of both estrogen and progestagen receptors, and progestagens inhibit this synthesis. Part of the antiestrogenic effect of the antiestrogenic effect of progestagens may involve the stimulation of estradiol 17β-hydrolases in the endometrial cell and accelerated conversion of estradiol to estrone, a less potent estrogen than estradiol. Consequently, the proliferation of the endometrial epithelium, both endometrial glands and stroma, proceeds at a reduced rate with less mitotic activity."

OK... that's convincing. What would you propose changing the article text to say? MastCell 18:06, 19 January 2007 (UTC)


 * I would suggest omitting from this Wikipedia article the sentence:
 * "The decrease in risk may extend even after Depo Provera is discontinued."
 * and leaving the duration of reduced risk unstated and indefinite. One of the references provides a link to the abstract of the WHO study([]) that found an 80% reduction of risk that "appeared to last at least 8 years after cessation of use".


 * The duration of reduced risk is probably at least 20 years as found with oral contraceptives which have been more studied, but I am not aware of a study that confirms this for Depo-Provera. Explicitly stating the duration of reduced risk is "at least 8 years" probably significantly understates the real duration of reduced risk.
 * 69.208.168.135 22:28, 19 January 2007 (UTC)


 * I think that suggestion (omitting the "may extend" sentence) would be fine. Alternately, you could say that the duration of risk reduction "is unclear, but probably extends for at least 8 years", with the citations. Either one. MastCell 22:31, 19 January 2007 (UTC)

Seizures and Sickle-Cell Crises
 However, the  potential  benefits of Depo Provera in epilepsy and sickle-cell disease ''have been described in case reports and have not been studied in randomized controlled trials.
 * Benefits
 * Misrepresents and understates the significance and importance of the reduced risk of seizures in women with epilepsy:
 * Misrepresents and understates the significance and importance of the reduced risk of sickle cell crises in women with sickle-cell disease:
 * citing: Westhoff (2003). "Depot-medroxyprogesterone acetate injection (Depo-Provera®): a highly effective contraceptive option with proven long-term safety". which says:
 * "Women with sickle cell anemia also report total absence or a significant reduction in painful crises during treatment with DMPA. Unlike combination and progestin-only OCs, the contraceptive efficacy of DMPA does not appear to be compromised among women taking concomitant anticonvulsive therapy. Data also indicate that DMPA has intrinsic anticonvulsant activity. Additionally, progestin-only contraceptives such as DMPA have been recommended as appropriate contraceptive choices for women who in whom estrogen (therefore any combination OC) is contraindicated. The potential benefits of DMPA in women with sickle cell disease and epilepsy have been described in case reports and have not been assessed in randomized trials."
 * Speroff & Darney (2005). A Clinical Guide for Contraception, 4th ed. ISBN 0-7817-6488-2
 * "Efficacy, p. 203
 * Because serum concentrations are relatively high, efficacy is not influenced by weight (making this a good choice for overweight women) or by the use of medications that stimulate hepatic enzymes. On the contrary, depot-medroxyprogesterone acetate is an excellent contraceptive choice for women taking antiepileptic drugs because the high progestin levels raise the seizure threshold."
 * "Advantages, p. 205
 * As noted, depot-medroxyprogesterone should be considered in patients with seizure disorders; an improvement in seizure control can be achieved probably because of the sedative properties of progestins.
 * An important advantage exists for patients with sickle cell disease because evidence indicates an inhibition of in vivo sickling with hematologic improvement during treatment. Both the frequency and the intensity of painful sickle crises are reduced."
 * Hatcher (2004). "Depo-Provera Injections, Implants, and Progestin-Only Pills (Minipills)" in Hatcher et al. Contraceptive Technology, 18th ed. ISBN 0-9664902-5-8
 * "Advantages and Indications
 * Advantages of Depo-Provera, p. 467 (specifically as opposed to Advantages of All Progestin-Only Methods)
 * 1. Culturally acceptable. In some cultures, a woman may consider medication by injection desirable. Some women wish to use a contraceptive without the knowledge of their partner. Many couples find Depo-Provera attractive because it is not coitally dependent. A subcutaneous formulation of Depo-Provera that women could self-inject is being evaluated.
 * 2. Minimal drug interactions. There has been no demonstrated interaction between Depo-Provera and antibiotics or enzyme-inducing drugs. The only drug that decreases the effectiveness of Depo-Provera is aminoglutethimide (Cytadren), which is usually used to suppress adrenal function in selected cases of Cushing's disease.
 * 3. Fewer seizures. Depo-Provera has been found to decrease the frequency of grand mal seizures. Improvement in seizure control is probably due to the sedative properties of progestins. Taking anti-seizure medication has no impact on the efficacy of Depo-Provera.
 * 4. Fewer sickle cell crises."
 * "Depo-Provera
 * Instructions for Using Depo-Provera, p. 481
 * Depo-Provera injections confer a number of noncontraceptive benefits by decreasing the following:
 * Risk of sickle cell crisis
 * Frequency of grand mal seizures"
 * Mishell (2004). "Contraception" in Strauss & Barbieri, Yen & Jaffe's Reproductive Endocrinology, 5th ed. ISBN 0-7216-9546-9
 * "Long-Acting Contraceptive Steroids
 * Injectable Suspensions
 * Depot Formulation of Medroxyprogesterone Acetate
 * Non-contraceptive Health Benefits, p. 926
 * DMPA also has a beneficial effect on hematologic parameters in women with sickle cell disease, as well as reducing their incidence of clinical problems. Seizure frequency is reduced in women with epilepsy who take DMPA.

As with her description of the duration of reduced risk of endometerial cancer, I think the characterization in Westhoff's review article of "potential benefits" of Depo-Provera as having only been demonstrated in "case reports" is misleading and the further emphasis in this Wikipedia article of benefits not being based on a "randomized controlled trials" is even more misleading.

For the reduced risk of sickle cell crises, Westhoff cites 2 studies that found significant hematological and clinical benefits: 1) a 2-year placebo-controlled crossover trial completed by 23 patients and 2) a 1-year 3-way (DMPA, COCP, placebo) controlled trial with 43 women. They may not have been "randomized", but they were placebo-controlled trials, not "case reports".

For the reduced risk of seizures, Westhoff cites a 1-year clinical trial involving 14 women at the Yale Epilepsy Center, that was not placebo controlled, but was a "clinical trial," not a "case report."

Speroff & Darney, Hatcher, and Mishell all cite fewer sickle-cell crises and fewer seizures as significant, specific noncontraceptive health benefits of Depo-Provera without any qualifications implying the benefits are based on weak evidence that should be heavily discounted.

Of note, Darney, currently the chief of obstetrics & gynecology at UCSF's San Francisco General Hospital, co-wrote a JAMA article "Use of oral contraceptives by women with epilepsy" with the lead authors (Mattson & Cramer) of the Yale DMPA study and should be the most knowledgeable of its significance among the review and textbook authors.

I would suggest omitting from this Wikipedia article the sentence:
 * "However, the potential benefits of Depo Provera in epilepsy and sickle-cell disease have been described in case reports and have not been studied in randomized controlled trials.

and separating the benefits of reduced seizures and reduced sickle cell crises into separate bullet items:
 * Decreased incidence of seizures in women with epilepsy. Additionally, unlike most other hormonal contraceptives, Depo-Provera's contraceptive effectiveness is not affected by enzyme-inducing antiepileptic drugs.
 * Decreased incidence and severity of sickle cell crises in women with sickle-cell disease.

I would also suggest changing: to: A decrease in symptoms of endometriosis was found in a clinical trial.([], cited in Westhoff's review article).
 * Possible decrease in the symptoms of endometriosis, primary dysmenorrhea, and ovulation pain.
 * Decreased symptoms of endometriosis.
 * Decreased incidence of primary dysmenorrhea, ovulation pain and functional ovarian cysts.

The decreased incidence of primary dysmenorrhea, ovulation pain and functional ovarian cysts are a direct result of the anovluation caused by Depo-Provera.

69.208.168.135 22:28, 19 January 2007 (UTC)

Failure Rates & Breastfeeding
I think we do a disservice to women by stating that Depo is near 100% effective when for so may groups this is not really true. I changed the wording under Benefits to reflect this. I've also added some information about failure rates that explains what some users can expect based on the National Survey of Family Growth.

I notice that in the discussion of Breastfeeding that there is no mention of the fact that Depo Provera appears in the breast milk. Although this is thought to be safe, nursing moms might find this information important. Not all moms will feel comfortable exposing their newborn to unneeded artificial sex hormones. Other thoughts?

Monnica Williams

Neutrality tag
Can we remove it? Please? I'm not saying the article doesn't need more work, but what are the "neutrality" issues here? MastCell 17:27, 21 February 2007 (UTC)


 * No.


 * Please see the NPOV tag section above with the long, extensive list of the pervasive NPOV issues that plague this Wikipedia article. It will take a long time to fix these. Unlike the banned Wikipedia editor, Cindery, who spent several months full-time wrecking this and many other Wikipedia articles on birth control topics with the acquiescence of the other regular editors of those articles (who now demand very time-consuming, extensive documentation of every single revision of the intentionally deceptive misinformation in "The Gospel According to Cindery"), some of us cannot devote all of their time to fixing bad articles like this one. The NPOV tag should stay on this article to alert its readers until the NPOV issues are resolved (and should probably be added to other Wikipedia birth control articles, like mifepristone and emergency contraception, two other articles severely damaged by Cindery).
 * 68.255.19.25 19:04, 21 February 2007 (UTC)


 * OK... if you think I've "acquiesced" to Cindery's editing, all I can say is you're way off base. I agree it's a challenge to produce sources - the verifiability requirement is indeed "very time-consuming", but nonetheless it's a core policy here. The tag's been on this article for a long time - if you feel strongly enough to respond within minutes to a suggestion to remove it, then I think that "...so fix it" is a valid response to your concerns about the article. As you note, Cindery is banned from Wikipedia. I haven't seen anyone oppose your more recent edits, other than to ask that you provide sources. I think we're all pretty much on the same page as to what should happen with the article - I'm just asking you to help improve it instead of affixing an NPOV tag, leaving us a "to-do" list, and then reappearing only when it's suggested that the tag be removed. MastCell 19:17, 21 February 2007 (UTC)


 * I know I am not in the top rung of editors here by any means, but I think the neutrality tag needs to stay there, because if you read the entire article, the last section makes you really feel like if your doctor were to approve your use of this medication, it's because they are trying to destroy you. Meateatingvegan 21:26, 1 March 2007 (UTC)

After a quick glance, it appears the article as a whole potrays the manufacturer in an overly positive light. For example: "Other, less frequently reported adverse reactions are listed in the patient and physician label information for Depo-Provera." Why aren't these listed? Even if they are rare? Sounds a lot like a company line. — Manti  core  11:30, 21 April 2007 (UTC)


 * The "Side effects" subsection lists the six adverse reactions (which may or may not be related to the use of Depo-Provera) most frequently reported (those reported by more than 5% of subjects) during the largest clinical trial of Depo-Provera involving over 3,900 women treated for up to 7 years. Of those six most frequently reported adverse reactions, menstrual irregularities (the most frequently reported adverse reaction) is the only one known to be caused by Depo-Provera (i.e. a side effect).


 * Adding a laundry list of almost seventy other less frequently reported adverse reactions (which may or may not be related to the use of Depo-Provera), none of which have been shown to be caused by Depo-Provera, to the "Side effects" subsection of this article would be inaccurate and misleading.


 * The "Side effects" subsection has footnotes with online links to U.S. patient labeling and U.S. physician prescribing information for those interested in knowing every adverse reaction (which may or may not be related to the use of Depo-Provera) reported over the 7 years of the largest clinical trial of Depo-Provera involving over 3,900 women.
 * 69.208.173.15 14:10, 21 April 2007 (UTC)

Alleged bias of OB-GYN committee
Removed the following intentionally deceptive false and deliberately misleading statement:


 * Alleged bias of OB-GYN committee. A former director of the FDA Bureau of Drugs reportedly said that the OB-GYN Committee, which advised the FDA to approve Depo on the two occasions when it was not approved, was not capable of objectivity because members of the committee were in "the population control business."

that was based on the last paragraph of a deceptive and misleading section of a 22-year-old Multinational Monitor article, that said:


 * And population control is a highly politicized field. "When it comes to contraception and abortion," says one FDA medical officer, "people refuse to be scientific and objective." As a past director of the FDA's Bureau of Drugs, Dr. J. Krout, said several years ago, "Most of the members of that [OB-GYN] committee are in the population control business."

68.255.19.25 05:08, 22 February 2007 (UTC)
 * 1) The first quote from "one FDA medical officer", that "when it comes to contraception and abortion, people refuse to be scientific and objective" does not indicate that it is referring to an FDA advisory committee.
 * 2) This is juxtaposed with a sentence fragment "most of the members of that committee are in the population control business" from the April 30, 1974 testimony of J. Richard Crout, MD (Director, Bureau of Drugs, FDA) in the Fountain subcommittee hearings on the "Use of Advisory Committees by the FDA" that is misleadingly and deceptively quoted out of context. Dr. Crout was replying to hostile questioning by a House subcommittee staff member about the recommended approval of DES as an emergency contraceptive (only for emergency situations such as following rape). The subcommittee staff member's questioning was insinuating that the FDA Obstetrics-Gynecology Advisory Committee (whose main job was reviewing NDAs for contraceptives) was "not balanced" because it did not have an oncologist on it, but instead was primarily composed of leading obstetrician-gynecologists with extensive experience in contraceptive research. In part of the question that Dr. Crout was replying to, the subcommittee staff member said: "But, let's take this Ob-Gyn Committee. It seems to me this committee was composed almost exclusively of population control people. That is the impression I got." Instead of arguing over the subcommittee staff member's use of the politically loaded term "population control", Dr. Crout used the subcommittee staff member's terminology in agreeing that the ob-gyn advisory committee was primarily composed of ob-gyn's with experience in contraceptive research (along with some endocrinologists) and did not have an oncologist, or a cardiologist, or a hepatologist, or a nephrologist, etc., but that instead, specialists from other fields of medicine were brought in if needed to address specific issues requiring specialized expertise. (ref: p. 436, Use of Advisory Committees by the Food and Drug Administration, Hearings before the Intergovernmental Relations Subcommittee of the Committee on Government operations, House of Representatives, 93rd Congress, 2nd session, April 30, 1974)
 * 3) Dr. Crout never said: "the OB-GYN Committee, which advised the FDA to approve Depo on the two occasions when it was not approved, was not capable of objectivity because members of the committee were in 'the population control business.'"


 * That's interesting - thanks for the context. It makes a lot of sense. Have you written on this topic before? You clearly have a great deal of knowledge about the history of Depo. MastCell 06:05, 22 February 2007 (UTC)

Name Change
I've put in a request to move the article from here Depo Provera to Depo-Provera as that it how it is referenced throughout http://www.depoprovera.com/ I've changed the references within the article to reflect the change. -- MacAddct1984 14:34, 21 March 2007 (UTC)

Weight gain parameter in infobox
I would like to treat this parameter the same on all the hormonal contraception articles. Please read my opinion and discuss this issue at Talk:Combined oral contraceptive pill. LyrlTalk C 21:30, 20 August 2007 (UTC)

Added by anon
"Likewise, users of Depo-Provera have reported a significantly decreased risk of contracting cervical cancer. Because of it's carcinogenic benefits to users, it is sometimes administered with or as a carcinogenic medication."


 * Obviously, this text has issues. Not only is it unsourced (though it was inserted as though it did), it uses the word carcinogenic wrongly. -- Ec5618 22:58, 31 January 2008 (UTC)


 * Not to mention that users seldom self-report a decreased risk of cancer. beefman (talk) 07:06, 23 January 2009 (UTC)

Merge with Medroxyprogesterone?
Medroxyprogesterone beefman (talk) 07:06, 23 January 2009 (UTC)


 * Don't think they should be merged. DMPA contains Medoxyprogesterone, but it is formulated for injection as a contraceptive.  There are other uses which may use different formulations.  Zodon (talk) 08:51, 23 January 2009 (UTC)

Other uses
Is DMPA FDA-approved for use in sex offenders? If not, perhaps this should be mentioned. beefman (talk) 07:06, 23 January 2009 (UTC)

Can a note be included in the use for migraines? I don't expect it is FDA approved for this - but it has amazing results for some and should be more widely known for this so people don't have to suffer. Becky B-C (talk) 22:45, 31 December 2009 (UTC)

Information Not Supported by Current Citation
I have removed text in the Warnings and Precautions section which stated "although one [study] notes that bone loss was not reversible in long-term users of Depo-Provera." None of the cited studies makes such a note. The one study (citation #36) which examined long-term users did not examine long-term users after they had discontinued using the drug. These long-term users were only studied while still taking the drug--thus it is not appropriate to conclude that the bone loss was not reversible. Rather, there is no information in the cited studies on bone-loss reversibility in these users.

If it is in fact true that there is a study showing irreversibility in long-term users, the citation needs to be updated to reflect the appropriate study. Without such an update, the unsupported claim should not be reinserted in the article. It was most likely originally based on an incomplete reading or understanding of the study in citation #36. 24.17.183.46 (talk) 22:16, 19 September 2009 (UTC)

Decreased sex drive?
Why doesn't this article mention decreased sex drive caused by the use of depo?

Here's a quick source--just look on google for more: http://answers.google.com/answers/threadview/id/785123.html —Preceding unsigned comment added by 209.211.34.13 (talk) 23:24, 11 October 2009 (UTC)

It's strange that this doesn't seem to be more widely talked about, because anecdotal evidence suggests this is incredibly common. Personally I felt awful when I tried it - no libido, flat mood, etc - and almost everyone I've ever spoken to about it seems to report adverse side effects like this (at the very least they felt a bit "weird", and most had reduced sex drive, mood problems, etc). Only one person I've ever had a conversation with about it said they were absolutely fine, and significantly she was not in a long term relationship, which I think would make many of these symptoms less obvious (low sex drive is less of a problem when you don't have a partner with a normal libido! And I've always found that when my moods are messed up, e.g. PMT, having a partner & children makes it so much more of a problem as they bear the brunt of it. If I lived alone I'd just sleep more & curl up on the sofa with chocolates!). I can't help but wonder if women are just not reporting these problems (I know I didn't) - it would be interesting to see how many people only ever have one injection & give up on it (does anyone know any statistics on this?); if there wasn't something that made them unhappy with the treatment you'd expect that most women would continue as it seems on the surface to be an ideal method of contraception! I do realise this comment doesn't contribute anything wildly significant to the discussion as it is only based on anecdote & personal experience, if I had the time I'd like to look into the evidence properly & edit the entry to reflect this, but I just don't have the time to do the thorough research I would want to do before making any edits about this. missdipsy (talk) 11:16, 14 December 2012 (UTC)

Bone loss
This site: [Youtube] has a video about this product.Agre22 (talk) 14:07, 22 November 2009 (UTC)agre22

Chemical castration
The article is weak about the depo-provera's use in chemical castration in men.Agre22 (talk) 13:45, 29 December 2009 (UTC)agre22

Progestin-Only Injectable Contraceptive
It would be great if there were another page, or at least a redirect page, that wasn't dependent on the Depo Provera brand name for progestin-only injectable contraceptives. Something like the Combined injectable contraceptive or Contraceptive impant pages. Was trying to clean up some pages and remove brand names and redirect to types of contraceptives instead. Sorry, as a newbie can't really figure out how to do this myself. —Preceding unsigned comment added by Emhawkins (talk • contribs) 07:56, 4 July 2010 (UTC)

External links modified
Hello fellow Wikipedians,

I have just added archive links to 1 one external link on Depot medroxyprogesterone acetate. Please take a moment to review my edit. If necessary, add after the link to keep me from modifying it. Alternatively, you can add to keep me off the page altogether. I made the following changes:
 * Added archive https://web.archive.org/20060506074850/http://www.issuesinmedicalethics.org:80/131di008.html to http://www.issuesinmedicalethics.org/131di008.html

When you have finished reviewing my changes, please set the checked parameter below to true to let others know.

Cheers. —cyberbot II  Talk to my owner :Online 01:03, 19 October 2015 (UTC)

Redirected to Medroxyprogesterone acetate
In an effort to reduce duplication. We should not have a separate article for each method of using this medication. It was simply a lot of duplication of content. Doc James (talk · contribs · email) 23:13, 23 December 2016 (UTC)