The association between depot medroxyprogesterone acetate and meningiomas: Emerging data and their relevance to the South African context

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. IN PRACTICE The association between depot medroxyprogesterone acetate and meningiomas: Emerging data and their relevance to the South African context R J Burman,1,2 MB ChB, DPhil ; R de Waal,3 MB ChB, MPH ; K Cohen,4 MB ChB, MMed (Clin Pharm) ; M Blockman,4 MB ChB, MMed (Clin Pharm) ; M Patel,5 MB ChB, FCOG (SA) ; D Hockman,2,6 MSc, PhD ; D M Fountain,7 MB BChir, MRCS ; S Jeyaretna,8 BMBS, FRCS (SN) ; S Singh,9 MB ChB, FC Path (SA) Anat ; H Mustak,10 MB ChB, FCOphth (SA) ; B De John,1,2 MB ChB, FC Neurosurg (SA) ; D Lubbe,2,11 MB ChB, FCORL (SA) Division of Neurosurgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, South Africa 3 C  entre for Integrated Data and Epidemiological Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa 4 Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 5 Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, South Africa 6 Division of Cell Biology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, South Africa 7 MRC Weatherall Institute of Molecular Medicine, University of Oxford, UK 8 Division of Neurosurgery, Nuffield Department of Surgery, University of Oxford, UK 9 Division of Anatomical Pathology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa 10 Division of Ophthalmology, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 11 Division of Otolaryngology, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 1 2 Corresponding authors: R J Burman (); D Lubbe () In the past 2 years, evidence suggesting an association between depot medroxyprogesterone acetate (dMPA) use and meningioma has emerged. As dMPA remains one of the most widely used contraceptive methods worldwide, this finding has led to increasing media attention, and regulatory and legal proceedings. The South African Health Products Regulatory Authority (SAHPRA) has issued a statement acknowledging the association between dMPA exposure and the development for meningiomas. However, the paucity of local data on dMPA use and the incidence of and risk factors for meningioma in both the public and private health sector make it difficult to fully assess the implications in SA. This report discusses the relevance of the association between dMPA and meningiomas in the SA context. We provide a summary of the current data on the risk of meningioma with dMPA exposure, and suggest how this should impact on recommendations for the prescribing and use of dMPA from a public health perspective. We further identify gaps in local data, and propose where efforts should be directed to collect relevant data to inform a rational national contraceptive strategy. Keywords: depot medroxyprogesterone acetate, intracranial meningiomas, hormonal contraception, pharmacovigilance, South Africa S Afr Med J 2026;116(1):e4529. https://doi.org/10.7196/SAMJ.2026.v116i1.4529 Depot medroxyprogesterone acetate (dMPA) remains a commonly used contraceptive among women worldwide, particularly in low- and middle-income countries.[1] This injectable contraceptive is frequently preferred by women due to its convenient 3-monthly dosing, its efficacy and its discretion.[2] In South Africa (SA), it is the agent used by nearly a quarter of women utilising contraception.[3] In the past 2 years, retrospective studies[4-8] using large datasets from both Europe and the USA have shown an association between dMPA use and meningioma. The strength of the association appears to increase with prolonged dMPA use.[4,6,8] These findings have gained local and international media attention and have led to class-action lawsuits against Pfizer, the largest manufacturer of dMPA, in some countries.[9,10] Since dMPA is the most widely used contraceptive among SA women,[11] understanding any potential association with meningioma is of particular relevance locally. Despite widespread dMPA use, there are currently no robust SA data exploring this association. This limits the ability to quantify the risk of meningioma in women who use, or have previously used, dMPA for contraception to 20 guide evidence-based prescribing and counselling on safety of contraceptive choices for our clients. In this report we aim to summarise and contextualise current data on the epidemiology of meningiomas, and the associated risk between dMPA exposure and meningioma. We will discuss why this association may have unique relevance in SA, and identify gaps for further intervention and research. Our aim is to increase awareness while also appealing to the broader SA healthcare community to assist in efforts to monitor dMPA use in SA. Epidemiology of meningiomas Meningiomas are the most common primary brain tumours in adults, with an age-adjusted incidence of 8 - 10 per 100 000 personyears.[12] Advancing age, obesity, neurofibromatosis and female sex are well-established risk factors, with incidence in women nearly double that in men.[13-15] Emerging evidence from the USA also suggests that ancestry mediates risk, with non-Hispanic black populations showing a higher incidence than non-Hispanic white populations.[13,16] Epidemiological data describing meningioma February 2026, Vol. 116, No. 1 IN PRACTICE incidence and risk factors in SA or across the African continent are limited. Small regional and single-centre retrospective studies in SA (with samples of between 48 and 505 patients) have confirmed that meningiomas are the most common adult brain tumours locally, and appear more common in women than men and among patients who were recorded as ‘black African’ in demographic data.[17-20] The anatomical location of meningiomas is clinically and biologically significant. Most arise at convexity and parasagittal sites, with other common locations including the skull base, such as the sphenoid ridge.[21] Tumour site influences presentation, surgical accessibility and prognosis.[21,22] Molecular studies show that location corresponds to distinct genetic profiles. Specifically, skull base tumours are often associated with TRAF7, PI3K and hedgehog pathway mutations, whereas convexity tumours more commonly harbour NF2 alterations.[23,24] Recent data also suggest differences in molecular subtypes across different demographic groups, with patients from the USA recorded as ‘black’ showing a higher prevalence of anterior skull base tumours, increased hedgehog pathway mutations and poorer progression-free survival despite similar extents of resection.[25] These findings highlight the need for further geographically and ethnically (...truncated)