Depot medroxyprogesterone acetate DMPA is a highly effective injectable contraceptive that affords privacy and has a convenient dose schedule of four times per year, depo provera and osteoporosis, making it appealing to many users, especially adolescents. No high-quality data answer the important clinical question of whether DMPA affects fracture cancer and vitamin e in adolescents or adults later in life.
Health care providers should inform women and adolescents considering initiating DMPA or continuing to use the method about the benefits and the risks of DMPA and should discuss the U, depo provera and osteoporosis. Depot medroxyprogesterone acetate DMPA is an injectable contraceptive that has been used by approximately 1 in 5 adolescents and adult women in the United States who have had sex 1.
Depot medroxyprogesterone acetate is a highly effective contraceptive that affords privacy similar to an intrauterine system and has a convenient dose schedule of four times per year, making it appealing to many users, especially adolescents. In a large cohort study of women and adolescents initiating contraception, depo provera and osteoporosis, unintended pregnancy rates for women using DMPA were similar to rates for women using intrauterine devices and implants and were significantly lower than rates for women using combined hormonal contraceptives oral contraceptives, the contraceptive patch, or the vaginal ring 2.
Limiting depo provera and osteoporosis options like DMPA may disproportionately affect adolescents and disadvantaged women. Depot medroxyprogesterone acetate inhibits the secretion of pituitary gonadotropins, resulting in anovulation and decreased production of estrogen.
Decreased estrogen production is of concern because it is associated with a decrease in bone mass or bone mineral density BMD. Inthe U. Limiting the use of DMPA because of concerns over bone effects of DMPA would reduce contraceptive options for adolescents and other women for whom unintended pregnancy confers the greatest burden. Bone mass or BMD refers to the amount of mineral matter per volume of bones and directly correlates with bone strength 6, depo provera and osteoporosis.
Bone mineral density is influenced by many factors, including, gender, age, race, body mass index, hereditary factors, physical stress on bones related to physical activity depo provera and osteoporosis weight bearing, nutritional factors such as dietary calcium and vitamin D, alcohol consumption, smoking, corticosteroid exposure, and sex hormones and conditions that affect sex hormones eg, pregnancy, breastfeeding, menopause, and use of hormonal contraceptives 6.
Peak bone mass is the amount of bone tissue present at the end of skeletal maturation. It is a major depo provera and osteoporosis of the risk of fracture due to osteoporosis because the mass of bone tissue at any time during adult life is the difference between the amount accumulated at maturity and the amount lost due to aging or other factors. During puberty, the rate of accumulation of BMD at both the lumbar spine and femoral neck increases fourfold to sixfold over a 3-year period in females and then decreases rapidly after menarche.
By 2 years after menarche, the rate of accumulation of BMD is insignificant 7. These losses are temporary; within 6—12 months after giving birth or cessation of breastfeeding, BMD values increase to near preconception values in most women Lon-gitudinal studies report BMD losses of 0.
In trials that included depo provera and osteoporosis adults and adolescents, depo provera and osteoporosis, with a duration of DMPA use of 2—5 years and follow-up of up to 5 years after discontinuation, losses in BMD appeared to be substantially or depo provera and osteoporosis reversible; however, recovery at the hip and femoral neck generally took longer compared with recovery at the spine 14, 16, 19, 23 In a study reviewed by the FDA from an open-label, nonrandomized, prospective multicenter study of females aged 12—18 years with follow-up 5 years after discontinuation of DMPA, complete recovery in BMD at the spine, hip, and femoral neck was observed in adolescents who used DMPA for less than 2 years.
The clinical outcome of interest is the occurrence of fracture. Bone mineral density measurements and fracture have been best studied in postmenopausal women 6. Unlike for adult women, BMD has not been validated in adolescents as a marker of future fracture risk. In the United States, a prospective, cohort study of female military recruits and a cross-sectional study of girls and women with developmental disabilities found an increased risk of fractures in DMPA users; however, both studies had methodologic flaws that included selection bias and lack of information on potential confounders eg, clinical information on range and severity of disability that limit interpretation in the general population depo provera and osteoporosis Observational results from other countries provide mixed data on the association of DMPA use and fracture risk.
A case—control study of women aged 20—44 years using the United Kingdom General Practice Research Database found an increased risk of fracture among women with current use of DMPA prescriptions compared with nonuse odds ratio [OR], 1.
In a population-based case—control study in Denmark, depo provera and osteoporosis, where all women with a fracture were compared with age-matched controls from the general population, DMPA use was associated with an increased risk of fracture OR, 1. Although these observational studies suggest depo provera and osteoporosis possible increased risk of fracture in DMPA users, the results must be interpreted with caution because of inherent limits in study design, depo provera and osteoporosis.
This warning stated that prolonged use of DMPA may result in significant loss of BMD, that the loss is greater the longer the drug is used, and that the loss may not be completely reversible after discontinuation. The warning notes that it is unknown if use of DMPA during adolescence or early adulthood will reduce peak bone mass and increase the risk for osteoporotic fracture in later life and cautions that use of DMPA depo provera and osteoporosis 2 years should be considered only if other contraceptive methods are inadequate.
The FDA warning was based on independent analyses of data from clinical trials that indicated 1 the magnitude of the average decrease in BMD observed at the total hip and femoral neck were greater than decreases at the lumbar spine in adolescents with DMPA use for more than 2 years; 2 this decrease occurs at a time in life when adolescents normally experience a significant increase in BMD; and 3 there also was a lack of complete recovery of BMD at the hip at 5 years following 2 or more years of DMPA use.
These findings are based on a small sample size of fewer than 50 adolescents, depo provera and osteoporosis. Inthe World Health Organization convened a technical consultation on the effects of hormonal contraception on bone health 5. Experts reviewed extensive data on BMD changes in adolescents and considered depo provera and osteoporosis findings on changes in BMD and fracture risk in the context of the worldwide public health burden of unintended and adolescent pregnancy. They concluded that there should be no restriction on the use of DMPA in women aged 18—45 years, including no restriction on the duration of use.
They also concluded that among females younger than 18 years and women older than 45 years, the advantages of using DMPA generally outweigh the theoretic safety concerns regarding fracture risk. Because data are insufficient to determine if BMD changes lead to increased fracture risk with long-term use, the overall risks and benefits of continuing use of DMPA should be reevaluated over time with the individual user 5.
Individualized care and counseling is recommended for women with coexisting conditions that may influence bone health eg, disabilities that increase risk of falls, chronic steroid use, renal disease, or malabsorption. Regular exercise, including weight-bearing exercise; smoking cessation; and age-appropriate calcium and vitamin D intake should be encouraged for all women.
Although depo provera and osteoporosis have been no studies showing that these measures will offset loss of BMD during DMPA use, these recommendations can benefit general health. Adolescents should be counseled about other contraceptive methods and offered the option of initiating or transitioning to long-acting reversible contraceptive methods that have no effect on BMD, such as intrauterine devices depo provera and osteoporosis contraceptive implants, as alternatives to long-term DMPA use Although studies of adolescents and women demonstrate that low-dose estrogen supplementation limits BMD loss in DMPA users 3536estrogen supplementation during DMPA use also is not recommended because of potential adverse effects and a lack of evidence from clinical trials demonstrating effectiveness in adolescent populations for the prevention or treatment of fractures.
Depot medroxyprogesterone acetate and bone effects. American College of Obstetricians and Gynecologists. Introduction Depot medroxyprogesterone acetate DMPA is an injectable contraceptive that has been used by approximately 1 in 5 adolescents and adult women in the United States who have had sex 1.
Bone Mineral Density and Fracture Risk Bone mass or BMD refers to the amount of mineral matter per volume of bones and directly correlates with bone strength 6.
Depot Medroxyprogesterone Acetate Use and Fracture Risk The clinical outcome of interest is the occurrence of fracture. Depot medroxyprogesterone acetate DMPA is a highly effective injectable contraceptive that affords privacy similar to an intrauterine system and has a convenient dose schedule of four times per year, depo provera and osteoporosis, making it appealing to many users, especially adolescents.
Adolescents should be counseled about other contraceptive methods and offered the option of initiating or transitioning to long-acting reversible contraceptive methods that have no effect on BMD, such as intrauterine devices and contraceptive implants, as alternatives to long-term DMPA use.
Use of contraception in the United States: Vital Health Stat 23 ; Effectiveness of long-acting reversible contraception. N Engl J Med ; Unintended pregnancy in the United States: Letter to health care professionals. Retrieved October 18, Technical consultation on the effects of hormonal contraception on bone health.
Retrieved February 12, Depo provera and osteoporosis and management of osteoporosis: Bone acquisition in adolescence. Pregnancy and lactation confer reversible bone loss in humans. Changes in bone density with lactation. Bone mineral density in mother-daughter pairs: Am J Clin Nutr ; Spinal bone density in women using depot medroxyprogesterone contraception. A prospective, controlled study of the effects of hormonal contraception on bone mineral density.
Bone mineral density at various anatomic bone sites in women receiving combined oral contraceptives and depot-medroxyprogesterone acetate for contraception. Injectable hormone contraception and bone density: Effects of hormonal contraception on bone mineral density after 24 months of use.
Bone mineral density loss and recovery during 48 months in first-time users of depot medroxyprogesterone acetate. Bone mineral density changes over two years in first-time users of depot medroxyprogesterone acetate. Progestogen-only contraception and bone mineral density: Bone mineral density in women aged 25—35 years receiving depot medroxyprogesterone acetate: Recovery of bone density in women who stop using medroxyprogesterone acetate.
Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception. Arch Pediatr Adolesc Med ; Longitudinal study of depot medroxyprogesterone acetate Depo-Provera effects on bone health in adolescents: Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections. Bone density recovery after depot medroxyprogesterone acetate injectable contraception use.
Steroid hormone contraception and bone mineral density: The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women.
Long-term assessment of forearm bone mineral density in postmenopausal former users of depot medroxyprogesterone acetate. The impact of lifestyle factors on stress fractures in female Army recruits. Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities. Womens Health Issues ; Use of depot medroxyprogesterone acetate and fracture risk.
J Clin Endocrinol Metab ; Use of depot medroxyprogesterone acetate contraception and incidence of bone fracture, depo provera and osteoporosis. The effects of depot medroxyprogesterone acetate and intrauterine device use on fracture risk in Danish women, depo provera and osteoporosis. Depo-provera CI medroxyprogesterone acetate injectable suspension, for intramuscular use: A randomized controlled trial of estrogen replacement therapy in long-term users of depot medroxyprogesterone acetate.