Trabecular bone in long-term depot-medroxyprogesterone acetate users

A cross-sectional study was designed to determine trabecular bone density in 75 long-term depot-medroxyprogesterone acetate (DMPA) users (> 3 yr) matched with non-DMPA users by age, body mass index (18-25), limitation of age (< 45 yr), and body weight (< 60 kg). The long-term DMPA cases were divided into 3 groups according to duration of injectable contraceptive use. Neither cases nor controls had a smoking or chronic alcohol consumption history. Cases and controls were matched by age. Trabecular bone of the femoral neck were assessed by X-ray and interpreted by a single-blinded radiologist. Trabecular bone patterns were graded according to Singh's Index. Blood collection for determination of estradiol, prolactin, calcium, phosphorus, and medroxyprogesterone acetate were performed in cases and controls. Venous blood was taken at twelfth week of injection of DMPA and within 5 days after menstrual bleeding cessation in the controls. Mean trabecular bone in the cases was 5.5 +/- 0.6 (range 4-6). It was not statistically different from that in the controls (mean 5.5 +/- 0.6, range 2-6). No statistically significant difference of serum, calcium, phosphorus, prolactin, and estradiol was seen in the cases when compared to controls at mid follicular phase of normal menstrual cycle. Serum MPA of individual case at twelfth week of injection was 4.1 +/- 1.1 nmol/l. In conclusion, trabecular bone density in long-term DMPA users were not statistically different from normal menstruating women who have not received injectable DMPA.

Depo-Provera use in an Australian metropolitan practice

OBJECTIVE

To review the characteristics and experience of Australian women treated with depot medroxyprogesterone acetate (DMPA) in one gynaecological practice in Melbourne since 1973.

DESIGN

A detailed retrospective review of clinical data on 363 women treated with a total of 2298 injections of DMPA over the past 20 years.

RESULTS

The main indication was contraception, although a substantial minority (20%) were treated with DMPA predominantly for medical indications such as endometriosis. No pregnancy occurred within three months of an injection. There was also high acceptability, with a mean of 6.3 injections per subject, and a mean overall follow-up of 43.3 months. The median delay in the return of fertility in those wishing to conceive immediately was 9.2 months. Only one patient complained of difficulty in conceiving. Menstrual bleeding disturbances only led to 7.3% of the discontinuations, although fairly frequent use of short courses of oral oestrogen (in 40% of women) was employed in the early months of DMPA treatment. Other side effects were relatively infrequent, the most common being superficial dyspareunia or reduced libido (in 8%).

CONCLUSIONS

This much maligned drug merits a legitimate place among the contraceptive choices available for Australian women. Accurate, unbiased information about the extensive worldwide experience needs to be made available to all Australian medical practitioners.

Review of ovulation return upon discontinuation of once-a-month injectable contraceptives

Once-a-month combined injectable preparations draw their contraceptive efficacy from continuous ovulation suppression. When their use is discontinued, ovulation resumes within a few weeks or a few months, depending on the formulation. After use of the dihydroxyprogesterone acetophenide 150 mg/estradiol enanthate 5 mg combination for one to two years, ovulation returns in most subjects 3-4 months after discontinuation of treatment. Similarly, recent data show that after 2-year use of the depot-medroxyprogesterone acetate 25 mg/estradiol cypionate 5 mg or the norethisterone enanthate 50 mg/estradiol valerate 5 mg combination, approximately 70% women have resumed ovulation by the third month post-treatment. This is shorter than the time for return of ovulation experienced by ex-users of progestogen-only injectable contraceptives.

Monthly combined injectable contraceptives and neoplasia

Monthly injectable contraceptives, containing a combination of a long-acting progestogen and an estrogen, have been used in Latin America and China for many years. While knowledge about the effects of other hormonal contraceptives on cancer risk is relevant, close analogies with monthly injectables cannot be made. The relation between use of these preparations and cancers of the breast and cervix has been examined in case-control studies, but no firm conclusions can be drawn because of limitations in sample size. Adequate studies of the influence of monthly injectable contraceptives on risk of neoplasia need to be carried out.

Vaginal bleeding patterns in women using once-a-month injectable contraceptives

The main raison d'être for the development of once-a-month injectable contraceptives is the need for a long-acting method which produces a regular vaginal bleeding pattern. Although many women will successfully tolerate the amenorrhea or irregular bleeding which frequently accompany use of long-acting progestogen-only methods, there is a substantial minority, especially in certain ethnic groups, who find this unacceptable. The extensive literature does indicate that although combined estrogen-progestogen once-a-month injectables produce much more regular bleeding patterns than long-acting injectables like depot-medroxyprogesterone acetate, the patterns are not entirely normal. Detailed studies by the World Health Organization have demonstrated some deviation from normal menstrual patterns by users of the two once-a-month injectables, Cyclofem and Mesigyna. For example, 23.5% of Cyclofem and 25.2% of Mesigyna users experience irregular bleeding between 3 and 6 months of use compared with 4.8% of untreated women, and 13.3% of Cyclofem and 11.1% of Mesigyna users experience prolonged bleeding compared with 2.3% of untreated women. Comparable figures are much worse for DMPA users with a 35.7% incidence of irregular and 27.7% incidence of prolonged bleeding after similar duration of use. Bleeding patterns with all long-acting methods tend to improve with time. Overall group data for once-a-month injectable users are reasonably close to those of untreated women with, for example, a median of 15.6 days (5th and 95th percentiles: 7.5 and 26; confidence limits) of bleeding or spotting per 90-day reference period compared with a median of 18.5 days (5th and 95th percentiles: 12.2 and 25.5) for untreated women. Twelve-month life table discontinuation rates for menstrual bleeding disturbances are lower than expected for most progestogen-only methods at 2.1-5.2% for Cyclofem and 0.8-4.2% for Mesigyna for amenorrhea, and 6.3-12.7% for Cyclofem and 7.5-12.0% for Mesigyna for bleeding-related reasons. Once-a-month injectable contraceptives produce vaginal bleeding patterns much closer to normal than other injectables, but there are still significant deviations which lead to some discontinuation for menstrual reasons. Hence, full explanation and counselling about possible menstrual changes are still essential for all intending users of these methods.

Once-a-month injectable contraceptives: efficacy and reasons for discontinuation

Reports of the phase III clinical trials on four combined progestogen-estrogen once-a-month injectable contraceptives, Deladroxate, Cyclofem, Mesigyna and Chinese Injectable No. 1, are reviewed focussing on efficacy and reasons for discontinuation. Deladroxate, currently used in many Latin American countries has proved to be highly effective and well accepted. However, this combination was withdrawn by the original manufacturer because the progestogen component of this drug induced a high number of breast cancers in dogs and very curious pituitary hyperplasia in rats. Cyclofem and Mesigyna were found to be highly effective and highly acceptable drugs. Side-effects were minimal and were of minor importance. The Chinese Injectable No. 1 had unacceptably high failure rates with a monthly injection schedule. After doubling the dose in the first month of use, the efficacy was satisfactory. It was found that all monthly injectable contraceptives provided better cycle control than the every 3 months depot-medroxyprogesterone acetate, although abnormal bleeding was still the main drug-related complaint and reason for discontinuation. Missed appointment is another reason for discontinuation which might reflect the problem of frequent injection schedule, thus indicating the need for proper selection of the users and good counselling.

Changes in mammographic densities induced by a hormonal contraceptive designed to reduce breast cancer risk

BACKGROUND

It has been known for some time that oral contraceptives substantially reduce the risk of endometrial and ovarian cancer, but they do not reduce the risk of breast cancer. A hormonal contraceptive regimen has been developed which uses a gonadotropin-releasing hormone against (GnRHA) to suppress ovarian function, and this regimen includes the administration of very low doses of both estrogen and progestogen. This hormonal contraceptive regimen attempts to minimize exposure of the breast epithelium to these steroids and to preserve the maximum beneficial effects of estrogen, while still preventing endometrial hyperplasia.

PURPOSE

Our purpose was to determine whether changes occurred in mammographic densities between baseline and 1 year for women on this hormonal contraceptive regimen with reduced estrogen and progestogen levels compared with women in a control group.

METHODS

Twenty-one women were randomly assigned in a 2:1 ratio to the GnRHA-based contraceptive group (14 women) or to a control group (seven women). The contraceptive group received the following: 7.5 mg leuprolide acetate depot by intramuscular injection every 28 days; 0.625 mg conjugated estrogen by mouth for 6 days out of 7 every week; and 10 mg medroxyprogesterone acetate orally for 13 days every fourth 28-day cycle. The control group received no medication. Baseline and 1-year follow-up mammograms of contraceptive and control subjects were reviewed in a blinded fashion by two radiologists.

RESULTS

Comparison of the changes between the baseline and 1-year mammograms in the two groups of women showed significant (P = .039) reduction in mammographic densities at 1 year for women on the contraceptive regimen. Assessing the reduction in mammographic densities by noting the fineness of fibrous septae showed a highly significant (P = .0048) difference in the contraceptive regimen group. One of the women on the contraceptive regimen was withdrawn from the study because of poor compliance.

CONCLUSION

The reduced estrogen and progestogen exposures to the breast that were achieved by the hormonal contraceptive regimen resulted in substantial reductions in follow-up mammographic densities at 1 year compared with baseline. Although there is no direct evidence that such a reduction in densities will lead to a reduced risk of breast cancer, indirect evidence for a protective effect of this regimen is that early menopause reduces breast cancer risk, and that menopause is associated with a reduction in mammographic densities.

PFPP re-introduces DMPA

The Philippine Family Planning Program formally re-introduced depomedroxyprogesterone acetate (DMPA) or DepoProvera as a program method last March 22, 1994. DMPA will be added to the choices available to couples who desire to practice responsible parenthood. DMPA is an injectable contraceptive containing synthetic progestin which resembles progesterone. It is a scientifically effective, medically safe and legal contraceptive which is injected every three months. Its effectivity reaches up to 99.7% in the first year of use. A WHO [World Health Organization] study had shown that its effectiveness is comparable to bilateral tubal ligation. DMPA's mechanism of action is the inhibition of ovulation and the thinning of the endometrium. It is a safe contraceptive which the US Drug and Food Authority (USDFA) and our own Bureau of Food and Drug Authority had approved for contraceptive use. WHO studies had shown that DMPA does not lead to increased cancer risk, congenital malformation and infertility. DMPA was initially developed in the 1960s as a treatment for endometrial and renal cancer. Its contraceptive effects then led to its use as a family planning method. Over 9 million women had used DMPA. It is a very safe, reversible and effective family planning method with manageable side effects. These include: menstrual irregularities, amenorrhea, weight gain, nausea and vomiting. These effects can be adequately managed by a trained service provider. DMPA will be initially introduced by the Department of Health in 10 pilot areas. IMCH will soon introduce the method in our clinics once the supplies are available and the clinic staff are prepared in the service provision of DMPA.

Recent experience with and future directions of contraceptive implants and injectable contraceptives

Subdermal implantable contraception has been the most important addition to contraceptive technology in the past 2 decades. The Norplant system is only the first of a new family of long acting methods of high effectiveness, high acceptability, and prompt reversibility. The main advantage of the second generation implant systems, to be available soon, is the reduction in the number of implants, which greatly facilitates insertion and removal. However, great improvement in bleeding control is not to be expected. Large and carefully designed epidemiological studies have contributed to clear the main objections to the US Food and Drug Administration (FDA) approval of depot medroxyprogesterone acetate (DMPA) as an injectable contraceptive. New progestin-only, long acting injectables are being tested, but significant improvements over existing methods are difficult to foresee, although every alternative is welcome. Monthly combined injectables have been in great demand, at least in China and Latin America, because of better bleeding control. Improved combined monthly injectables, less estrogenic and more progestin dominated, have been developed and are being introduced in several countries and should soon replace the old monthly injectables. Contraceptive implants and injectables have shown to be an important addition to the contraceptive options available to women throughout both the developing and developed world.

Family planning in the teen population

As an increasing percentage of adolescents reach their sexual debut at younger ages, effective contraceptive methods, which will decrease the risks of unintended pregnancies and sexually transmitted diseases (STDs), become even more critical. Contraceptive methods which are less 'compliance-dependent', such as the implantable subdermal levonorgestrel and the injectable depot formulation of medroxyprogesterone acetate, are popular in adolescents but careful counseling before method selection and on-going counseling when side-effects are experienced are necessary and essential. The use of condoms to decrease the risks of STDs will continue to be important for adolescents, and it remains to be seen what impact the long-term methods will have on effective condom use. Adolescents' access to abortions when contraceptive methods fail, or when no method is used, is being challenged with state laws which mandate parental notification or permission. A greater knowledge about the option of emergency contraception could potentially lead to increased use of this method, particularly when the option of medications such as RU486 becomes available. The potential for a reduction in unintended pregnancies in adolescents, and a reduced need for abortions is a welcome prospect.

Fasting plasma lipids, lipoproteins and apolipoproteins in Nigerian women using combined oral and progestin-only injectable contraceptives

Fasting plasma lipid, lipoprotein, and apolipoprotein (apo) profiles were determined in Nigerian women using a low-dose combined oral (Lo-Feminal + Fe) (n = 18), a progestin-only injectable (Depo-Provera) (n = 16) contraceptives and matched controls (n = 18). The mean of plasma total and low-density lipoprotein (LDL) cholesterol, apo B and Lp(a) were significantly higher (p < 0.01) in women using contraceptives than the controls. The mean of total and LDL-cholesterol and apo B were also significantly higher in the oral contraceptive users than those on progestin-only injectables. Furthermore, the mean of cardiovascular disease (CVD) risk indices, total/HDL-cholesterol (p < 0.05) and LDL/HDL-cholesterol (p < 0.01), were significantly higher in women on oral contraceptives than the controls. There were no statistically significant differences between the indices in the women using progestin-only injectables and the controls. Based on this finding, it is concluded that the use of steroidal contraceptives is associated with alterations of lipid and apolipoprotein profiles in Nigerian women and that the use of low-dose combined oral contraceptives may be associated with an increased CVD risk.

The safety of physiological estrogen plus progestin replacement therapy and with oral contraceptive therapy in women with pathological hyperprolactinemia

In summary, E- replacement therapy may be administered to women with E deficiency, despite the presence of pathological hyperprolactinemia, with apparently no adverse effect on the underlying disease process. The concern of induction of rapid growth of an underlying pituitary adenoma was not substantiated.