Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety

Effect of depot medroxyprogesterone acetate on bone density in a Scottish industrial city

OBJECTIVE

To determine if long-term users of depot medroxyprogesterone acetate injectable contraception (DMPA) were more likely than their peers to have low bone density.

DESIGN

Cross-sectional observational study.

SETTING

The Domiciliary Family Planning Service, Glasgow, Scotland.

SUBJECTS

Clients of the Domiciliary Service who had used DMPA for contraception for longer than 5 years (mean 12 years) were invited to participate and select their own control, a friend or relative who had never used this method of contraception.

MAIN OUTCOME MEASURES

Bone density measured at the hip and lumbar spine by dual X-ray absorptiometry (DXA).

RESULTS

DMPA users had a significantly lower bone density than controls, 12-13% less at both hip and lumbar spine. This difference remained even when controlling for parity, smoking, family history of kyphosis or hip fracture, and body mass index.

CONCLUSIONS

DMPA significantly decreases bone density in a group of long-term users with significant social deprivation. The long-term significance of this remains uncertain.

Helping women choose appropriate hormonal contraception: update on risks, benefits, and indications

Primary care physicians frequently provide contraceptive counseling to women who are interested in family planning, have medical conditions that may be worsened by pregnancy, or have medical conditions that necessitate the use of potentially teratogenic medications. Effective counseling requires up-to-date knowledge about hormonal contraceptive methods that differ in hormone dosage, cycle length, and hormone-free intervals and are delivered by oral, transdermal, transvaginal, injectable, or implantable routes. Effective counseling also requires an understanding of a woman's preferences and medical history as well as the risks, benefits, side effects, and contraindications of each contraceptive method. This article is designed to update physicians on this information.

Steroidal contraceptives: effect on bone fractures in women

BACKGROUND

Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.

OBJECTIVES

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

We searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as in clinical trials databases (ClinicalTrials.gov and ICTRP). We wrote to investigators to find additional trials.

SELECTION CRITERIA

Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The mean difference was computed with 95% confidence interval (CI) using a fixed-effect model.

MAIN RESULTS

We found 13 RCTs, 2 of which used a placebo. No trial had fracture as an outcome but most measured BMD. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density

BACKGROUND

A formulation of depot medroxyprogesterone acetate (DMPA) has been developed that allows subcutaneous injection (104 mg/0.65 mL; DMPA-SC) and achieves highly effective contraception with a similar tolerability profile to intramuscular DMPA (150 mg/mL; DMPA-IM).

STUDY DESIGN

This randomized, evaluator-blinded study was designed to compare efficacy, safety, and user satisfaction in women receiving DMPA-SC (n=266) or DMPA-IM (n=268) for 2 years with an option to continue for a third year. The primary objectives were to evaluate bone mineral density (BMD) changes and contraceptive efficacy after 2 years.

RESULTS

A total of 225 women completed the first 2 years of this study (DMPA-SC, n=116; DMPA-IM, n=109). After 2 years of DMPA use, BMD loss was marginally smaller in the DMPA-SC group than in the DMPA-IM group at both the total hip (-3.3% and -3.6%, respectively) and lumbar spine (-4.3% and -5.0%, respectively). In those women who received DMPA during the third year, there were no statistically significant differences in BMD loss between DMPA-SC and DMPA-IM groups at the end of Year 3. Recovery of BMD was observed in the small subpopulation of women who had discontinued DMPA-SC or DMPA-IM after the second year. The 2-year treatment-failure cumulative pregnancy rate was 0% in the DMPA-SC group and 0.8% (95% confidence interval, 0.00-2.37%) in the DMPA-IM group (life-table method). Adverse events were similar in the two groups except that injection site reactions were more common in the DMPA-SC group.

CONCLUSION

DMPA-SC is an effective and well-tolerated contraceptive option, providing comparable efficacy and BMD safety to DMPA-IM.

Hormonal contraception

Hormonal contraceptives have been a part of clinical practice for more than 40 years, and family planning programs, based largely on contraceptive provision, are regarded as one of the most successful public health interventions of the 20th century. Thus, discussion of family planning issues and contraceptive considerations has become an integral component of women's health care and one of the benchmarks of the traditional annual well-women visit. In terms of cost-effectiveness, prevention of unplanned pregnancies through contraceptive use has repeatedly been shown to be a highly cost-effective use of health care dollars. Options for effective hormonal contraception have expanded tremendously and include a variety of delivery options, including the pills both in traditional 21/7 format, and more recently in a 24/4 format, as well as a vaginal ring, a skin patch, implants, and the hormonally medicated intrauterine device. Importantly, the overall risks associated with hormonal contraceptives have been reduced as compared with older formulations, even for women with medical conditions. Many modern hormonal contraceptives also offer valuable noncontraceptive benefits. To help clinical decision making, a number of evidence-based guides have been published, and the American College of Obstetricians and Gynecologists has recently updated their practice bulletin on contraception use in women with medical conditions. In general, clinical protocols for provision of hormonal contraceptives have been streamlined, and unnecessary practices, tests, and procedures are identified and discouraged. In this review, we will summarize both technical and programmatic aspects of hormonal contraceptive use, and methods are discussed in order of efficacy from highest to lowest.

Analysis why nulliparous women over age 33 wish to use contraception

BACKGROUND

In industrialized countries, the average age of first childbirth is increasing and more women are having no children. An understanding of the reasons for delay might provide strategies aimed at reversing this trend.

STUDY DESIGN

A questionnaire survey of 234 nulliparous women aged 34 and over attending a family planning clinic in Scotland in 2006 for contraception to determine fertility intentions; awareness of fertility decline with age; and factors influencing the decision to delay childbearing.

RESULTS

One hundred and sixteen women (49.6%) definitely/possibly wanted children; 118 women (50.4%) did not. Of those wanting children, 71% were concerned or very concerned about their future fertility. Most were realistic about the time it may take to conceive. Seventy-four percent of women who definitely/may want children gave reasons to do with their relationship/s as the most common reason for delay. The second most common reason was having other distractions in life. Only 34% of those wanting children, and 15% of those who did not, reported that work/training issues caused the delay.

CONCLUSION

Most women were aware of the risks of delaying childbirth; however, the most common reason for delay concerned lack of the 'right' partner, something which does not lend itself to intervention.

Physiologic and psychologic symptoms associated with use of injectable contraception and 20 microg oral contraceptive pills

OBJECTIVE

The objective of the study was to compare menstrual, physiologic, and psychologic symptoms over 2 years among women initiating use of depot medroxyprogesterone acetate or an oral contraceptive pill with a reduced pill-free interval and those not using hormonal contraception.

STUDY DESIGN

A total of 608 women reported their experience regarding 17 symptoms prior to initiating contraception and every 6 months thereafter for 24 months. Longitudinal relationships between symptoms and contraceptives were assessed after adjusting for age, visits, and baseline status of symptoms.

RESULTS

Oral contraceptive pills were protective against mastalgia (odds ratio [OR], 0.7), cramping (OR, 0.5), hair loss (OR, 0.6), acne (OR, 0.4), nervousness (OR, 0.5), and mood swings (OR, 0.7). Depot medroxyprogesterone acetate (DMPA) was protective against bloating (OR, 0.5) and mood swings (OR, 0.7) but caused weight gain (OR, 2.3), bleeding episodes more than 20 days (OR, 13.4), and missed periods (OR, 96.9). Both methods caused intermenstrual bleeding.

CONCLUSION

Evidence-based data regarding beneficial and adverse symptoms associated with these methods may help clinicians counsel patients appropriately prior to contraceptive initiation.

Forearm bone mineral density in postmenopausal former users of depot medroxyprogesterone acetate

BACKGROUND

The aim of the study was to compare the bone mineral density (BMD) of postmenopausal women who had used depot-medroxyprogesterone acetate (DMPA) or a copper intrauterine device (IUD) as a comparison group until menopause.

STUDY DESIGN

BMD was measured using dual-energy X-ray absorptiometry at the nondominant forearm for up to 3 years following menopause in 135 women aged 43-58 years: 36 former DMPA users and 99 former IUD users.

RESULTS

Mean duration of use was (mean+/-SEM) 9.4+/-3.8 and 14.7+/-6.2 years for the DMPA and IUD groups, respectively. One year after menopause, mean distal radius BMD was 0.435 and 0.449 in DMPA and IUD users, respectively, and 0.426 and 0.447 at 2-3 years following menopause. Ultra-distal BMD was 0.369 and 0.384 in DMPA and IUD users, respectively, at 1 year, and 0.340 and 0.383 at 2-3 years.

CONCLUSIONS

At 1 and 2-3 years following menopause, no significant differences were observed in the BMD of postmenopausal women aged 43-58 years, who had used DMPA or an IUD until menopause.

The influence of hormonal contraception on mood and sexual interest among adolescents

Mood and sexual interest changes are commonly cited reasons for discontinuing hormonal contraceptives. Data, however, are inconsistent and limited to adult users. We examined associations of hormonal contraceptive use with mood and sexual interest among adolescents. We recruited 14-17-year-old women from primary care clinics and followed them longitudinally for up to 41 months. Participants completed face-to-face interviews quarterly and two 12-week periods of daily diary collection per year. On daily diaries, participants recorded positive mood, negative mood, and sexual interest. We classified 12-week diary periods as "stable OCP use," "non-use," "initiated use," "stopped use," and "DMPA use" based on self-report of oral contraceptive pill (OCP) use and depot medroxyprogesterone acetate (DMPA) use from medical charts. Diary periods were the unit of analysis. Participants could contribute more than one diary period. We analyzed data using linear models with a random intercept and slope across weeks in a diary period, an effect for contraceptive group, and an adjustment for age at the start of a diary period. Mean weekly positive mood was higher in diary periods characterized by stable OCP use, compared to other groups. Mean weekly negative mood was lower in diary periods characterized by stable OCP use and higher in periods characterized by DMPA use. Periods characterized by stable OCP use additionally showed less mood variation than other groups. Changes in mood among adolescent hormonal contraceptive users differed from those anticipated for adult users. Attention to adolescent-specific changes in mood and sexual interest may improve contraceptive adherence.

Bone density recovery after depot medroxyprogesterone acetate injectable contraception use

BACKGROUND

While depot medroxyprogesterone acetate (DMPA) is a highly effective contraceptive used by millions of women, its use is associated with bone mineral density (BMD) loss, raising concerns about long-term risk of osteoporosis and/or fractures.

STUDY DESIGN

We conducted a systematic review of studies published in PubMed from 1996 to 2006, evaluating changes in BMD after discontinuation of DMPA. Ten primary clinical or observational studies were identified addressing this issue.

RESULTS

BMD consistently returned toward or to baseline values following DMPA discontinuation in women of all ages. This recovery in BMD was seen as early as 24 weeks after stopping therapy and persisted for as long as women were followed up; BMD in past DMPA users was similar to that in nonusers.

CONCLUSIONS

Bone loss occurring with DMPA use is reversible and is not likely to be an important risk factor for low bone density and fractures in older women, although data on fracture risk in DMPA users are lacking.

Long-acting contraceptives in adolescents

PURPOSE OF REVIEW

To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed.

RECENT FINDINGS

The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits.

SUMMARY

The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.

Changes in weight with depot medroxyprogesterone acetate subcutaneous injection 104 mg/0.65 mL

INTRODUCTION

The study was conducted to assess the impact of depot medroxyprogesterone acetate subcutaneous injection 104 mg/0.65 mL (DMPA-SC 104) on body weight.

METHODS

Changes in weight from pretreatment were analyzed using data from two 1-year, noncomparative trials of DMPA-SC 104 (North/South American, N=722; European/Asian, N=1065) and a 3-year, randomized study (SC/IM) comparing DMPA-SC 104 (N=266) with the DMPA intramuscular injection 150 mg/mL (DMPA-IM 150). For each study, additional analyses were conducted for changes in body weight by age (<25, 25 to 35 and >35 years) and body mass index (BMI) (<or=25, >25 to <or=30 and >30 kg/m2) subgroups.

RESULTS

In both 1-year trials, the mean (+/-SD) weight gain at month 12 was <2 kg [1.7 kg (+/-4.5 SD) in the Americas trial and 1.4 kg (+/-3.6 SD) in the Europe/Asia trial]. In the SC/IM trial, mean weight changes were similar between DMPA-SC 104 and DMPA-IM 150 groups, with mean (+/-SD) gains at month 36 of 4.5+/-8.5 and 5.8+/-8.7 kg, respectively. Similar differences in weight gain were observed by age or baseline BMI in all studies.

CONCLUSION

DMPA-SC 104 was associated with modest weight gain in most women.

The role of progestins in treating the pain of endometriosis

Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical resection. A variety of oral agents have been employed in this regard with investigators demonstrating differing degrees of benefit. Unfortunately, due to the lack of large-scale, appropriately controlled, randomized trials, or dose-ranging studies, no single agent can be demonstrated to be truly efficacious. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Injectable administration of long-acting depot medroxyprogesterone acetate preparations intramuscularly or subcutaneously has been investigated in three randomized trials. The lower dose subcutaneous injection holds promise with an apparent reduction in side effects. Issues of reversible bone mineral density loss, breakthrough bleeding, and return of menses have not been completely resolved. Selective progesterone receptor modulators represent an intriguing alternative. These orally administered agents have been shown in preliminary investigations to be not only efficacious in reducing symptoms but also associated with minimal side effects. Further investigation of these agents is clearly required.

Steroidal contraceptives: effect on bone fractures in women

BACKGROUND

Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.

OBJECTIVES

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

We searched MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of fracture or bone health and hormonal contraceptives. We wrote to investigators to find additional trials.

SELECTION CRITERIA

Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The weighted mean difference (WMD) was computed with 95% confidence interval (CI) using a fixed-effect model.

MAIN RESULTS

No trial had fracture as an outcome. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.

Hormonal contraception in adolescents: special considerations

With the rates of unintended pregnancies in teenagers remaining high, it is crucial to present adolescents with all of the contraceptive options available to them. While barrier methods, for example, male condoms, are easily accessible and do not have adverse effects, their use must be consistent and correct with each act of intercourse. Hormonal contraception affords much better efficacy in preventing pregnancy when used with full compliance. Oral contraceptives are a popular method of contraception among adolescents and offer many non-contraceptive benefits along with the prevention of pregnancy. They have very few significant adverse effects, which are outweighed by the significant morbidity associated with teenage pregnancies, and can be used by most adolescent females. However, their minor bothersome effects do contribute to the high discontinuation rates seen. In addition, many girls find it difficult to remember to take a pill every day, leading to higher failure rates in teenagers than in adult women. The advent of long-acting, progestogen (progestin)-only methods, such as injectables and implantables, has been generally accepted by adolescents and these methods have proven to be more efficacious by avoiding the need for daily compliance. However, progestogen-only methods cause irregular bleeding and amenorrhea, which is not acceptable to many teenagers. In addition, the most widely used implant was taken off the market a few years ago and newer forms are not yet widely accessible. Other novel methods are currently available, including the transdermal patch and the vaginal ring. Both are combinations of estrogen and progestogen and have similar efficacy and adverse effect profiles to oral contraceptives. Their use may be associated with greater compliance by adolescents because they also do not require adherence to a daily regimen. However, there may be some drawbacks with these newer methods, for example, visibility of the patch and difficulty with insertion of the vaginal ring. When regular contraceptive modalities fail, emergency contraception is available. Choices include combination oral contraceptives, progestogen-only pills, mifepristone, or placement of a copper-releasing intrauterine device. These methods can be very useful for preventing pregnancy in adolescents as long as adolescents are aware of their existence and have easy access to them.

Bone mineral density in women aged 25–35 years receiving depot medroxyprogesterone acetate: recovery following discontinuation

INTRODUCTION

This 7-year, prospective, matched-cohort, clinical study evaluated the effects of intramuscular depot medroxyprogesterone acetate (DMPA) (150 mg/mL) on bone mineral density (BMD) in women aged 25-35 years.

METHODS

Bone mineral density changes in new DMPA-IM users (n=248) were compared with those in women using nonhormonal contraception (n=360) for up to 240 weeks of treatment and 96 weeks of posttreatment follow-up (in subjects receiving >or=1 dose).

RESULTS

At week 240 of treatment, mean percentage changes from baseline in DMPA-IM vs. nonhormonal subjects were: -5.16% (n=21) vs. +0.19% (n=65), total hip (p<.001); -5.38% (n=33) vs. +0.43% (n=105), lumbar spine (p<.001). At week 96 posttreatment, these values were: -0.20% (n=25) vs. +0.84% (n=43), total hip (p=.047); -1.19% (n=41) vs. +0.47% (n=66), lumbar spine (p=.017).

CONCLUSIONS

These results show BMD declines during DMPA-IM use; following discontinuation, significant increases in BMD occur through 96 weeks posttreatment.

Evidence based contraceptive choices

People who attend for contraceptive advice have usually formulated an idea of the type of contraceptive that will suit them best. They may wish to use a method that is long, short or medium acting. These are defined as follows: Long-acting method requires renewal no more frequently than every 3 months (e.g. injectable or intrauterine). Short-acting method used daily or with every act of intercourse (e.g. pills, condoms) Medium-acting method requires renewal weekly or monthly (e.g. ring, patch). For men the choice is limited to condoms or vasectomy. Some women do not wish to use hormonal preparations or have an intrauterine device (IUD) or implant inserted. There may also be cultural influences making certain methods of contraception unacceptable. Each of these factors influences the final decision of which method of contraception is decided upon. In addition to taking a full medical and sexual history to identify any risks to the individual's health, which might be increased by a particular contraceptive, time must be spent discussing the options available. It is important to ensure that there is a full understanding of the advantages and disadvantages of each method. The most successful contraceptive method is likely to be the one that the woman (or man) chooses, rather than the one the clinician chooses for them. Access for women to contraception can be improved by having convenient clinic times and service developments such as nurse prescribing and Patient Group Directions.

Inhibitory effect of medroxyprogesterone acetate on human liver cytochrome P450 enzymes

OBJECTIVE

Medroxyprogesterone acetate (MPA), frequently used in contraception and chemotherapy, was involved in a report of drug-drug interaction (DDI) when co-administrated with phenytoin, doxifluridine and cyclophosphamide. In order to clarify the mechanism of such interaction, an in vitro study was undertaken to evaluate MPA's potential to inhibit cytochrome P450 (CYP) enzymes.

METHODS

Inhibitory effects of MPA on seven CYPs, including CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP2D6, CYP2E1 and CYP3A4, were conducted in human liver microsomes. Time- and NADPH-dependent inhibitions were also tested. DDI potential was predicted according to the [I]/K ( i ) value.

RESULTS

MPA was found to inhibit CYP2C9 and CYP3A4; half inhibition concentration (IC(50)) was 16.1 microM and 31.5 microM, respectively. Slight inhibition was observed on CYP1A2, CYP2A6, CYP2C8 and CYP2D6 with IC(50) of more than 100 microM. MPA exhibited activation rather than inhibition on CYP2E1. Further study revealed that MPA showed a noncompetitive inhibition on CYP2C9 and a competitive inhibition on CYP3A4 with K ( i ) of 9.0 microM and 36 microM, respectively. In addition, MPA was not a mechanism-based inhibitor to any of seven isoforms tested. By using predicted concentration of MPA in liver, [I]/K ( i ) was estimated to be 0.24 and 0.06 for CYP2C9 and CYP3A4, respectively. The concentration of phenytoin co-administrated with MPA was calculated to increase by 24%.

CONCLUSION

Based on our results, MPA can possibly cause clinically relevant DDI via the inhibition of CYP2C9.

Weight, fat mass, and central distribution of fat increase when women use depot-medroxyprogesterone acetate for contraception

OBJECTIVE

To compare longitudinal changes in weight, body fat, and ratio of central to peripheral fat mass among first-time depot-medroxyprogesterone acetate (DMPA) users to women using no hormonal contraception, and to evaluate user characteristics associated with that change.

DESIGN

Prospective longitudinal study.

SUBJECTS

Healthy women, aged 18-35 y, using DMPA for contraception (n=178) and women using no hormonal contraception (n=145).

MEASUREMENTS

Weight, body fat, and the central distribution of fat, measured at 3-month intervals for 30 months, by electronic scale and dual-energy X-ray absorptiometry (DEXA). The ratio of central to peripheral distribution of body fat was computed by dividing the body fat in the conventional DEXA trunk region of interest (ROI) by the ROI's that encompass the arms, hips and legs.

RESULTS

Women using DMPA had a significantly greater increase in all measures of fatness than women using no hormonal method of contraception (P<0.03). The observed weight of DMPA users increased from a mean of 69.4 kg (s.d.=16.9) at baseline to 75.5 kg (s.d.=25.0) at 30 months; an increase of 6.1 kg (8.8.%). Fat mass increased from a mean of 25.3 kg (s.d.=12.6 kg) at baseline to 31.4 kg (s.d.=17.8); an increase of 6.1 kg (23.6%) in DMPA users. The ratio of central to peripheral fat mass in DMPA users changed from 0.95 (s.d.=0.155) at baseline to 1.01(s.d.=0.198) at 30 months. In contrast, weight, fat mass and the ratio of central to peripheral fat mass of control participants remained virtually unchanged over the same time period. Women with higher baseline physical activity levels had a smaller increase in body fat (P=0.003) and the fat ratio (P=0.03), but not weight (P=0.48). No other user characteristics including, smoking, past oral contraceptive use or previous pregnancies predicted change in level of fatness.

CONCLUSIONS

This study has demonstrated a change in body composition toward greater fatness and toward a central redistribution of fat among DMPA users as compared to controls and provides important information to be used when counseling women regarding contraceptive methods. Given the potential long-term implication of these changes, further study is recommended to determine whether the gains in fatness are reversed following DMPA discontinuation and to examine the role of progestins in the development and maintenance of obesity.

Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain

OBJECTIVE

To compare the efficacy and safety of SC depot medroxyprogesterone acetate (DMPA-SC 104) with that of leuprolide acetate in treatment of endometriosis.

DESIGN

Phase 3, multicenter, randomized, evaluator-blinded, comparator-controlled trial.

SETTING

Clinical trial sites in Canada and United States.

PATIENT(S)

Two hundred seventy-four women with surgically diagnosed endometriosis.

INTERVENTION(S)

Intramuscular injections of DMPA-SC (104 mg) or leuprolide acetate (11.25 mg), given every 3 months for 6 months, with 12 months of posttreatment follow-up.

MAIN OUTCOME MEASURE(S)

Reduction in five endometriosis symptoms or signs (dysmenorrhea, dyspareunia, pelvic pain, pelvic tenderness, pelvic induration); change in bone mineral density (BMD), hypoestrogenic symptoms, bleeding, and weight.

RESULT(S)

The depot medroxyprogesterone acetate given SC was statistically equivalent to leuprolide in reducing four of five endometriosis symptoms or signs at the end of treatment (month 6) and in reducing all five symptoms after 12 months' follow-up (month 18). Patients in the DMPA-SC 104 group showed significantly less BMD loss than did leuprolide patients at month 6, with scores returning to baseline at 12 months' follow-up. No statistically significant differences in median weight changes were observed between groups. Compared with leuprolide, DMPA-SC 104 was associated with fewer hypoestrogenic symptoms but more irregular bleeding.

CONCLUSION(S)

Efficacy of DMPA-SC 104 was equivalent to that of leuprolide for reducing endometriosis-associated pain, with less impact on BMD and fewer hypoestrogenic side effects but more bleeding.

Randomized assignment to copper IUD or depot-medroxyprogesterone acetate: feasibility of enrollment, continuation and disease ascertainment

OBJECTIVES

We conducted a feasibility study to enroll and follow family planning acceptors who were randomly assigned to use an intrauterine device (IUD) or injectable depot-medroxyprogesterone acetate (DMPA).

METHODS

Centers in Brazil, Guatemala, Egypt and Vietnam aimed to enroll 100 participants per site. Enrolled women were randomly assigned to have inserted a TCu 380A IUD, or to receive injections of 150 mg of DMPA every 3 months, and scheduled for up to 12 months of follow-up. We tested for cervical infection at first and final visits, and examined for signs of pelvic inflammatory disease (PID) at each visit.

RESULTS

The sites screened 555 women and enrolled 368. Two women (0.5%) had three discomfort signs of PID during follow-up. The prevalence of gonorrhea at each woman's final follow-up visit was 0.5%, and the prevalence of chlamydia at final visit was 5.4%. Sixty-eight percent of women either completed 12 months of observation with their assigned method or were still using their method at the end of the study.

CONCLUSION

A larger, definitive clinical trial appears feasible. The majority of women we approached agreed to participate; nearly 400 women were enrolled; two thirds continued to use their assigned method until study closeout; and the STI risk was moderate.

Prevention of severe menorrhagia in oncology patients with treatment-induced thrombocytopenia by luteinizing hormone-releasing hormone agonist and depo-medroxyprogesterone acetate

BACKGROUND

Menorrhagia is a serious complication in young female oncology patients who suffer from severe thrombocytopenia during myelosuppressive treatment. To the authors' knowledge, little is known regarding the incidence of this complication or the effectiveness of possible therapies for its prevention.

METHODS

In this retrospective clinical study, after a thorough gynecologic evaluation, young female oncology patients with regular menstrual cycles undergoing myelosuppressive treatments received either depo-medroxyprogesterone acetate (DMPA), or D-tryptophan-6-luteinizing hormone-releasing hormone depot treatment (gonadotropin-releasing hormone agonist [GnRH-a]), or no treatment before the administration of myelosuppresive chemotherapy. Only patients who later developed severe thrombocytopenia (<25,000 platelets per muL) were included in the study. Daily blood counts, menorrhagia, nonvaginal bleeding episodes, and the need for blood products, gynecologic consultations, and other medical interventions were determined.

RESULTS

Of 101 women with cancer who met the inclusion criteria, 42 patients received DMPA, 39 patients received GnRH-a, and 20 patients remained untreated. The mean duration (+/- standard deviation) of severe thrombocytopenia was 24.76 +/- 23.6 days. Four patients were not included because of significant gynecologic pathologies. General bleeding from nongynecologic sites was similar for all groups and was not associated with vaginal bleeding. Severe or moderate menorrhagia was documented in none of the 39 women who received GnRH-a, in 9 patients (21.4%) who received DMPA, and in 9 untreated patients (40%; P = .02). Fewer calls for urgent gynecologic consultations were documented in the GnRH-a group compared with the untreated group (P < .0001).

CONCLUSIONS

Female patients undergoing myelosupressive therapy are at high risk of developing significant menorrhagia during prolonged, severe thrombocytopenia. Pretreatment gynecologic evaluation can detect significant pelvic pathologies. GnRH-a treatment effectively prevented menorrhagia, whereas DMPA administration was less effective.

A patient with autism and severe depression: medical and ethical challenges for an adolescent medicine unit

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

Medroxyprogesterone acetate binds the glucocorticoid receptor to stimulate alpha-ENaC and sgk1 expression in renal collecting duct epithelia

Medroxyprogesterone acetate (MPA), a widely used synthetic progestational contraceptive, occasionally leads to Cushingoid side effects such as hypertension, fluid retention, and centripetal obesity. We investigated the effect of MPA on classic mineralocorticoid target genes, alpha-epithelial Na channel (ENaC) and sgk1, in the collecting duct. In adrenalectomized mice, aldosterone, dexamethasone, and MPA increased alpha-ENaC mRNA levels in kidney cortex. MPA and dexamethasone, but not progesterone, dose dependently increased alpha-ENaC and sgk1 mRNA in M-1 and in Madin-Darby canine kidney-C7 cells, both collecting duct cell lines. The stimulatory effect of MPA and dexamethasone on alpha-ENaC expression was inhibited by RU-38486, a combined glucocorticoid receptor (GR) and progesterone receptor (PR) antagonist, but not by Org31710, a pure PR antagonist. MPA and dexamethasone dose dependently increased alpha-ENaC promoter-driven luciferase activity in M-1 cells, which was not inhibited by Org31710, indicating that MPA regulates alpha-ENaC in a PR-independent manner. When tested in HT29 cells, MPA could only stimulate alpha-ENaC-driven reporter activity when GR was coexpressed, confirming the requirement for functional GR in the transcriptional effect of MPA. The activation of steroid receptors such as GR can explain the apparent glucocorticoid effects of MPA, independent of PR activation.

Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain

BACKGROUND

A clinical study compared efficacy and safety of depot medroxyprogesterone acetate (DMPA) with leuprolide for endometriosis-associated pain.

METHODS

This multicentre, 18 month, evaluator-blinded, comparator-controlled trial randomized 300 women with laparoscopically diagnosed endometriosis to 6 month treatment with subcutaneous injection of 104 mg/0.65 ml DMPA (DMPA-SC 104) every 3 months or leuprolide (3.75 mg monthly or 11.25 mg every 3 months), with 12 months post-treatment follow-up. Endpoints included patient response to treatment in five signs/symptoms (dysmenorrhoea, dyspareunia, pelvic pain, pelvic tenderness, induration) and changes in bone mineral density (BMD) and productivity at 6 and 18 months.

RESULTS

DMPA-SC 104 and leuprolide produced equivalent (P < 0.02) reductions in at least four pain categories and significant (P < 0.001) improvements in composite score at months 6 and 18. At month 6, reductions in total hip and lumbar spine BMD were significantly less (P < 0.001) with DMPA-SC 104 versus leuprolide. BMD returned to pre-treatment levels 12 months post-treatment in the DMPA-SC 104 but not the leuprolide group. Total productivity also significantly (P < or = 0.05) improved in both groups at 6 and 18 months.

CONCLUSIONS

DMPA-SC 104 reduces endometriosis-associated pain as effectively as leuprolide and improves productivity with significantly less BMD decline.

Enhancing contraception A comprehensive review

This review covers familiar and emerging contraceptive methods, comparing the risks and benefits of each. These basics will help you connect patients with the most acceptable form of contraception for them.

Depo-Provera: use of a long-acting progestin injectable contraceptive in Turkish women

OBJECTIVE

To assess the demographic and clinical characteristics and experience of Turkish women treated with depot medroxyprogesterone acetate (DMPA).

STUDY DESIGN

This prospective clinical study was carried on 9262 subjects, treated with DMPA at Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey, between 1996 and 2004.

RESULTS

The mean age of study population was 28.4+/-4.6 years; 1759 (19%) subjects were breast-feeding at the time of the first injection. Eight (0.08%) pregnancies occurred, within 3 months of injection in 9262 women. Of 9262 cases, irregular bleeding occurred in 80% (7410) of the women. Discontinuation rate with this contraceptive method was recorded as 71% (6576) of the subjects. The rate of other predominant side effects was observed as follows: 8% for increase in weight, 8% for breast engorgement, 7% for mastalgia, 5% for headache.

CONCLUSION

The results of this study suggest that DMPA may be an attractive contraceptive choice for both the patient and the physician in some clinical situations, especially in women at risk for complications with oral hormonal contraceptives and women who have had low compliance with other contraceptive methods. Moreover, DMPA contraception might be particularly appropriate in some cases such as in the postpartum period and in lactating women.

Same-day administration of depot-medroxyprogesterone acetate injection: a retrospective chart review

A chart review of clients administered depot-medroxyprogesterone acetate (DMPA) injection in September of 2000 was performed to assess implementation of a same-day injection administration protocol irregardless of menstrual cycle day. Women were classified into one of the three categories: (1) routine injection (injection given as specified by the package label), (2) same-day start injection (no injection for more than 6 months, did not meet labeled criteria for administration and received an injection the day of the visit) or (3) same-day restart injection (injection given within 6 months prior to receiving an injection at the visit despite being late for their injection). Of the 228 women receiving an injection, 104 (46%) had a nonroutine same-day injection, meaning almost half of the women receiving a contraceptive injection would have had to return for another visit if this protocol had not been in place. Among these women administered a same-day injection, 23 (22%) were also dispensed emergency contraception. Only 1 of the 104 women was subsequently identified to have become pregnant. Other pregnancies are presented to illustrate the importance of adherence to pregnancy testing at the time of injection and revisit, and the need for backup contraception. Using a same-day injection protocol, women can have increased access to injection contraception, and proper adherence to a protocol can assure few pregnancies.

Beyond the pill: new data and options in hormonal and intrauterine contraception

With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.

Effect of long-term progestin treatment on endometrial vasculature in normal cycling mice

The aim of this study was to develop a mouse model to investigate the effects of long-term progestin-only exposure on endometrial vascular structure. Normal cycling mice received Silastic implants containing either medroxyprogesterone acetate (MPA) or levonorgestrel (LNG) and were dissected after 1, 3 or 6 weeks. Endometrial vascular density increased significantly within 1 week of MPA (482 +/- 40.2 vessels/mm2) or LNG (440 +/- 26.5 vessels/mm2) treatment compared with normal cycling mice (293 +/- 10.5 vessels/mm2). MPA increased stromal cell density within 1 week of treatment (13813 +/- 1450 cells/mm2) compared with normal cycling mice (8256 +/- 928 cells/mm2). However, although LNG significantly increased stromal cell density overall, the increase did not reach significance within the individual weeks examined. There was no significant change in the ratio of vascular to stromal cell density among treated and normal cycling mice. Epithelial cell height significantly decreased within 1 week of LNG (17.6 +/- 1.3 microm) treatment compared with normal cycling mice (23.5 +/- 1.3 microm); epithelial cell height also decreased within 1 week of MPA treatment (16.6 +/- 2.1 microm), although this did not reach statistical significance. VEGF immunostaining increased significantly in luminal epithelium after MPA or LNG treatment, and in glandular epithelium after LNG treatment. These observations are similar to those reported in human endometrium, suggesting that this mouse model may facilitate further investigations into breakthrough bleeding due to long-term progestin use.

Context of care and contraceptive method use

OBJECTIVES

We assessed the relationship between context of care (incorporates insurance status with clinical setting) on contraceptive use among a national sample of reproductive-aged women. Our hypothesis is that compared to privately insured women who receive their health care in private doctors' offices, women who are publicly insured or self-pay and/or receive their health care in a clinic are more likely to use permanent or long-acting contraceptive methods.

METHODS

The study population, consisting of 4,358 women surveyed as part of the 1995 National Survey of Family Growth (NSFG) who were both at risk of unintended pregnancy and currently sexually active, was analyzed using polytomous logistic regression.

RESULTS

Following adjustment for age, race/ethnicity, marital status, education, income, parity and smoking, there was a trend toward long-acting contraceptive use among women with public insurance or who were self-pay, regardless of clinical setting compared to privately insured women seen in private clinics. Self-pay and publicly insured women of low parity tended to use long-acting contraception, as did privately insured women seen in clinics.

CONCLUSIONS

Insurance information, as well as clinical setting, may guide clinicians' contraceptive decision-making.

Clinical evaluation and management of myasthenia gravis

Myasthenia gravis (MG) is a syndrome of fluctuating skeletal muscle weakness that worsens with use and improves with rest. Eye, facial, oropharyngeal, axial, and limb muscles may be involved in varying combinations and degrees of severity. Its etiology is heterogeneous, divided initially between those rare congenital myasthenic syndromes, which are genetic, and the bulk of MG, which is acquired and autoimmune. The autoimmune conditions are divided in turn between those that possess measurable serum acetylcholine receptor (AChR) antibodies and a smaller group that does not. The latter group includes those MG patients who have serum antibodies to muscle-specific tyrosine kinase (MuSK). Therapeutic considerations differ for early-onset MG, late-onset MG, and MG associated with the presence of a thymoma. Most MG patients can be treated effectively, but there is still a need for more specific immunological approaches.