Depo Provera: a review

Subclinical cardiovascular disease parameters after one year in new users of depot medroxyprogesterone acetate compared to copper-IUD

PURPOSE

To evaluate markers of cardiovascular disease in women with normal insulin sensitivity who had recently initiated use of depot medroxyprogesterone acetate (DMPA) as a contraceptive.

MATERIALS AND METHODS

A prospective, non-randomised, comparative study. Data of 30 women of 18-40 years of age, with normal hyperinsulinaemic-euglycaemic clamp at baseline and body mass index (BMI) < 30, who opted to use DMPA or a copper intrauterine device (IUD) as a contraceptive, were analysed. Serum samples were collected for evaluation of the lipid and hepatic profile, C-reactive protein, TNF-α, interleukin-6, leptin/adiponectin ratio and free fatty acids; body composition was evaluated using DXA, blood pressure and carotid intima-media thickness were measured. Evaluations were performed at baseline and 12 months later. The groups were compared using repeated measures analysis of variance (ANOVA). Significance level was 5%.

RESULTS

The mean age of the women in the DMPA and IUD group was 28.7 ± 6.5 and 28.3 ± 5.8 years, respectively; the BMI was 23.0 ± 3.4 and 24.3 ± 2.7 kg/m², respectively, in the same groups. At 12 months, triglyceride levels were higher in the DMPA group compared to the IUD group and there was an increase in apolipoprotein B-100 in relation to baseline in DMPA group; there were no other difference between the groups.

CONCLUSIONS

No clinical cardiovascular effect was found but deterioration in CV markers was observed in the first year of use of DMPA.

Hyperinsulinemic-euglycemic clamp over the first year of use of depot-medroxyprogesterone acetate as a contraceptive

OBJECTIVE

The literature lacks data on the use of the gold-standard hyperinsulinemic-euglycemic clamp (HEC) technique for the evaluation of insulin resistance (IR) in depot-medroxyprogesterone acetate (DMPA) users. This study assessed carbohydrate metabolism in non-obese users of DMPA using the HEC technique.

STUDY DESIGN

A prospective, non-randomized, comparative study conducted at the Family Planning Clinic/Metabolic Unit, University of Campinas, Brazil. Forty-eight women aged 18-39 years underwent HEC: 30 initiating use of DMPA and 18 initiating use of a copper intrauterine device (IUD). Data from 15 women in each group, who completed the follow-up and underwent HEC at12 months, were compared using repeated measures ANOVA. All women were advised to perform aerobic physical exercise for 150 min/week; body composition and total energy intake were evaluated. Main outcome measures were IR defined by M-value <4 mg/kg/min, and blood levels of insulin. Additional outcomes were total cholesterol, HDL-cholesterol, triglycerides, LDL-cholesterol, adipokines and free fatty acids.

RESULTS

At 12 months, two women in the DMPA group and none in the IUD group had developed IR. The groups were similar in in M-values and in blood levels of insulin, total cholesterol, HDL-cholesterol, LDL-cholesterol, adipokines or free fatty acids. Triglyceride levels increased in the DMPA group when compared to the IUD group, 80.0 (SD 47.8) versus 61.8 (SD 35.8) mg/dL respectively, (p=.033); and increased the total daily energy intake, 1828.3 (SD 518.9) versus 1300.8 (SD 403.4) kilocalories/24hs, respectively in the same groups, (p=.041). All the DMPA users showing higher insulin sensitivity at 12 months reported performing physical activity regularly.

CONCLUSIONS

Changes occurred in carbohydrate metabolism in DMPA users in the first year of use of the method. It is possible that the regular aerobic exercise may exert a beneficial and protective effect against the factors that trigger these changes.

IMPLICATIONS STATEMENT

Carbohydrate metabolism undergoes adverse changes in few young non-obese women during the first year of DMPA use and regular aerobic exercise may exert a beneficial and protective effect against these changes.

Insulin resistance parameters in users of the injectable contraceptive depot medroxyprogesterone acetate during one year of use

OBJECTIVES

The aim of the study was to assess insulin resistance parameters using successive homeostasis model assessment (HOMA) and clinical evaluations in healthy new users of depot medroxyprogesterone acetate (DMPA).

METHODS

A prospective 12-month study was carried out to compare 31 DMPA users with 25 copper intrauterine device (Cu-IUD; TCu380A) users, matched for age (± 1 year) and body mass index (BMI; ± 1 kg/m(2)). Participants met the following criteria: age 18 to 40 years, BMI < 30 kg/m(2), fasting glucose < 5.5 mmol/l, 2-h glucose after a 75 g oral glucose load < 140 mg/dl. BMI, waist circumference, fasting glucose, fasting insulin and HOMA of insulin resistance (HOMA-IR) were evaluated at baseline and after 6 and 12 months of contraceptive use. Insulin resistance was defined as a HOMA-IR value > 2.7.

RESULTS

The DMPA group showed significant increases in BMI, waist circumference, fasting insulin and HOMA-IR throughout the observation period in relation to baseline. Significant increases in BMI and waist circumference were observed in the DMPA group at 12 months compared with the Cu-IUD group. Five DMPA users had abnormal HOMA-IR values, three of whom had gained > 5 kg in weight at 12 months.

CONCLUSIONS

HOMA-IR represents a useful tool to indicate changes in carbohydrate metabolism in non-obese DMPA users, especially when accompanied by measurement of clinical parameters such as BMI and waist circumference.

Physical findings and symptoms of depot medroxyprogesterone acetate use in adolescent females

STUDY OBJECTIVE

To document physical and symptomatic changes in adolescent females using depot medroxyprogesterone acetate (DMPA) for contraception.

DESIGN

A 30-month prospective experimental study using a convenience sample of subjects.

SETTING

A pediatric primary care clinic in Milwaukee, Wisconsin that serves an urban population of low socioeconomic status.

PARTICIPANTS

A mostly African-American group of 53 patients (mean age 16.5 +/- 1.3 years).

INTERVENTIONS

Subjects received 150 mg DMPA intramuscularly in either the deltoid or gluteus muscle. The first two DMPA injections were given 6-8 weeks apart in an effort to decrease menstrual irregularity. Subsequent injections were given every 3 months. A questionnaire was administered at each visit to document physical and symptomatic changes.

MAIN OUTCOME MEASURES

Included weight change, frequency and amount of menstrual bleeding, and perceived side effects and satisfaction both documented with a 5-point Likert scale.

RESULTS

At 5, 11, and 17 months of DMPA use, 75%, 40%, and 19% of subjects continued DMPA. The most commonly perceived side effects were weight gain (27%), headache (25%), irregular periods (24%), fatigue (23%), abdominal pain (18%), and decreased sexual desire (15%). Significant weight gain was noted with an average increase of 6.0 +/- 6.0 kg at 11 months of DMPA use and 9.0 +/- 5.4 kg at 17 months. No menstrual bleeding was experienced by 30%-40% of adolescents in any 3-month injection period, and those who bled averaged 8-13 days of bleeding between injections. No pregnancies occurred and 87% of patients were either satisfied or very satisfied with DMPA as a method of contraception.

CONCLUSION

Despite the documented side effects, DMPA is an effective, acceptable contraceptive for some adolescent females who are at high risk for pregnancy.

The effects of a long-acting progestin on the hypothalamic-pituitary-ovarian axis in women with normal menstrual cycles

This study was performed to determine how a long-acting, slow-release preparation of norethindrone (NET) affects the hypothalamic-pituitary-ovarian axis of normal ovulatory women. Ten women were studied during the luteal phase of their menstrual cycle, and again at six and twelve weeks following intramuscular administration of 100 mg NET microencapsulated in poly-D,L-lactide-co-glycolide. Serial LH samples, serum E, P, and NET were followed by a GnRH stimulation test. Compared to luteal phase values, six and twelve weeks of treatment with NET inhibited serum E2 and P while mean serum LH remained unchanged and mean serum FSH increased significantly (p < 0.05). LH pulse frequency after NET treatment was twice the rate (p < 0.01) as that of the luteal phase, whereas LH pulse amplitude was decreased significantly (p < 0.05). Finally, although there was no significant change in pituitary LH secretion in response to GnRH, NET treatment augmented FSH responsiveness to GnRH at the times studied. Preserved pituitary responsiveness to GnRH in NET-treated patients suggests that inhibited ovarian function results in an increase in GnRH pulse frequency but not GnRH pulse amplitude. Since the progestational milieu is maintained in these patients by NET treatment, the decrease in serum E2 may be responsible for the increase in GnRH pulse frequency. The presence of a critical level of E2 may be necessary for progestins to affect the hypothalamic GnRH pulse generator.

Mass spectrometric and high-performance liquid chromatographic studies of medroxyprogesterone acetate metabolites in human plasma

Medroxyprogesterone acetate (MPA) treatment has been shown to exert several beneficial effects in cancer patients. It has been suggested that such effects are due in part to the metabolites derived from MPA in vivo. The first results are reported on the identification of 2 alpha-hydroxy- and 21-hydroxy-MPA, 20-dihydro-MPA, 17 alpha-acetoxy-2 alpha,3 beta-dihydroxy-6 alpha-methylpregn-1,4-dien-20-one and two X,21-dihydroxy-MPAs, one of them presumably being 6 alpha-hydroxymethyl-21-hydroxy-MPA, in patient's plasma by high-performance liquid chromatographic (HPLC), gas chromatographic-mass spectrometric and NMR methods. Additionally, the presence of other metabolites such as di- and tetrahydro-MPAs and 6,21-dihydroxy-MPA, found in urine and other samples, was demonstrated in plasma. For routine clinical examinations an HPLC method is described for determination of, e.g., the unreduced MPA metabolite group in Sep-Pak-ODS column extracts of patients' plasma.

Specific and sensitive quantitation of medroxyprogesterone acetate in human serum by gas chromatography-mass spectrometry

A procedure for the quantitation of medroxyprogesterone acetate in serum using gas chromatography-quadrupole mass spectrometry is described. Medroxyprogesterone propionate, synthesized from medroxyprogesterone, was used as the internal standard. The serum samples were extracted on Bond Elut C18 cartridges, and the acetate and propionate were determined as their 3-enol heptafluorobutyrate esters by selected-ion monitoring technique. The linear range of the standard curve in serum was 0.5-30 ng/ml with a lower limit of quantitation of 0.5 ng/ml. The coefficient of variation of the method was 3.1% at 10 ng/ml and 5.5% at 1 ng/ml. The method is very rapid, and it has been applied for routine measurements of medroxyprogesterone acetate levels in human serum after oral administration of 10 or 20 mg.

Clinical evaluation of two monthly injectable contraceptives and their effects on some metabolic parameters

One-hundred-and-thirty normally menstruating females were subgrouped equally and enrolled from the family planning clinic to study the clinical performance of the monthly injectable contraceptives medroxyprogesterone acetate 25 mg + estradiol cypionate 5 mg (Cycloprovera) and norethisterone enanthate 50 mg + estradiol valerate 5 mg (HRP-102) and their effects on some metabolic parameters. The contraceptive efficacy after 6 months of use for both drugs was 100%. No change in menstrual pattern occurred in 74% of Cycloprovera users and 67.3% of HRP-102 users. A statistically significant decrease (P less than 0.01) occurred in HDL-cholesterol and total serum protein values and a statistically significant increase (P less than 0.01) was observed in hematocrit value of Cycloprovera users only. Body weight and blood pressure values after 6 months of drug use showed no statistically significant changes in both groups. Also, no statistically significant changes were noticed in both groups for hemoglobin, post-prandial blood glucose, cholesterol, A/G ratio, SGPT and SGPT values following 6 months of injectable contraceptive use. None of the injectable users developed cervical dysplastic changes cytologically.

Acceptability of injectable contraceptives in Assiut, Egypt

The present work was a randomized comparative study of two injectable progestogen-only contraceptives. The first group (200 subjects) received 150 mg of depotmedroxyprogesterone acetate (Depoprovera) every 84 +/- 7 days and the second (200 subjects) received 200 mg of norethisterone enanthate (Noristerat) every 56 +/- 7 days. Acceptors of injectable contraceptives in Assiut, Egypt, were mainly women looking for fertility termination. Menstrual disruption was the main side effect among both treatment groups. Amenorrhoea was the commonest menstrual complaint and was the main reason for discontinuation in both groups. Only one pregnancy occurred during NET-EN use; two more pregnancies occurred, one in each of the two groups but there were indications that conception preceded the first injection. Menstrual irregularities were generally more frequent with DMPA users. However, DMPA had better one-year continuation rates than NET-EN (68.8 +/- 3.5 and 57.1 +/- 3.6 per 100 women, respectively).

Pituitary response to LHRH in long-term users of injectable contraceptives

The site of gonadotrophin inhibition in long-term users of injectable contraceptives is still debatable. The pituitary response to LHRH (50 micrograms, I.V.) was assessed in 32 women. Sixteen cases were using either medroxyprogesterone acetate (DMPA; n = 8 150 mg I.M. every three months) or norethisterone enanthate (NET-EN; n = 8, 200 mg every 2 months) for at least 18 months. The remaining cases (n = 16) were normal fertile females not using any hormonal contraceptive (control group). The pituitary response to LHRH injection in both injectable subgroups was nearly identical to that in the control group. Neither the basal levels nor the net increase in gonadotrophins following LHRH injection were significantly different in the study groups from those of the control group. Long-term use of DMPA or NET-EN does not affect the pituitary responsiveness to LHRH injection and the pituitary is not a primary site for ovulation inhibition in these cases.

Metabolic effects of depot-medroxyprogesterone acetate in long-term users: a cross-sectional study

Oral glucose tolerance test and determination of insulin, cholesterol, triglycerides, total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), alkaline phosphatase and cortisol in blood were performed on 57 Thai women who had used depot-medroxyprogesterone acetate (DMPA) for 5 years or more and 24 healthy non-DMPA users. Plasma insulin, alkaline phosphatase and morning cortisol levels were significantly higher in the DMPA users than in the non-users. There were no significant differences for other laboratory tests. The findings suggest some effects of DMPA on carbohydrate metabolism and liver function in long-term users.

Time course of hepatic changes produced by medroxyprogesterone acetate in the rat

The time course of the effects of medroxyprogesterone acetate (MPA) treatment (100 mg/kg, i.p.) on hepatic drug metabolism was investigated in female rats. The findings demonstrate that the maximum effects of MPA on the microsomal enzyme systems, liver weight and protein content were attained within 3-7 days depending on the measured parameter. The blood concentration of MPA reached a constant level of about 120 ng/ml in 3 days. After cessation of MPA administration the induced values decreased to the control level within about 11 days.

Long acting contraceptives. Present status

Long acting injectable hormonal contraceptives are among the most effective fertility regulating agents developed; yet they are also among the most controversial because of animal data indicating a possible carcinogenic potential in several species. A critical analysis of these animal findings has revealed, in all instances, the existence of specific mechanisms not occurring in the human. For this reason, most national and international scientific bodies who have reviewed this issue have concluded that there are no toxicological reasons for not using long acting hormonal contraceptives. Long acting agents can be divided into 2 separate groups: those having a duration of action of one month, which are composed of a long acting oestrogen and a progestagen, and those lasting for several months which consist of only a progestagen. Among the injectable progestagen-only contraceptives tested, only 2 have so far reached the international market: depot medroxyprogesterone acetate (DMPA), which has been administered at 3- or 6-month intervals and norethisterone enanthate, which has been injected at intervals ranging between 2 and 3 months. The most important side effect observed with these 2 agents is a complete disruption of the menstrual bleeding pattern, leading - in some cases - to total amenorrhoea, which is more frequent with depot medroxyprogesterone acetate than with norethisterone enanthate. The latter, however, has a shorter duration of action with a higher pregnancy rate than the former. Other adverse reactions are rare and of no real importance. Metabolic effects with progestagen-only injectable preparations are, in general, mild and less marked than with combined oestrogen-progestagen formulations. Recent investigations have shown that the return of fertility following their use is delayed but in no way impaired. Monthly injectable oestrogen-progestagen combinations have been tested to a more limited extent and these agents are available only in a very few countries. Their main advantage over progestagen-only preparations is that they allow a reasonable menstrual bleeding pattern in the majority of cases. Their obvious disadvantage is that they contain a long acting oestrogen.

The Depo-Provera debate. Commentary on the article "Depo-Provera, a critical analysis"

A widely publicized article has in recent months caused a great deal of concern among individuals interested in responsible promotion of family planning. The article contains a long series of factual errors, distortions and biased quotations. This commentary presents evidence, based on current knowledge, that Depo-Provera is a satisfactory contraceptive with several advantages and some disadvantages, and poses no more unresolved problems than oral contraceptives. There is no evidence that, at contraceptive doses, it increases the risk of cancer, impairs bone mineralization, "shocks" the hypothalamus, damages the liver or the immune system, or causes premature aging. Studies to date have not shown damaging effects on infants exposed to the drug in utero or via breast milk. To most women, disruption of the menstrual cycle, the major side effect, is not a health hazard. Finally, women in various parts of the world have shown to be quite capable of choosing for themselves whether or not the advantages of the drug can overcome the disadvantage of almost certain menstrual disturbance.

Studies on ovarian and adrenal steroids at different phases of the menstrual cycle. III. Steroid and lutropin levels before and after the administration of a single contraceptive dose of depot-medroxyprogesterone acetate (DMPA)

Ovarian and adrenal steroids and biologically active lutropin were measured in peripheral plasma samples obtained from 5 normally menstruating women. Plasma samples were collected every 3 h for a period of 39 hours in the periovulatory period of a pretreatment (control) cycle and then 16 and 54 days after a single i.m. injection of 150 mg of depot-medroxyprogesterone acetate (DMPA). Sixteen days after DMA administration, the levels of estradiol, progesterone, 17-hydroxyprogesterone, and lutropin were reduced to early follicular phase levels. No further decrease was found in 17-hydroxyprogesterone and lutropin levels; however an additional decrease occurred in the levels of estradiol and in the "morning" levels of progesterone 54 days after the administration of DMPA. Furthermore, the levels of pregnenolone, androstenedione, testosterone and dihydrotestosterone were significantly diminished in all samples collected after the administration of DMPA. Fifty-four days following the administration of DMPA, the levels of cortisol and 17-hydroxypregnenolone were significantly reduced. The administration of DMPA did not interfere with the circadian rhythm of cortisol, pregnenolone, 17-hydroxypregnenolone, dehydroepiandrosterone, 17-hydroxyprogesterone, and androstenedione levels. A significant circadian rhythm was also found in testosterone (after 16 days) and lutropin (after 54 days) levels. No circadian variation was found in estradiol, progesterone and dihydrotestosterone levels.

Low dose injectable contraceptive norethisterone enanthate 20mg monthly--I. Clinical trials

Clinical trials were undertaken with an injectable low dose progestational contraceptive, norethisterone enanthate 20 mg monthly (Net-en - 20). Data from the study indicate that Net-en - 20 is an effective contraceptive with lower incidence of menstrual cycle disturbances than the currently used injectable progestogens. There was a prompt return of fertility after the withdrawal of the drug. Net-en - 20 did not have any adverse effect on maternal nutritional status as assessed by anthropometric indices of nutritional status, and clinical sign of nutritional deficiencies or on lactational performance as assessed by mothers' impression on milk output and mean duration of lactation.

The use of quinesterol for the control of vaginal bleeding irregularities caused by DMPA

A comparative clinical trial examined the effect of oral administration of a long-acting estrogen (quinesterol) on the vaginal bleeding pattern of 214 Thai women receiving 3 monthly injections of the contraceptive depot-medoxyprogesterone acetate. Although the proportion of subjects with amenorrhea was lower in the group receiving quinesterol, there was no substantial increase in the proportion of women with normal bleeding patterns.

Specific quantitation of plasma medroxyprogesterone acetate by gas chromatography/mass spectrometry

Investigation of various derivatives (O-methyloxime, trifluoroenol acetate and t-butyldimethylsilyl enol ether) coupled with the efficient preparation of a trideuterated analogue of medroxyprogesterone acetate, has allowed the development of a rapid and accurate assay for its quantitation in plasma by isotope dilution gas chromatography/mass spectrometry. High oral doses (2.8 g weekly) of medroxyprogesterone acetate are shown to lead consistently to plasma levels of less than 16 ng.ml-1.

Isolation and partial synthesis of a new metabolite of medroxyrogesterone acetate

3 alpha-Hydroxy-17-acetoxy-6 alpha-methyl-5 beta-pregnan-20-one (IIIa) has been isolated from urine of patients receiving medroxyprogesterone acetate (MPA). It was characterized by partial synthesis from MPA by catalytic reduction with palladium-charcoal to 17-acetoxy-6 alpha-methyl-5 beta-pregnan-3,20-dione (IV) and reduction of the latter with sodium borohydride. The isolation of 6 beta, 17,21-trihydroxy-6 alpha-methyl-pregn-4-ene-3,20-dione (IIc) is reported for the first time. The 17- and 21-monoacetates of this compound have been isolated and characterized earlier by other investigators. 7 alpha-3H-Medroxyprogesterone acetate was administered to 4 subjects by intravenous and intramuscular injections and by mouth. The ring A saturated metabolite IIIa was excreted in 0.1% to 4.0% of the administered dose; the highest excretion was after the intravenous dose and lowest after oral ingestion. 6 beta, 17,21-Trihydroxy-6 alpha-methylpregn-4-ene-3,20-dione (IIc) and its 17- and 21-monoacetates were excreted in about 5% of the doses in all subjects. No increase in 6 beta-hydroxylation was observed in the patient treated with o,p'-DDD,2,2-bis(2-chlorophenyl, 4'-chlorophenyl)-l,1-dichloroethane.

The effect of medroxyprogesterone acetate on blood pressure

Twenty-four women (21 normotensive and 3 hypertensive) aged 16-35 years received 150-mg injections of medroxyprogesterone acetate (MPA) for contraception. Their blood pressure (BP) was measured under basal conditions by the same nurse before treatment and at 1-, 2- and 3-month intervals. Their mean BP fell from 124.1/79.4 to 119.8/74.6 mm Hg at one month (p less than 0.05 for diastolic pressure) to 117.0/74.9 mm Hg at two months and to 115.6/73.2 mm Hg at three months. When the normotensive patients were analyzed separately, their BP fell, but not significantly. Only one patient had a rise of 20 mm Hg systolic, but she remained normotensive. We conclude that medroxyprogesterone acetate does not raise BP.

Experience with medroxyprogesterone acetate (Depo-Provera) as an injectable contraceptive

Depo-Provera injections appear to be a safe and effective alternative for women who cannot tolerate the estrogenic side effects associated with oral contraceptives or the pain and bleeding associated with IUDs. However, women considering the method should be fully aware of the possible risks: (a) inability to withdraw the drug promptly in the event of a serious reaction, (b) disruption of menstrual patterns, and (c) delayed return of fertility after discontinuing therapy. Some women may consider the required trip to the doctor every 3 months an additional disadvantage. For women in developing countries where anemia and nutritional problems are prevalent, Depo-Provera has additional advantages in relation to IUDs and OCs: it causes less bleeding than IUDs or OCs and, unlike oral contraceptives, it does not suppress vitamin levels (4-8). Since it requires a trip to the doctor every 3 months, it also provides a better opportunity for medical supervision and care. For postpartum women who which to breastfeed their babies, Depo-Provera has the additional advantage of causing no adverse effect on lactation (1, 2, 13, 14, 16, 18, 19, 25, 32, 36).