Bone status after cessation of use of injectable progestin contraceptives

Proandrogenic and Antiandrogenic Progestins in Transgender Youth: Differential Effects on Body Composition and Bone Metabolism

CONTEXT

Progestins can be used to attenuate endogenous hormonal effects in late-pubertal transgender (trans) adolescents (Tanner stage B4/5 and G4/5). Currently, no data are available on the effects of progestins on the development of bone mass or body composition in trans youth.

OBJECTIVE

To study prospectively the evolution of body composition and bone mass in late-pubertal trans adolescents using the proandrogenic or antiandrogenic progestins lynestrenol (L) and cyproterone acetate (CA), respectively.

DESIGN AND OUTCOME MEASUREMENTS

Forty-four trans boys (Tanner B4/5) and 21 trans girls (Tanner G4/5) were treated with L or CA for 11.6 (4 to 40) and 10.6 (5 to 31) months, respectively. Anthropometry, grip strength, body composition, and bone mass, size, and density were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography before the start of progestin and before addition of cross-sex hormones.

RESULTS

Using L, lean mass [+3.2 kg (8.6%)] and grip strength [+3 kg (10.6%)] significantly increased, which coincided with a more masculine body shape in trans boys. Trans girls showed loss of lean mass [-2.2 kg (4.7%)], gain of fat mass [+1.5 kg (9.4%)], and decreased grip strength Z scores. CA limited normal bone expansion and impeded pubertal bone mass accrual, mostly at the lumbar spine [Z score: -0.765 to -1.145 (P = 0.002)]. L did not affect physiological bone development.

CONCLUSION

Proandrogenic and antiandrogenic progestins induce body composition changes in line with the desired appearance within 1 year of treatment. Bone health, especially at the lumbar spine, is of concern in trans girls, as bone mass accrual is severely affected by androgen suppressive therapy.

Bone mineral density in midlife long-term users of hormonal contraception in South Africa: relationship with obesity and menopausal status

BACKGROUND

In South Africa, hormonal contraception is widely used in women over the age of 40 years. One of these methods and the most commonly used is depot-medroxyprogesterone acetate (DMPA) which has been found to have a negative effect on bone mass. Limited information is available on the effect of norethisterone enanthate (NET-EN) on bone mass, and combined oral contraceptives (COCs) have not been found to be associated with loss of bone mass. The aim of this study was to investigate bone mineral density (BMD) in pre and perimenopausal women (40-49 years) in relation to use of DMPA, NET-EN and COCs for at least 12 months preceding recruitment into the study and review associations with body mass index (BMI) and menopausal status.

METHODS

One hundred and twenty seven users of DMPA, 102 NET-EN users and 106 COC users were compared to 161 nonuser controls. Menopausal status was assessed, BMI and forearm BMD was measured at the distal radius using dual X-ray absorptiometry. Comparison analysis was conducted at baseline and 2.5 years.

RESULTS

There was no significant difference in BMD between the four contraceptive user groups (p = 0.26) with and without adjustment for age at baseline or at 2.5 years (p = 0.52). The BMD was found to be significantly associated with BMI (p = < 0.0001) with an increase of one unit of BMI translating to an increase of 0.0044 g/cm2 in radius BMD. Follicle stimulating hormone (FSH) level ≥ 25.8 mIU/mL was associated with a decrease of 0.017 g/cm2 in radius BMD relative to women with FSH < 25.8 mIU/mL. Significant interaction between FSH and BMI in their effect on BMD was observed (p = .006).

CONCLUSION

This study found no evidence that long-term use of DMPA, NET-EN and COCs affects forearm BMD in this population at baseline or after 2.5 years of follow-up. This study also reports the complex relationship and significant interaction between FSH and BMI in their effect on BMD. BMD research in older women needs to ensure that women are assessed for menopausal status and BMI.

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

Association between depot medroxyprogesterone acetate (DMPA), physical activity and bone health

Physical activity has been advocated for women in the hope of offsetting progestin-only contraceptive-related loss in bone mineral density. There is limited evidence for the beneficial effect of physical activity on bone health of hypo-oestrogenic premenopausal women. The aim of this cross-sectional study was to examine the relationship between physical activity and bone health [as measured by quantitative ultrasound (QUS)] of depot-medroxyprogesterone acetate (DMPA) users, and to investigate whether QUS measurements of DMPA users and non-users differed according to physical activity. Bone health of 48 DMPA users and 48 age-matched controls (22.83 ± 3.2 years) was assessed using calcaneal broadband ultrasound attenuation (BUA). Participants were categorised into low and high levels of physical activity based on their exposure to bone-loading exercise. Analysis of covariance was conducted to determine if QUS measurements of DMPA users and non-DMPA users differed within levels of bone-loading physical activity after controlling for body mass index. The duration of DMPA use ranged from 6 to 132 months. Participants' reference bone-loading exposure time averaged 3.3 ± 1.8 years. Data analysis revealed that DMPA users had significantly lower BUA by 6.54 dB/MHz (t (95) = -2.411, p = 0.018) compared to non-users of DMPA. Concurrently high levels of physical activity and DMPA use led to 1.996 dB/MHz decreases in BUA. A cycle of prolonged DMPA use and concurrent engagement in high levels of physical activity appears detrimental to bone health. It is suggested that the lack of oestrogen may counteract the effects of physical activity by inhibiting bone formation in response to mechanical bone-loading.

Site-specific differences in bone mineral density in black and white premenopausal South African women

SUMMARY

We examined ethnic differences in bone mineral density (BMD) and the contribution of body composition, lifestyle and socioeconomic factors in South African women. Femoral neck and total hip BMD were higher, but lumbar spine BMD was lower in black women, with body composition, lifestyle and socioeconomic status (SES) factors contributing differently in ethnic groups.

INTRODUCTION

There is a paucity of data on the relative contribution of body composition, lifestyle factors and SES, unique to different ethnic groups in South Africa, to BMD. We examined differences in femoral neck (FN), total hip (TH) and lumbar spine (LS) BMD between black and white premenopausal South African women and the associations between BMD and body composition, lifestyle factors and SES in these two ethnic groups.

METHODS

BMD and body composition were measured in 240 black (27 ± 7; 18-45 years) and 187 white (31 ± 8; 18-45 years) women using dual-energy X-ray absorptiometry. Questionnaires were administered to examine SES, physical activity and dietary intake.

RESULTS

After co-varying for age, FN and TH were higher in black than white women (FN 0.882 ± 0.128 vs. 0.827 ± 0.116 g/cm(2), P < 0.001; TH 0.970 ± 0.130 vs. 0.943 ± 0.124 g/cm(2), P = 0.018). When adjusting for ethnic differences in body composition, LS was higher in white than black women. In black women, fat-free soft tissue mass, SES and injectable contraceptive use explained 33-42% of the variance in BMD at the hip sites and 22% at the LS. In white women, fat-free soft tissue mass and leisure activity explained 24-30% of the variance in BMD at the hip sites, whereas fat mass, leisure activity and oral contraceptive use explained 11% of the variance at the LS.

CONCLUSION

FN and TH BMD were higher, but LS BMD was lower in black than white South African women with body composition, lifestyle and SES factors contributing differently to BMD in these women.

Update on hormonal contraception and bone density

Combination hormonal contraception and progestin-only contraception (including depot medroxyprogesterone acetate [DMPA]) are effective and convenient forms of reversible contraception that millions of women use worldwide. In recent years, observations of reduced bone mineral density in current users of these methods have led to concerns that this hormone-induced bone loss might translate into long-term increased fracture risk. Special focus has been placed on adolescent users who have not yet attained their peak bone mass as well as perimenopausal users. In 2004, the FDA added a black box warning to DMPA package labeling warning of the risk of significant bone loss and cautioning against long-term use (> 2 years). This article reviews evidence on the use of hormonal contraception and its effect on bone density in adolescent, premenopausal, and perimenopausal populations. Recommendations from reproductive healthcare organizations are reviewed and clinical recommendations are provided.

A pilot investigation of load-carrying on the head and bone mineral density in premenopausal, black African women

Although the influence of weight-bearing activity on bone mass has been widely investigated in white women, few studies have been conducted in black, African populations. We investigated bone mineral density (BMD) in black South African women, with and without a history of load-carrying on the head. We also investigated whether load carrying may offer protection against low BMD in users of injectable progestin contraception (IPC). Participants were 32 black, South African women (22.4 +/- 3.2 years). Load carrying history was determined by questionnaire and interview; participants were grouped as load carriers (LC; n = 18) or non-load carriers (NLC; n = 14). Ten women were using IPC and 6 were load-carriers. Total body (TB), lumbar spine (LS) and total hip (H) BMD were measured by dual energy X-ray absorptiometry. There were no differences in BMD between LC and NLC, and after controlling for age and BMI using two-tailed partial correlations. IPC users had lower BMD at all sites compared to non-IPC users (p < 0.05) and there were no associations between load carrying and BMD in this group. When IPC users were excluded from analysis, LC had higher LS BMD than NLC (p < 0.005). Correlations were found between the weight of load carried and LS BMD (r = 0.743, p < 0.005), and between years of load carrying and LS and TB BMD (r = 0.563, r = 0.538, respectively; both p < 0.05). Load carrying on the head may offer osteogenic benefits to the spine but these benefits did not appear in women using IPC.

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.

Bone mineral density in young women aged 19-24 after 4-5 years of exclusive and mixed use of hormonal contraception

BACKGROUND

Use of depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and low-dose combined oral contraceptives (COCs) has been associated with loss of bone mineral density (BMD) in adolescents. However, the effect of using a combination of these methods over time in this age group is limited. The aim of this cross-sectional study was to investigate BMD in young women (aged 19-24 years) with a history of mixed hormonal contraceptive use.

STUDY DESIGN

BMD was measured at the spine, hip and femoral neck using dual X-ray absorptiometry. Women were classified into three groups: (1) injectable users (DMPA, NET-EN or both) (n=40), (2) mixed COC and injectable users (n=13) and (3) non-user control (n=41).

RESULTS

Women in the injectables-only user group were found to have lower BMDs compared to the non-user group at all three sites, and there was evidence of a difference in BMD between these two groups at the spine after adjusting for body mass index (p=.042), hip (p=.025) and femoral neck (p=.023). The mixed COC/injectable user group BMD values were lower than those for controls; however, there was no evidence of a significant difference between this group and the non-user group at any of the three sites.

CONCLUSION

This study suggests that BMD is lower in long-term injectable users but not when women have mixed injectable and COC use.

Bone mineral density in a cohort of adolescents during use of norethisterone enanthate, depot-medroxyprogesterone acetate or combined oral contraceptives and after discontinuation of norethisterone enanthate

BACKGROUND

Depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) and combined oral contraceptives (COCs) have been shown to have a negative effect on bone mineral density (BMD) in adolescents. The aim of this study was to investigate BMD in 15- to 19-year-old new users of DMPA, NET-EN and COCs.

STUDY DESIGN

This 5-year longitudinal study followed up new users of DMPA (n=115), NET-EN (n=115) and COCs (n=116) and 144 nonuser controls. BMD was measured at the distal radius using dual-energy X-ray absorptiometry.

RESULTS

BMD increased in all groups (annual percent increase: nonusers, 1.49%; DMPA, 1.39%; NET-EN, 1.03%; COCs, 0.84%) during follow-up (p<.001). There was evidence for lower BMD increases per annum in NET-EN (p=.050) and COC (p=.010) users compared to nonusers but no difference between DMPA and nonusers (p=.76). In 14 NET-EN discontinuers, an overall reduction of 0.61% per year BMD was followed upon cessation by an increase of 0.69% per year (p=.066).

CONCLUSION

This study suggests that BMD increases in adolescents may be less in NET-EN and COC users; however, recovery of BMD in NET-EN users was found in the small sample of adolescents followed post-discontinuation.

The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health

BACKGROUND

In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology.

STUDY DESIGN

Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations.

RESULTS

The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA.

CONCLUSION

Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

Quantitative ultrasound in relation to risk factors for low bone mineral density in South African pre-menopausal women

SUMMARY: The study describes the association between risk factors and quantitative ultrasound bone measures in black and mixed-race pre-menopausal South African women. Despite some differences between the two study groups, the findings generally lend support to the use of ultrasound for epidemiological studies of bone mass in resource-limited settings. INTRODUCTION: Quantitative ultrasound at the calcaneus is a convenient and inexpensive method of estimating bone strength well suited to community-based research in countries with limited resources. This study determines, in a large sample of pre-menopausal South African women, whether characteristics associated with quantitative ultrasound measures are similar to those shown to be associated with bone mineral density as measured by dual X-ray absorptiometry. METHODS: This cross-sectional study included 3,493 women (1,598 black and 1,895 mixed race), aged 18-44 living in Cape Town. Study nurses administered structured interviews on reproductive history, lifestyle factors, and measured height and weight. Calcaneus quantitative ultrasound measurements were obtained using the Sahara device. Adjusted means of ultrasound measures according to categories of risk factors were obtained using multivariable regression analysis. RESULTS: Associations between quantitative ultrasound measures and age, body mass index, age at menarche, parity, and primary school physical activity were similar to those known for bone mineral density as measured by dual X-ray absorptiometry. There were no clear associations between quantitative ultrasound measures and educational level, alcohol use, cigarette smoking, and current calcium intake. CONCLUSION: The data give qualified support to the use of quantitative ultrasound as an epidemiological tool in large studies of bone strength in pre-menopausal women.