The effects of depot medroxyprogesterone acetate and intrauterine device use on fracture risk in Danish women

Bone health and hormonal contraception

INTRODUCTION

Short-term and long-term steroid contraceptive systems are widely employed in adolescents and premenopausal women; they could induce variation in bone metabolism, but whether these changes increase the overall fracture risk is not yet clear.

EVIDENCE ACQUISITION

A systematic search of scientific publications about "hormonal contraceptives" and "bone metabolism" in reproductive age women was conducted.

EVIDENCE SYNTHESIS

In adolescent girl, combined oral contraceptives could have a deleterious effect on bone health when their onset is within three years after menarche and when they contain ethinyl estradiol at the dose of 20 mcg. In perimenopausal women, steroid contraceptives seem not influence bone health nor increase osteoporotic fractures risk in menopause. The oral progestogens intake is not related to negative effects on skeletal health. Depot medroxyprogesterone acetate (DMPA) induce a prolonged hypoestrogenism with secondary detrimental effect on healthy bone; the higher bone loss was observed at the DMPA dose of 150 mg intramuscular such as after long-term DMPA-users. Progestin-based implants and intrauterine devices have not negative effect on bone health.

CONCLUSIONS

Since sex-steroid drugs induce variations in hormonal circulating concentrations, they may negatively affect bone metabolism. Contraceptive choice should be tailored evaluating any possible effect on bone health. Clinicians should always perform a precontraceptive counselling to identify any coexisting condition that may affect bone health. Further randomized studies are needed to confirm these results.

Hormonally Active Contraceptives Part I: Risks Acknowledged and Unacknowledged

Hormonal contraceptives have been on the market for over fifty years and, while their formulations have changed, the basic mechanism of action has remained the same. During this time, numerous studies have been performed documenting side effects, some of which appear over time, some within weeks or months, but all can have a serious impact on health and quality of life. An effort was made to perform a series of comprehensive literature surveys to better understand immediate and long-term side effects of these agents. The results of this literature review uncovered a number of potential side effects, some of which are acknowledged and many of which are not noted in the prescribing information for these agents. Among the unacknowledged side effects are: an increased risk of HIV transmission for depot medroxyprogesterone acetate (DMPA), and for combination contraceptives breast cancer, cervical cancer, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, depression, mood disorders and suicides (especially among women twenty-five years of age and younger, in the first six months of use), multiple sclerosis, interstitial cystitis, female sexual dysfunction, osteoporotic bone fractures (especially for progesterone-only contraceptives), and fatty weight gain. Misleading prescribing information regarding cardiovascular and thrombotic risks are also noted. Women seeking birth control have a right to be informed and educated about risk avoidance through the use of effective nonhormonal methods like fertility awareness methods. In one case-that of DMPA-the increased risk of HIV acquisition has been conclusively demonstrated to be both real and unique to this drug. Considering the availability of numerous alternatives, there is no justification for the continued marketing of DMPA to the public.

SUMMARY

We reviewed the effect of hormonal contraceptives on women's health. A number of potential side effects were noted including increased risks of breast cancer, cervical cancer, inflammatory bowel  disease, lupus, multiple sclerosis, cystitis, bone fractures, depression, mood disorders and suicides,  fatty weight gain, and female sexual dysfunction.  With the long-acting injectable contraceptives there is an increased risk of getting HIV.  Misleading prescribing information regarding the risks of heart attacks, strokes and blood clotting problems were also noted. Women seeking birth control have a right to know about how to avoid these risks by using effective hormone-free Fertility Awareness Methods.

Novel drug delivery methods for improving efficacy of endometriosis treatments

INTRODUCTION

Pharmacotherapy has a key role in the management of endometriosis. However, a significant proportion of patients gains only intermittent or limited benefits. In this regard, alternative and novel drug delivery methods are of paramount importance to improve efficacy and compliance of available treatments and develop alternative medical approaches.

AREAS COVERED

This review aims to provide the reader with a complete overview of available evidence about alternative and novel drug delivery methods for endometriosis pharmacotherapy and highlight new research lines.

EXPERT OPINION

Progestins and estroprogestins, which represent the first-line therapy, are already available in different formulations, being employed for contraception. Nevertheless, evidence on their adoption is still limited for some drug delivery methods, such as vaginal rings, patches, and subcutaneous implants. Further research is needed to define better their clinical utility in patients with endometriosis. Nanotechnologies have been investigated as novel drug delivery methods able to target the drug at the disease level. However, data are very limited and preliminary, and further research is needed to consider a possible clinical application in endometriosis.

Drugs Causing Bone Loss

Drugs may cause bone loss by lowering sex steroid levels (e.g., aromatase inhibitors in breast cancer, GnRH agonists in prostate cancer, or depot medroxyprogestone acetate - DMPA), interfere with vitamin D levels (liver inducing anti-epileptic drugs), or directly by toxic effects on bone cells (chemotherapy, phenytoin, or thiazolidinedions, which diverts mesenchymal stem cells from forming osteoblasts to forming adipocytes). However, besides effects on the mineralized matrix, interactions with collagen and other parts of the unmineralized matrix may decrease bone biomechanical competence in a manner that may not correlate with bone mineral density (BMD) measured by dual energy absorptiometry (DXA).Some drugs and drug classes may decrease BMD like the thiazolidinediones and consequently increase fracture risk. Other drugs such as glucocorticoids may decrease BMD, and thus increase fracture risk. However, glucocorticoids may also interfere with the unmineralized matrix leading to an increase in fracture risk, not mirrored in BMD changes. Some drugs such as selective serotonin reuptake inhibitors (SSRI), paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) may not per se be associated with bone loss, but fracture risk may be increased, possibly stemming from an increased risk of falls stemming from effects on postural balance mediated by effects on the central nervous system or cardiovascular system.This paper performs a systematic review of drugs inducing bone loss or associated with fracture risk. The chapter is organized by the Anatomical Therapeutic Chemical (ATC) classification.

Contraception for midlife women: a review

Family planning represents a key component of reproductive health care. Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. The risk of pregnancy is decreased, but not trivial, among women over 40 years of age. Evidence-based guidelines for contraceptive use can assist clinicians in counseling their patients in this population. Intrauterine contraception is one of the most effective methods and is safe to use in midlife women with few exceptions. Progestin-only contraception is another safe option for most midlife women because it is not associated with an increased risk of cardiovascular complications. Combined (estrogen-containing) contraception can be safely used by midlife women who do not have cardiovascular risk factors. Unique noncontraceptive benefits for this population include: improvement in abnormal uterine bleeding, decreased hot flashes, and decreased cancer risk. Finally, guidelines state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy.

[Contraception for women after 40: CNGOF Contraception Guidelines]

INTRODUCTION

Choosing contraception for women over 40 can be sometimes difficult but it is crucial since fertility and pregnancy's risks still exist. It requires a thorough evaluation of the situation, in order to identify any vascular and metabolic risk factors, along with the uterine and mammary benign pathologies already diagnosed.

OBJECTIVE

The objective of this review was to elaborate some guidelines for clinical practice regarding contraception's prescription for women over 40.

METHODS

A systematic review of the French and English existing literature was conducted. Pubmed and the Cochrane library were used to identify studies about contraception for perimenopausal women. International guidelines published by scientific societies were also reviewed (RCOG, FSRH, ESHRE, ACOG, WHO, HAS).

RESULTS

No contraceptive methods are contraindicated on the sole basis of age alone. However, because age is a risk factor for vascular and metabolic diseases, combined hormonal contraception and DMPA should not be prescribed at first intention. Copper IUD and progestin-only contraceptives (pill, implant, intrauterine device) should primarily be considered, since they offer good efficacy with lower risks.

CONCLUSIONS

Contraception for women over 40 should not be put aside. Long acting reversible contraception and progestin-only pill have to be prescribed as first-ine. Contraception is no longer needed for women over 50 who use non-hormonal contraception, after a 12 month-amenorrhea. Patients treated with combined hormonal contraception must stop using it over 50. Measuring hormonal levels while using hormonal contraception is not recommended. An hormonal-contraception-free interval must be considered, while using barrier contraception method. If an ovarian activity persists, a non-hormonal contraception or progestin-only contraception (except for DMPA) should be (re-)established.

Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis

INTRODUCTION

Endometriosis is a chronic estrogen and progestogen responsive inflammatory disease associated with pain symptoms and infertility. The medical therapy of endometriosis aims to induce decidualization within the hormonally dependent ectopic endometrium, and it is often administered to ameliorate women' pain symptoms or to prevent post-surgical disease recurrence. A variety of progestins have been used in monotherapy for the medical management of women with endometriosis. Areas covered: This review aims to offer the reader a complete overview of pharmacokinetic (PK) and clinical efficacy of progestins for the treatment of endometriosis. Expert opinion: Each progestin has a distinct PK parameters and pharmacodynamics affinity not only for progesterone receptor, but also for other steroid receptors, such as estrogen, androgen, and glucocorticoid. Moreover, progestins can also be delivered in different formulations. All these characteristics influence their final biological effect. Randomized, controlled, non-blinded studies support the use of oral progestin-only treatment for pelvic pain associated with endometriosis. Currently, the only two progestins approved by Food and Drug Administration (FDA) for the treatment of endometriosis are norethindrone acetate (NETA) and depot medroxyprogesterone acetate (DMPA).

The impact of depot medroxyprogesterone acetate on fracture risk: a case-control study from the UK

There has been concerning about women receiving depot medroxyprogesterone acetate (DMPA) contraception because of the prolonged hypoestrogenemic state regarding the potential negative effects on bone health. This study showed that DMPA exposure is associated with increased fracture risk and that fracture risk increases with longer DMPA exposure.

INTRODUCTION

DMPA has been associated with impaired bone mineral acquisition during adolescence and accelerated bone loss in later life. We performed this large population-based study to assess the association between use of DMPA or combined oral contraceptives and the incident risk of fracture.

METHODS

We identified 4189 women between 20 and 44 years of age with a first-time fracture diagnosis, matched them with 4189 random controls using the Disease Analyzer database and investigated the relation with DMPA exposure.

RESULTS

Overall, 11 % of the fracture cases and 7.7 % of the controls had DMPA use recorded. The adjusted OR for developing a fracture in patients with current use of DMPA compared to non-users was 0.97 (95 % CI 0.51-1.86), 2.41 (95 % CI 1.42-4.08), and 1.46 (95 % CI 0.96-2.23) for 1-2, 3-9, and ≥10 prescriptions, respectively. The adjusted OR for developing a fracture in patients with past use of DMPA compared to non-users was 0.96 (95 % CI 0.73-1.26), 1.14 (95 % CI 0.86-1.51), and 1.55 (95 % CI 1.07-2.27) for 1-2, 3-9, and ≥10 prescriptions, respectively. The highest fracture risk was identified in young patients less than 30 years with longer DMPA exposure (≥10 prescriptions; OR 3.04, 95 % CI 1.36-6.81), as well as in patients in the late reproductive years with past use of DMPA (OR 1.72, 95 % CI 1.13-2.63).

CONCLUSIONS

Our results indicate that DMPA exposure is associated with increased fracture risk and may have negative effects on bone metabolism, resulting in impaired bone mineral acquisition during adolescence and accelerated bone loss in adult life.

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.

Steroidal contraceptives and bone fractures in women: evidence from observational studies

BACKGROUND

Age-related decline in bone mass increases the risk of skeletal fractures, especially those of the hip, spine, and wrist. Steroidal contraceptives have been associated with changes in bone mineral density in women. Whether such changes affect the risk of fractures later in life is unclear. Hormonal contraceptives are among the most effective and most widely-used contraceptives. Concern about fractures may limit the use of these effective contraceptives. Observational studies can collect data on premenopausal contraceptive use as well as fracture incidence later in life.

OBJECTIVES

We systematically reviewed the evidence from observational studies of hormonal contraceptive use for contraception and the risk of fracture in women.

SEARCH METHODS

Through June 2015, we searched for observational studies. The databases included PubMed, POPLINE, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, EMBASE, CINAHL, and Web of Science. We also searched for recent clinical trials through ClinicalTrials.gov and the ICTRP. For other studies, we examined reference lists of relevant articles and wrote to investigators for additional reports.

SELECTION CRITERIA

We included cohort and case-control studies of hormonal contraceptive use. Interventions included comparisons of a hormonal contraceptive with a non-hormonal contraceptive, no contraceptive, or another hormonal contraceptive. The primary outcome was the risk of fracture.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One author entered the data into RevMan, and a second author verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale (NOS), developed for case-control and cohort studies. Sensitivity analysis included studies of moderate or high quality based on our assessment with the NOS.Given the need to control for confounding factors in observational studies, we used adjusted estimates from the models as reported by the authors. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs, we did not conduct meta-analysis.

MAIN RESULTS

We included 14 studies (7 case-control and 7 cohort studies). These examined oral contraceptives (OCs), depot medroxyprogesterone acetate (DMPA), and the hormonal intrauterine device (IUD). This section focuses on the sensitivity analysis with six studies that provided moderate or high quality evidence.All six studies examined oral contraceptive use. We noted few associations with fracture risk. One cohort study reported OC ever-users had increased risk for all fractures (RR 1.20, 95% CI 1.08 to 1.34). However, a case-control study with later data from a subset reported no association except for those with 10 years or more since use (OR 1.55, 95% CI 1.03 to 2.33). Another case-control study reported increased risk only for those who had 10 or more prescriptions (OR 1.09, 95% CI 1.03 to 1.16). A cohort study of postmenopausal women found no increased fracture risk for OC use after excluding women with prior fracture. Two other studies found little evidence of association between OC use and fracture risk. A cohort study noted increased risk for subgroups, such as those with longer use or specific intervals since use. A case-control study reported increased risk for any fracture only among young women with less than average use.Two case-control studies also examined progestin-only contraceptives. One reported increased fracture risk for DMPA ever-use (OR 1.44, 95% CI 1.01 to 2.06), more than four years of use (OR 2.16, 95% CI 1.32 to 3.53), and women over 50 years old. The other reported increased risk for any past use, including one or two prescriptions (OR 1.17, 95% CI 1.07 to 1.29) and for current use of 3 to 9 prescriptions (OR 1.36, 95% CI 1.15 to 1.60) or 10 or more (OR 1.54, 95% CI 1.33 to 1.78). For the levonorgestrel-releasing IUD, one study reported reduced fracture risk for ever-use (OR 0.75, 95% CI 0.64 to 0.87) and for longer use.

AUTHORS' CONCLUSIONS

Observational studies do not indicate an overall association between oral contraceptive use and fracture risk. Some reported increased risk for specific user subgroups. DMPA users may have an increased fracture risk. One study indicated hormonal IUD use may be associated with decreased risk. Observational studies need adjusted analysis because the comparison groups usually differ. Investigators should be clear about the variables examined in multivariate analysis.

Prevalence of Low Bone Mass and Osteoporosis in Long-Term Users of the Injectable Contraceptive Depot Medroxyprogesterone Acetate

BACKGROUND

Bone mineral density (BMD) loss among depot medroxyprogesterone acetate (DMPA) users is a controversial issue. Aspects under debate include whether the number of years of use has any effect on continuous BMD loss, whether this loss will stabilise over the years of use or if it will progress to low bone mass, osteoporosis and an increased fracture risk. The aim of this study was to compare the difference in osteoporosis and low bone mass between DMPA and copper intrauterine device (Cu-IUD) users.

METHODS

This was a cross-sectional study that evaluated BMD at the lumbar spine and femoral neck in 47 long-term DMPA users and 41 Cu-IUD users as control group. BMD was measured by dual-energy X-ray absorptiometry. The participants were 27 to 57 years of age, had used either DMPA or a Cu-IUD uninterruptedly for at least ten years, had initiated use of the method prior to 40 years of age and had follicle stimulating hormone values <40 mIU/mL.

RESULTS

Findings showed that 68.1% and 36.6% of the DMPA and Cu-IUD users, respectively, had low bone mass and 29.8% and 2.4% of DMPA and Cu-IUD users, respectively, had osteoporosis. BMD decreased as the number of years of DMPA use increased.

CONCLUSION

Long-term DMPA use was associated with low bone mass and osteoporosis in women who had used the method for 10 years or more. DMPA users with longer time of use showed a greater bone mass loss.

Adverse skeletal effects of drugs - beyond Glucocorticoids

Osteoporotic fractures are an important public health problem with significant individual and societal costs. In addition to the major risk factors for osteoporotic fracture, low bone mineral density (BMD), age, low body weight and history of fracture or falls, some drugs are now considered to be important secondary risk factor for bone loss and fracture, particularly amongst predisposed individuals. Currently available data are often generated from small observational clinical studies, making risk assessment and development of management guidelines difficult. In many cases, the exposed population has a low baseline risk for fracture and additional assessment and treatment may not be necessary. In this review, we focus on drugs other than glucocorticoids identified as potentially causing adverse skeletal effects, summarizing the existing evidence from preclinical and clinical studies, and suggest recommendations for patient management.

Medication-induced osteoporosis: screening and treatment strategies

Drug-induced osteoporosis is a significant health problem and many physicians are unaware that many commonly prescribed medications contribute to significant bone loss and fractures. In addition to glucocorticoids, proton pump inhibitors, selective serotonin receptor inhibitors, thiazolidinediones, anticonvulsants, medroxyprogesterone acetate, aromatase inhibitors, androgen deprivation therapy, heparin, calcineurin inhibitors, and some chemotherapies have deleterious effects on bone health. Furthermore, many patients are treated with combinations of these medications, possibly compounding the harmful effects of these drugs. Increasing physician awareness of these side effects will allow for monitoring of bone health and therapeutic interventions to prevent or treat drug-induced osteoporosis.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

Steroidal contraceptives and bone fractures in women: evidence from observational studies

BACKGROUND

Age-related decline in bone mass increases the risk of skeletal fractures, especially those of the hip, spine, and wrist. Steroidal contraceptives have been associated with changes in bone mineral density in women. Whether such changes affect the risk of fractures later in life is unclear. Hormonal contraceptives are among the most effective and most widely-used contraceptives. Concern about fractures may limit the use of these effective contraceptives. Observational studies can collect data on premenopausal contraceptive use as well as fracture incidence later in life.

OBJECTIVES

We systematically reviewed the evidence from observational studies of hormonal contraceptive use for contraception and the risk of fracture in women.

SEARCH METHODS

In May 2012, we searched for observational studies. The databases included MEDLINE, POPLINE, Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, EMBASE, CINAHL, and Web of Science. We also searched for recent clinical trials through ClinicalTrials.gov and the ICTRP. For other studies, we examined reference lists of relevant articles and wrote to investigators for additional reports.

SELECTION CRITERIA

We included cohort and case-control studies of hormonal contraceptive use. Interventions included comparisons of a hormonal contraceptive with a nonhormonal contraceptive, no contraceptive, or another hormonal contraceptive. The primary outcome was the risk of fracture.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One author entered the data into RevMan, and a second author verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale (NOS), developed for case-control and cohort studies. Sensitivity analysis included studies of moderate or high quality based on our assessment with the NOS.Given the need to control for confounding factors in observational studies, we used adjusted estimates from the models as reported by the authors. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs, we did not conduct meta-analysis.

MAIN RESULTS

We included 14 studies (7 case-control and 7 cohort studies). These examined oral contraceptives (OCs) (N=12), depot medroxyprogesterone acetate (DMPA) (N=4), and the hormonal intrauterine device (IUD) (N=1). This section focuses on evidence from the six studies with moderate or high quality evidence that we included in the sensitivity analysis.All six studies examined oral contraceptive use. We noted few associations with fracture risk. One cohort study found OC ever-users had increased risk for all fractures (reported RR 1.20; 95% CI 1.08 to 1.34). However, a case-control study with later data from a subset reported no association except for those with 10 years or more since use (reported OR 1.55; 95% CI 1.03 to 2.33). Another case-control study reported increased risk only for those who had 10 or more prescriptions (reported OR 1.09; 95% CI 1.03 to 1.16). A cohort study of postmenopausal women found no increased fracture risk for OC use after excluding women with prior fracture. Two other studies found little evidence of association between OC use and fracture risk. A cohort study noted increased risk for subgroups, such as those with longer use or specific intervals since use. A case-control study reported increased risk for any fracture only among young women with less than average use.Two case-control studies in the sensitivity analysis also examined progestin-only contraceptives. One reported increased fracture risk for DMPA ever-use (reported OR 1.44 (95% CI 1.01 to 2.06), more than four years of use (reported OR 2.16; 95% CI 1.32 to 3.53), and women over 50 years old. The other noted increased risk for any past use, including one or two prescriptions (reported OR 1.17; 95% CI 1.07 to 1.29), and for current use of 3 to 9 or 10 or more prescriptions. In addition, one study reported reduced fracture risk for ever-use of the hormonal IUD (reported OR 0.75; 95% CI 0.64 to 0.87) and longer use of that IUD.

AUTHORS' CONCLUSIONS

Observational studies do not indicate an overall association between OC use and fracture risk. Some reported increased risk for specific user subgroups. DMPA users may have an increased fracture risk. One study indicated hormonal IUD use may be associated with decreased risk. Observational studies need adjusted analysis because the comparison groups usually differ. Researchers should be clear about the variables examined in multivariate analysis.

Bone mineral density, fracture, and vitamin D in adolescents and young women using depot medroxyprogesterone acetate

STUDY OBJECTIVE

To evaluate bone mineral density (BMD) in adolescents and young adults treated with depot medroxyprogesterone acetate (DMPA).

DESIGN, SETTING, PARTICIPANTS

Eighty-three healthy subjects, 13-20 years old, who received at least 3 DMPA injections in an urban adolescent clinic and underwent dual energy x-ray absorptiometry (DXA) were evaluated by chart review.

MAIN OUTCOME MEASURES

Anthropometric data, DMPA use, BMD of the spine and hip, fracture history, and vitamin D status were collected.

RESULTS

Subjects were a median age of 16.4 years old (range 13-20 years) when DMPA was initiated. The median number of DMPA injections was 5 (range 3-18) before the first DXA. At the spine and hip, respectively, BMD was normal (Z-score > -1.0 SD) for most subjects (79%, 86%). Subjects who received > 5 injections were more likely to have low spinal BMD (Z-score ≤ -2.0 SD) at first DXA (P = .018). In 15 subjects with repeat DXA measurements, after an additional median 6 injections, spinal BMD Z-score decreased by -0.33 ± 0.10 (mean ± SD, P = .004), as did absolute BMD at the hip (-0.019 ± 0.007 g/cm(2), P = .014). History of fracture was not associated with initial or subsequent BMD measurements. Most (12/13, 92.3%) subjects with vitamin D measurements were deficient (25-hydroxy vitamin D < 20 ng/mL).

CONCLUSIONS

Most subjects on DMPA had normal BMD at first DXA. Low spinal BMD was associated with longer DMPA use, and some BMD measurements declined with prolonged use. Fracture history is not an absolute contraindication to DMPA use in this population. Studies are needed to determine possible benefits of vitamin D supplementation in DMPA users.

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.

Drug-induced osteoporosis: mechanisms and clinical implications

Drug-induced osteoporosis is common and has a significant impact on the prognosis of patients suffering from chronic debilitating diseases. Glucocorticoids are the drugs causing osteoporotic fractures most frequently, but osteoporosis with fractures is observed also in women treated with aromatase inhibitors for breast cancer, in men receiving anti-androgen therapy for prostate cancer, in postmenopausal women treated with high doses of thyroxine, and in men and women treated with thiazolinediones for type 2 diabetes mellitus. Bone loss with fractures also occurs in patients treated with drugs targeting the immune system, such as calcineurin inhibitors, antiretroviral drugs, selective inhibitors of serotonin reuptake, anticonvulsants, loop diuretics, heparin, oral anticoagulants, and proton pump inhibitors.

Recent advances in hormonal contraception

This report reviews some of the new studies regarding new hormonal contraceptive formulations (e.g., Yaz, Qlaira^®, extended-cycle or continuous combined contraceptives, subcutaneous depot medroxyprogesterone acetate, and ulipristal acetate as an emergency contraceptive). Recent data on the relationship between hormonal contraceptive use and bone health are also reviewed.