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Nguyen AT, Curtis KM, Tepper NK, Kortsmit K, Brittain AW, Snyder EM, Cohen MA, Zapata LB, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep 2024; 73:1-126. [PMID: 39106314 PMCID: PMC11315372 DOI: 10.15585/mmwr.rr7304a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
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Affiliation(s)
- Antoinette T. Nguyen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Kathryn M. Curtis
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Naomi K. Tepper
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Katherine Kortsmit
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Anna W. Brittain
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Emily M. Snyder
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Megan A. Cohen
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Lauren B. Zapata
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Maura K. Whiteman
- Division of Reproductive Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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White L, Losciale JM, Squier K, Guy S, Scott A, Prior JC, Whittaker JL. Combined hormonal contraceptive use is not protective against musculoskeletal conditions or injuries: a systematic review with data from 5 million females. Br J Sports Med 2023; 57:1195-1202. [PMID: 37225254 DOI: 10.1136/bjsports-2022-106519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Assess the association between combined hormonal contraceptives (CHC) use and musculoskeletal tissue pathophysiology, injuries or conditions. DESIGN Systematic review with semiquantitative analyses and certainty of evidence assessment, guided by the Grading of Recommendations Assessment, Development and Evaluation approach. DATA SOURCES MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched from inception to April 2022. ELIGIBILITY Intervention and cohort studies that assessed the association between new or ongoing use of CHC and an outcome of musculoskeletal tissue pathophysiology, injury or condition in postpubertal premenopausal females. RESULTS Across 50 included studies, we assessed the effect of CHC use on 30 unique musculoskeletal outcomes (75% bone related). Serious risk of bias was judged present in 82% of studies, with 52% adequately adjusting for confounding. Meta-analyses were not possible due to poor outcome reporting, and heterogeneity in estimate statistics and comparison conditions. Based on semiquantitative synthesis, there is low certainty evidence that CHC use was associated with elevated future fracture risk (risk ratio 1.02-1.20) and total knee arthroplasty (risk ratio 1.00-1.36). There is very low certainty evidence of unclear relationships between CHC use and a wide range of bone turnover and bone health outcomes. Evidence about the effect of CHC use on musculoskeletal tissues beyond bone, and the influence of CHC use in adolescence versus adulthood, is limited. CONCLUSION Given a paucity of high certainty evidence that CHC use is protective against musculoskeletal pathophysiology, injury or conditions, it is premature and inappropriate to advocate, or prescribe CHC for these purposes. PROSPERO REGISTRATION NUMBER This review was registered on PROSPERO CRD42021224582 on 8 January 2021.
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Affiliation(s)
- Lynita White
- Tall Tree Physiotherapy and Health Centre, Vancouver, British Columbia, Canada
| | - Justin M Losciale
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kipling Squier
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Guy
- City Sport + Physiotherapy Clinic, Vancouver, British Columbia, Canada
| | - Alex Scott
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jerilynn C Prior
- Centre for Menstrual Cycle and Ovulation Research, The University of British Columbia, Vancouver, British Columbia, Canada
- Women's Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jackie L Whittaker
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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Orsolini LR, Goldberg TBL, Caldeirão TD, Cristiane da Silva C, Rizzo ADCB, Biason TP, Teixeira AS, Carvalho Nunes HR. Bone impact after two years of low-dose oral contraceptive use during adolescence. PLoS One 2023; 18:e0285885. [PMID: 37289781 PMCID: PMC10249826 DOI: 10.1371/journal.pone.0285885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE Data regarding the use and effect of hormonal contraceptives on bone mass acquisition during adolescence are contradictory. The present study was designed to evaluate bone metabolism in two groups of healthy adolescents using combined oral contraceptives (COC). METHODS A total of 168 adolescents were recruited from 2014 to 2020 in a non-randomized clinical trial and divided into three groups. The COC1 group used 20 μg Ethinylestradiol (EE)/150 μg Desogestrel and the COC2 group used 30 μg EE/3 mg Drospirenone over a period of two years. These groups were compared to a control group of adolescent non-COC users. The adolescents were submitted to bone densitometry by dual-energy X-ray absorptiometry and measurement of bone biomarkers, bone alkaline phosphatase (BAP), and osteocalcin (OC) at baseline and 24 months after inclusion in the study. The three groups studied were compared at the different time points by ANOVA, followed by Bonferroni's multiple comparison test. RESULTS Incorporation of bone mass was greater in non-users at all sites analyzed (4.85 g in lumbar Bone mineral content (BMC)) when compared to adolescents of the COC1 and COC2 groups, with a respective increase of 2.15 g and loss of 0.43g in lumbar BMC (P = 0.001). When comparing subtotal BMC, the control increased 100.83 g, COC 1 increased 21.46 g, and COC 2 presented a reduction of 1.47 g (P = 0.005). The values of bone markers after 24 months are similar for BAP, being 30.51 U/L (± 11.6) for the control group, 34.95 U/L (± 10.8) for COC1, and 30.29 U/L for COC 2 (± 11.5) (P = 0.377). However, when we analyzed OC, we observed for control, COC 1, and COC 2 groups, respectively, 13.59 ng/mL (± 7.3), 6.44 ng/mL (± 4.6), and 9.48 ng/mL (± 5.9), with P = 0.003. Despite loss to follow-up occurring in the three groups, there were no significant differences between the variables in adolescents at baseline who remained in the study during the 24-month follow-up and those who were excluded or lost to follow-up. CONCLUSION Bone mass acquisition was compromised in healthy adolescents using combined hormonal contraceptives when compared to controls. This negative impact seems to be more pronounced in the group that used contraceptives containing 30 μg EE. CLINICAL TRIAL REGISTRATION http://www.ensaiosclinicos.gov.br, RBR-5h9b3c. "Low-dose combined oral contraceptive use is associated with lower bone mass in adolescents".
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Affiliation(s)
- Lilian Rodrigues Orsolini
- Postgraduate Program in Tocogynecology, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Tamara Beres Lederer Goldberg
- Postgraduate Program in Tocogynecology, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Talita Domingues Caldeirão
- Postgraduate Program in Tocogynecology, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | | | - Anapaula da Conceição Bisi Rizzo
- Postgraduate Program in Tocogynecology, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Talita Poli Biason
- Postgraduate Program in Tocogynecology, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Altamir Santos Teixeira
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Helio Rubens Carvalho Nunes
- Statistical Consultant, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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Ambrosio MR, Aliberti L, Gagliardi I, Franceschetti P, Zatelli MC. Bone health in adolescence. Minerva Obstet Gynecol 2021; 73:662-677. [PMID: 34905874 DOI: 10.23736/s2724-606x.20.04713-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adolescence is a fundamental period for the formation of the skeleton, because is the stage in which bones grow more in both size and strength, laying a solid foundation for the future health of the skeleton. Any condition interfering with optimal peak bone mass accrual can increase fracture risk later in life. Up to 80% of peak bone mass is genetically determined while the remaining 20% is modulated by environmental factors that, if deleterious, may result in low bone mineral density (BMD) and an increased risk of fracture. The preferred test to assess bone health is dual-energy x-ray absorptiometry (spine or total body less head) using Z scores instead of T scores, even though in short stature or growth delay, should be used the height Z-score. The correction of risk factors is the first treatment for low BMD in children and adolescents. It's necessary having a correct lifestyle for preserving bone health: a proper nutrition, an adequate physical weight-bearing activity and avoidance of alcohol intake and tobacco smoke. Bisphosphonates could be used in children who sustained osteoporotic fractures, impairing quality of life, when spontaneous recovery is low for the persistence of osteoporosis risk factors. This clinical review discusses factors affecting bone health during childhood and adolescence and deals with diagnosis and treatment of low bone mass or osteoporosis in this age group.
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Affiliation(s)
- Maria R Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy -
| | - Ludovica Aliberti
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Paola Franceschetti
- Operative Unit of Endocrinology and Metabolic Diseases, Department of Oncology and Specialty Medicine, Ferrara University Hospital, Ferrara, Italy
| | - Maria C Zatelli
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Farah D, Andrade TRDM, Di Bella ZIKDJ, Girão MJBC, Fonseca MCM. Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis. EUR J CONTRACEP REPR 2021; 27:127-135. [PMID: 34431421 DOI: 10.1080/13625187.2021.1964467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population. METHODS Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence. RESULTS Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%). CONCLUSION Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.
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Affiliation(s)
- Daniela Farah
- Department of Gynaecology, Health Technologies Assessment Centre, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Department of Gynaecology, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | | | | | - Manoel João Batista Castello Girão
- Department of Gynaecology, Health Technologies Assessment Centre, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Department of Gynaecology, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Marcelo Cunio Machado Fonseca
- Department of Gynaecology, Health Technologies Assessment Centre, Universidade Federal de São Paulo, Sao Paulo, Brazil.,Department of Gynaecology, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Almstedt HC, Cook MM, Bramble LF, Dabir DV, LaBrie JW. Oral contraceptive use, bone mineral density, and bone turnover markers over 12 months in college-aged females. J Bone Miner Metab 2020; 38:544-554. [PMID: 31983034 DOI: 10.1007/s00774-019-01081-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/24/2019] [Indexed: 01/30/2023]
Abstract
INTRODUCTION The purpose of this study was to compare bone mineral density (BMD) and bone turnover markers between combined oral contraceptive (COC) and non-COC users over 12 months. MATERIALS AND METHODS COC users (n = 34, age = 19.2 ± 0.5) and non-COC users (n = 28, age = 19.3 ± 0.6) provided serum at baseline, 6 months, and 12 months. C-terminal telopepetides (CTX) and pro-collagen type 1 N-terminal propeptides (P1NP) were determined using ELISA. BMD was measured at the three time points using dual-energy x-ray absorptiometry (DXA). RESULTS COC users had greater CTX than non-COC users at baseline (18.6 ± 8.2 vs. 13.8 ± 5.3 ng/mL, P = 0.021) and 6 months (20.4 ± 10.3 vs. 14.2 ± 8.5 ng/mL, P = 0.018). Controlling for lean mass, groups were similar in BMD. Over 12 months, non-COC users maintained BMD at the spine, while the COC users declined 2.2% in lateral spine BMD (0.773 ± 0.014 to 0.756 ± 0.014 g/cm2, P = 0.03) and 0.7% in anterior-posterior spine BMD (1.005 ± 0.015 to 0.998 ± 0.015 g/cm2, P = 0.069). Non-COC users increased in BMD of the whole body over 12 months (P < 0.001) while COC users had no change. Women who began COCs within 4 years after menarche had lower BMD at the hip and whole body. Women taking very low dose COCs (20 mcg ethinyl estradiol, EE) significantly declined in CTX, P1NP, and lateral spine BMD in comparison to participants using low dose COCs (30/35 mcg EE). CONCLUSION College-aged women who did not use COCs increased BMD of the whole body, while COC users had elevated bone turnover, declines in spinal BMD, and lack of bone acquisition of the whole body over 12 months. Young females who initiate COC use early after menarche may experience skeletal detriments.
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Affiliation(s)
- Hawley C Almstedt
- Human Performance Laboratory, Department of Health and Human Sciences, Loyola Marymount University, 1 LMU Drive MS 8888, Los Angeles, CA, 90045, USA.
| | - Makenzie M Cook
- Human Performance Laboratory, Department of Health and Human Sciences, Loyola Marymount University, 1 LMU Drive MS 8888, Los Angeles, CA, 90045, USA
| | - Lily F Bramble
- Human Performance Laboratory, Department of Health and Human Sciences, Loyola Marymount University, 1 LMU Drive MS 8888, Los Angeles, CA, 90045, USA
| | - Deepa V Dabir
- Department of Biology, Loyola Marymount University, 1 LMU Drive MS 8888, Los Angeles, CA, 90045, USA
| | - Joseph W LaBrie
- HeadsUp Laboratory, Department of Psychology, Loyola Marymount University, 1 LMU Drive Suite 4700, Los Angeles, CA, 90045, USA
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Merki-Feld GS, Bitzer J. Contraception in adolescents with anorexia nervosa. Is there evidence for a negative impact of combined hormonal contraceptives on bone mineral density and the course of the disease? EUR J CONTRACEP REPR 2020; 25:213-220. [PMID: 32336145 DOI: 10.1080/13625187.2020.1743826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: Adolescents with anorexia nervosa (AN) are at increased risk of unplanned pregnancies and bone loss, due to low oestrogen levels and low use of efficient contraception. The negative impact of combined hormonal contraceptives (CHC) on peak bone mass during adolescence might limit wider use in anorexic women. Another issue limiting CHC use is the concern, that CHC-induced cyclic bleeding reduces the motivation for further weight gain and thus exerts a negative impact on recovery. We wanted to find evidence based answers about the impact of CHC use on bone health and course of the disease in adolescents with AN.Methods: We performed a narrative review of the current literature investigating the effect of CHC or progestin-only contraceptives on bone density, body shape and course of disease in young women with anorexia.Results: There is no evidence that CHC use aggravates the bone loss associated with AN. In long-term users CHC exert a protective effect. Anorexic women using CHC showed at least the same or a greater weight gain in comparison with controls. Eating disorder attitudes did not worsen.Conclusion: We conclude, that at present there is no evidence, that use of CHC by AN patients has a negative impact on bone density or the course of disease.
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Affiliation(s)
| | - Johannes Bitzer
- Department of Obstetrics and Gynaecology, Basel University Hospital, Basel, Switzerland
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Goshtasebi A, Subotic Brajic T, Scholes D, Beres Lederer Goldberg T, Berenson A, Prior JC. Adolescent use of combined hormonal contraception and peak bone mineral density accrual: A meta-analysis of international prospective controlled studies. Clin Endocrinol (Oxf) 2019; 90:517-524. [PMID: 30614555 PMCID: PMC6850432 DOI: 10.1111/cen.13932] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/06/2018] [Accepted: 01/04/2019] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Many women use combined hormonal contraceptives (CHC) during adolescence during which they are accruing peak areal bone mineral density (BMD) that relates to lifetime fracture risk. To build BMD requires formation with which CHC-related exogenous oestrogen may interfere. We compared peak BMD accrual in adolescents using and not using CHC. DESIGN/PARTICIPANTS We performed literature searches for prospective published peer-reviewed articles providing 12- to 24-month BMD change in adolescent (12- to 19-year-old) women using CHC vs CHC-unexposed control women. METHODS Meta-analyses used random-effects models to assess BMD change rate at lumbar spine (LS) and other sites in adolescent CHC users vs CHC nonusers. RESULTS Literature searches yielded 84 publications of which nine were eligible. Adolescent-only data were sought from cohorts with wider age inclusions. The 12-month LS meta-analysis with eight paired comparisons in 1535 adolescents showed a weighted mean BMD difference of -0.02 (95% confidence interval [CI]: -0.05 to 0.00) g/cm2 in CHC-exposed adolescents (P = 0.04). The 24-month LS meta-analysis with five paired comparisons in 885 adolescents showed a highly significant weighted mean BMD difference of -0.02 (95% CI: -0.03 to -0.01) g/cm2 in CHC-exposed adolescents (P = 0.0006). Heterogeneities by I2 were 96% and 85%, respectively. Insufficient data for other bone sites precluded quantitative analysis. CONCLUSION Given that adolescent exposure to CHC appears to be increasing, this evidence for potential impairment of peak spinal BMD accrual is of concern and suggests a potential public health problem. Randomized controlled trial data are needed to determine CHC effects on adolescent bone health.
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Affiliation(s)
- Azita Goshtasebi
- Centre for Menstrual Cycle and Ovulation Research, Endocrinology and MetabolismUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- British Columbia Women’s Health Research InstituteVancouverBritish ColumbiaCanada
| | - Tatjana Subotic Brajic
- Centre for Menstrual Cycle and Ovulation Research, Endocrinology and MetabolismUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Delia Scholes
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente WashingtonSeattleWashington
| | - Tamara Beres Lederer Goldberg
- Postgraduate Program in Gynecology, Obstetrics, and MastologyDiscipline of Adolescent MedicineDepartment of PediatricsBotucatu Medicine SchoolSão Paulo State University (UNESP)BotucatuSãoBrazil
| | - Abbey Berenson
- Department of Obstetrics & GynecologyThe University of Texas Medical BranchGalvestonTexas
| | - Jerilynn C. Prior
- Centre for Menstrual Cycle and Ovulation Research, Endocrinology and MetabolismUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- British Columbia Women’s Health Research InstituteVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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Shah D, Patil M. Consensus Statement on the Use of Oral Contraceptive Pills in Polycystic Ovarian Syndrome Women in India. J Hum Reprod Sci 2018; 11:96-118. [PMID: 30158805 PMCID: PMC6094524 DOI: 10.4103/jhrs.jhrs_72_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To provide consensus recommendations for health-care providers on the use of oral contraceptive pills (OCPs) in polycystic ovarian syndrome (PCOS) women in India. PARTICIPANTS Extensive deliberations, discussions, and brainstorming were done with different fraternities (specialists) being involved. These included endocrinologists, gynecologists, reproductive endocrinologists, dermatologists, public health experts, researchers, and a project manager with a team to develop the guideline. EVIDENCE Published literature was retrieved through searches of Medline and The Cochrane Database from January 2003 to December 2017 using appropriate-controlled vocabulary (e.g., oral contraceptive pills, polycystic ovarian syndrome, long term outcomes, infertility). Clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies' publications and data were also reviewed to suggest the recommendations. PROCESS The working group for guideline committee included members from the PCOS Society (India), Indian Society for Assisted Reproduction, The Mumbai Obstetric and Gynecological Society, The Endocrine Society of India, Indian Association of Dermatologists, Venereologists and Leprologists, Cosmetic Dermatology Society (India), Academicians from Medical Colleges, National Institute for Research in Reproductive Health, and a Research Associate. The core team included five reproductive endocrinologists, five gynecologists, five dermatologists, three endocrinologists, two public health experts and one research associate. CONCLUSIONS This consensus statement provides the guidance/recommendations for Indian practitioners regarding the use of OCP in women with PCOS. PCOS is one of the common endocrinopathies encountered in gynecological/endocrine practice. The spectrum of this disorder may range from prepubertal girls with premature pubarche, young girls with hirsutism, acne and anovulatory cycles, married women with infertility, and elderly women. Although obesity is a common feature for most PCOS patients, 'lean PCOS' also exists. For several years, OCPs have played an important role in the symptom management of PCOS women. This is due to the fact that OCPs decrease the luteinizing hormone, reduce androgen production, and increase sex hormone-binding globulin, which binds androgens. Several new formulations of OCPs have been developed to decrease the side effects. This includes use of less androgenic progestins and lower doses of ethinyl estradiol. These consensus recommendations help the health provider to choose the right type of OCPs, which will alleviate the symptoms with least side effects. It also gives insight into the indications, contraindications, and concerns regarding its short, intermediate and long-term use.
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Affiliation(s)
- Duru Shah
- President PCOS Society of India, Mumbai, Maharashtra, India
- Director Gynaecworld the Center for Women's Health and Fertility, Mumbai, Maharashtra, India
| | - Madhuri Patil
- Scientific Coordinator, The PCOS Society of India, Bengaluru, Karnataka, India
- Editor, Journal of Human Reproductive Sciences, Bengaluru, Karnataka, India
- Clinical Director and Principal, Dr. Patil's Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
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Ebert AD, Dong L, Merz M, Kirsch B, Francuski M, Böttcher B, Roman H, Suvitie P, Hlavackova O, Gude K, Seitz C. Dienogest 2 mg Daily in the Treatment of Adolescents with Clinically Suspected Endometriosis: The VISanne Study to Assess Safety in ADOlescents. J Pediatr Adolesc Gynecol 2017; 30:560-567. [PMID: 28189702 DOI: 10.1016/j.jpag.2017.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 01/10/2017] [Accepted: 01/20/2017] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To study the safety and efficacy of dienogest 2 mg in adolescents with suspected endometriosis. DESIGN A 52-week, open-label, single-arm study. SETTING In 21 study centers, in 6 European countries. PARTICIPANTS Adolescents aged 12 to younger than 18 years with clinically suspected or laparoscopically confirmed endometriosis. INTERVENTIONS Dienogest 2 mg once daily. MAIN OUTCOME MEASURES The primary end point was relative change in lumbar spine (L2-L4) bone mineral density (BMD) measured using dual-energy x-ray absorptiometry. A key secondary end point was change in endometriosis-associated pain assessed using a visual analogue scale. RESULTS Of 120 patients screened, 111 comprised the full-analysis set (ie, patients who took ≥1 dose of study drug and had ≥1 post-treatment observation) and 97 (87.4%) completed the study. Mean lumbar BMD at baseline was 1.1046 (SD, 0.1550) g/cm2. At the end of dienogest treatment (EOT; defined as at 52 weeks or premature study discontinuation), mean relative change in BMD from baseline was -1.2% (SD, 2.3%; n = 103). Follow-up measurement 6 months after EOT in the subgroup with decreased BMD at EOT (n = 60) showed partial recovery in lumbar BMD (mean change from baseline: -2.3% at EOT, -0.6% 6 months after EOT). Mean endometriosis-associated pain score was 64.3 (SD, 19.1) mm at baseline and decreased to 9.0 (SD, 13.9) mm by week 48. CONCLUSION In adolescents with suspected endometriosis, dienogest 2 mg for 52 weeks was associated with a decrease in lumbar BMD, followed by partial recovery after treatment discontinuation. Endometriosis-associated pain was substantially reduced during treatment. Because bone accretion is critical during adolescence, results of the VISanne study to assess safety in ADOlescents (VISADO) study highlights the need for tailored treatment in this population, taking into account the expected efficacy on endometriosis-associated pain and an individual's risk factors for osteoporosis.
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Affiliation(s)
- Andreas D Ebert
- Praxis for Women's Health, Gynecology & Obstetrics, Berlin, Germany.
| | | | | | | | | | - Bettina Böttcher
- Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Horace Roman
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France; Research Group 4308 'Spermatogenesis and Gamete Quality', Reproductive Biology Laboratory, Rouen University Hospital, Rouen, France
| | - Pia Suvitie
- Department of Obstetrics and Gynecology, University of Turku and Turku University Hospital, Turku, Finland
| | - Olga Hlavackova
- Gynaecological Rehabilitation Center, Budějovické předměstí, Písek, Czech Republic
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Gersten J, Hsieh J, Weiss H, Ricciotti NA. Effect of Extended 30 μg Ethinyl Estradiol with Continuous Low-Dose Ethinyl Estradiol and Cyclic 20 μg Ethinyl Estradiol Oral Contraception on Adolescent Bone Density: A Randomized Trial. J Pediatr Adolesc Gynecol 2016; 29:635-642. [PMID: 27287084 DOI: 10.1016/j.jpag.2016.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 05/04/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To compare changes in lumbar spine bone mineral density after 12 months of a 91-day extended regimen or 28-day combined oral contraceptive with those in a healthy reference group not using hormonal contraceptives. DESIGN Phase 2, multicenter, open-label, randomized, controlled study. SETTING Forty-five academic centers, clinical research centers, and community practices in the United States. PARTICIPANTS Eight hundred twenty-nine postmenarcheal adolescent girls aged 12-18 years. INTERVENTIONS Adolescents were randomly assigned to 91-day levonorgestrel (LNG)/ethinyl estradiol (EE) extended regimen (84 days of LNG 150 μg/EE 30 μg with 7 days of EE 10 μg [LNG/EE extended regimen]) or 28 days of LNG/EE (21 days of LNG 100 μg/EE 20 μg with 7 days of placebo [LNG/EE 21/7]) for 12 months. A reference group not seeking hormonal contraception was also evaluated. MAIN OUTCOME MEASURES The primary end point was mean percent change in lumbar spine bone mineral density measured using dual-energy x-ray absorptiometry. RESULTS Of 1361 adolescents randomized/enrolled, 829 were included in the primary analysis. Mean changes in lumbar spine bone mineral density were +2.26% with LNG/EE extended regimen, +1.45% with LNG/EE 21/7, and +2.50% in the reference group. Noninferiority of the LNG/EE extended regimen compared with the reference group was shown. A statistically significant treatment difference was found between LNG/EE 21/7 and the reference group (1.05%; 95% confidence interval, 0.61%-1.49%) but not between LNG/EE extended regimen and the reference group (0.23%; 95% confidence interval, -0.20% to 0.67%). No new safety signals were noted. CONCLUSION Compared with the reference group, bone accrual was statistically significantly lower among LNG/EE 21/7 users but not among LNG/EE 30-μg extended regimen users. Additional research is needed to clarify the clinical relevance of these findings.
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Affiliation(s)
- Janet Gersten
- New Age Medical Research Corporation, Miami, Florida.
| | - Jennifer Hsieh
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pennsylvania
| | - Herman Weiss
- Teva Global Medical Affairs, Petach Tikva, Israel
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Biason TP, Goldberg TBL, Kurokawa CS, Moretto MR, Teixeira AS, Nunes HRDC. Low-dose combined oral contraceptive use is associated with lower bone mineral content variation in adolescents over a 1-year period. BMC Endocr Disord 2015; 15:15. [PMID: 25990414 PMCID: PMC4443632 DOI: 10.1186/s12902-015-0012-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 03/26/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Low-dose combined oral contraceptives (COCs) can interfere with bone mass acquisition during adolescence. This study aimed to evaluate bone mineral density (BMD) and bone mineral content (BMC) in female adolescents taking a standard low-dose COC (ethinylestradiol 20 μg/desogestrel 150 μg) over a 1-year period and to compare their data with those of healthy adolescents from the same age group not taking COCs. METHODS This was a non-randomized parallel-control study with a 1-year follow-up. Sixty-seven adolescents aged from 12 to 19 years, divided into COC users (n = 41) taking 20 μg ethinylestradiol/150 μg desogestrel and COC non-user controls (n = 26), were evaluated by bone densitometry examinations at baseline and after 12 months. Comparisons between the groups at the study onset were performed using the Mann-Whitney test with the significance level fixed at 5% or p < 0.05. Comparisons between the groups at the study onset and after 12 months were based on variations in the median percentages for bone mass variables. RESULTS The COC users presented with low bone mass acquisition in the lumbar spine, and had BMD and BMC median variations of 2.07% and +1.57%, respectively, between the measurements at baseline and 12 months. The control group had median variations of +12.16% and +16.84% for BMD and BMC, respectively, over the same period. The total body BMD and BMC showed similar evolutions during the study in both groups. Statistical significance (p < 0.05) was seen for the BMC percentage variation between COC users and non-users. CONCLUSIONS Use of a low-dose COC (ethinylestradiol 20 μg/desogestrel 150 μg) was associated with lower bone mass acquisition in adolescents during the study period. TRIAL REGISTRATION Registry Number, RBR-5h9b3c.
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Affiliation(s)
- Talita Poli Biason
- Department of Pediatrics, Adolescent Medicine Discipline, Graduate Program in Gynecology, Obstetrics, and Mastology, Botucatu School of Medicine, São Paulo State University (UNESP), São Paulo, Brazil.
| | - Tamara Beres Lederer Goldberg
- Department of Pediatrics, Adolescent Medicine Discipline, Graduate Program in Gynecology, Obstetrics, and Mastology, Botucatu School of Medicine, São Paulo State University (UNESP), São Paulo, Brazil.
| | - Cilmery Suemi Kurokawa
- Clinical and Experimental Pediatrics Research Center, Department of Pediatrics, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil.
| | - Maria Regina Moretto
- Clinical and Experimental Pediatrics Research Center, Department of Pediatrics, Botucatu Medical School, São Paulo State University (UNESP), São Paulo, Brazil.
| | - Altamir Santos Teixeira
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu School of Medicine, São Paulo State University (UNESP), São Paulo, Brazil.
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13
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Farr JN, Khosla S, Achenbach SJ, Atkinson EJ, Kirmani S, McCready LK, Melton LJ, Amin S. Diminished bone strength is observed in adult women and men who sustained a mild trauma distal forearm fracture during childhood. J Bone Miner Res 2014; 29:2193-202. [PMID: 24753047 PMCID: PMC4352579 DOI: 10.1002/jbmr.2257] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/24/2014] [Accepted: 03/30/2014] [Indexed: 11/08/2022]
Abstract
Children and adolescents who sustain a distal forearm fracture (DFF) owing to mild, but not moderate, trauma have reduced bone strength and cortical thinning at the distal radius and tibia. Whether these skeletal deficits track into adulthood is unknown. Therefore, we studied 75 women and 75 men (age range, 20 to 40 years) with a childhood (age < 18 years) DFF and 150 sex-matched controls with no history of fracture using high-resolution peripheral quantitative computed tomography (HRpQCT) to examine bone strength (ie, failure load) by micro-finite element (µFE) analysis, as well as cortical and trabecular bone parameters at the distal radius and tibia. Level of trauma (mild versus moderate) was assigned using a validated classification scheme, blind to imaging results. When compared to sex-matched, nonfracture controls, women and men with a mild trauma childhood DFF (eg, fall from standing height) had significant reductions in failure load (p < 0.05) of the distal radius, whereas women and men with a moderate trauma childhood DFF (eg, fall while riding a bicycle) had values similar to controls. Consistent findings were observed at the distal tibia. Furthermore, women and men with a mild trauma childhood DFF had significant deficits in distal radius cortical area (p < 0.05), and significantly lower dual-energy X-ray absorptiometry (DXA)-derived bone density at the radius, hip, and total body regions compared to controls (all p < 0.05). By contrast, women and men with a moderate trauma childhood DFF had bone density, structure, and strength that did not differ significantly from controls. These findings in young adults are consistent with our observations in children/adolescents with DFF, and they suggest that a mild trauma childhood DFF may presage suboptimal peak bone density, structure, and strength in young adulthood. Children and adolescents who suffer mild trauma DFFs may need to be targeted for lifestyle interventions to help achieve improved skeletal health.
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Affiliation(s)
- Joshua N Farr
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sundeep Khosla
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara J Achenbach
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Atkinson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Salman Kirmani
- Division of Medical Genetics, Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Louise K McCready
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - L Joseph Melton
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Shreyasee Amin
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Lopez LM, Grimes DA, Schulz KF, Curtis KM, Chen M. Steroidal contraceptives: effect on bone fractures in women. Cochrane Database Syst Rev 2014; 2014:CD006033. [PMID: 24960023 PMCID: PMC11127753 DOI: 10.1002/14651858.cd006033.pub5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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. 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 Our aim was to evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women. SEARCH METHODS Through April 2014, we searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as ClinicalTrials.gov and ICTRP. We examined reference lists of relevant articles for other trials. For the initial review, we wrote to investigators to find additional trials. SELECTION CRITERIA Randomized controlled trials (RCTs) were considered if they examined fractures, bone mineral density (BMD), or bone turnover markers in women with hormonal contraceptive use prior to menopause. Eligible interventions included comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive that differed in terms of drug, dosage, or regimen. They also included providing a supplement to one group. DATA COLLECTION AND ANALYSIS We assessed all titles and abstracts identified through the literature searches. Mean differences were computed using the inverse variance approach. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) was calculated. Both included the 95% confidence interval (CI) and used a fixed-effect model. Due to differing interventions, no trials could be combined for meta-analysis. We applied principles from GRADE to assess the evidence quality and address confidence in the effect estimates. In addition, a sensitivity analysis included trials that provided sufficient data for this review and evidence of at least moderate quality. MAIN RESULTS We found 19 RCTs that met our eligibility criteria. Eleven trials compared different combined oral contraceptives (COCs) or regimens of COCs; five examined an injectable versus another injectable, implant, or IUD; two studied implants, and one compared the transdermal patch versus the vaginal ring. No trial had fracture as an outcome. BMD was measured in 17 studies and 12 trials assessed biochemical markers of bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density (BMD). The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo supplement. COCs did not appear to negatively affect BMD, and some formulations had more positive effects than others. However, no COC trial was placebo-controlled. Where studies showed differences between groups in bone turnover markers, the results were generally consistent with those for BMD. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group but results were not consistent across all implant comparisons.The sensitivity analysis included 11 trials providing evidence of moderate or high quality. Four trials involving DMPA showed some positive effects of an estrogen supplement on BMD, a negative effect of DMPA-subcutaneous on lumbar spine BMD, and a negative effect of DMPA on a bone formation marker. Of the three COC trials, one had a BMD decrease for the group with gestodene plus EE 15 μg. Another indicated less bone resorption in the group with gestodene plus EE 30 μg versus EE 20 μg. AUTHORS' CONCLUSIONS Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. The evidence quality was considered moderate overall, largely due to the trials of DMPA, implants, and the patch versus ring. The COC evidence varied in quality but was low overall. Many trials had small numbers of participants and some had large losses. 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.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - David A Grimes
- University of North Carolina, School of MedicineObstetrics and GynecologyCB#7570Chapel HillNorth CarolinaUSA27599‐7570
| | - Kenneth F Schulz
- FHI 360 and UNC School of MedicineQuantitative Sciences359 Blackwell Street, Suite 200Suite 200DurhamNorth CarolinaUSA27701
| | - Kathryn M. Curtis
- Centers for Disease Control and PreventionDivision of Reproductive HealthMS K‐34, 4770 Buford Highway, NEAtlantaGeorgiaUSA30341
| | - Mario Chen
- FHI 360Division of Biostatistics359 Blackwell St, Suite 200Durham, NCNorth CarolinaUSA27709
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Abstract
PURPOSE OF REVIEW This review will empower the primary care provider (PCP) to evaluate, manage, and refer as needed adolescents with dysmenorrhea and/or chronic pelvic pain (CPP) who are suspected to have endometriosis. RECENT FINDINGS Endometriosis is a common cause of CPP in adolescents who do not respond to primary medical treatment. The presentation in adolescents is unique, causing high rates of misdiagnosis or delayed treatment. Endometriosis-related pain has a marked negative impact on social and mental health. Simple treatments that are available in the primary care setting can alleviate pain and improve quality of life for these young women if initiated in a timely fashion. SUMMARY Adolescents usually turn to their PCP for evaluation of dysmenorrhea and CPP. By maintaining a high index of suspicion, initiating treatment, and referring when needed, the PCP can have a tremendous effect on the patient's present and future quality of life.
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