A 2-year prospective study on the effects of depot medroxyprogesterone acetate on bone mass-response to estrogen and calcium therapy in individual users

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

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.

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.

Calcium intervention ameliorates experimental model of multiple sclerosis

OBJECTIVE

Multiple sclerosis (MS) is the most common inflammatory disease of the CNS. Experimental autoimmune encephalomyelitis (EAE) is a widely used model for MS. In the present research, our aim was to test the therapeutic efficacy of Calcium (Ca) in an experimental model of MS.

METHODS

In this study the experiment was done on C57BL/6 mice. EAE was induced using 200 μg of the MOG35-55 peptide emulsified in CFA and injected subcutaneously on day 0 over two flank areas. In addition, 250 ng of pertussis toxin was injected on days 0 and 2. In the treatment group, 30 mg/kg Ca was administered intraperitoneally four times at regular 48 hour intervals. The mice were sacrificed 21 days after EAE induction and blood samples were taken from their hearts. The brains of mice were removed for histological analysis and their isolated splenocytes were cultured.

RESULTS

Our results showed that treatment with Ca caused a significant reduction in the severity of the EAE. Histological analysis indicated that there was no plaque in brain sections of Ca treated group of mice whereas 4 ± 1 plaques were detected in brain sections of controls. The density of mononuclear infiltration in the CNS of Ca treated mice was lower than in controls. The serum level of Nitric Oxide in the treatment group was lower than in the control group but was not significant. Moreover, the levels of IFN-γ in cell culture supernatant of splenocytes in treated mice were significantly lower than in the control group.

CONCLUSION

The data indicates that Ca intervention can effectively attenuate EAE progression.

Inadequate vitamin D status in adolescents with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate injectable contraceptive: a pilot study

STUDY OBJECTIVE

To examine vitamin D and parathormone (PTH) levels in adolescents who experienced substantial bone mineral density (BMD) loss during depot medroxyprogesterone acetate (DMPA) use.

DESIGN

A non-randomized, multi-center study, during which DMPA was administered every 12 weeks and evaluation of lumbar spine and hip BMD by dual-energy X-ray absorptiometry (DXA) was conducted every 6 months. A blood sample for vitamin D and PTH measurements was obtained from adolescents who experienced >5% BMD loss. Vitamin D deficiency was defined as 25-hydroxyvitamin D (25OHD) level of <20 ng/mL, insufficiency as 25OHD level of 20-30 ng/mL, and sufficiency as 25OHD level of >30 ng/mL.

RESULTS

Evaluation of vitamin D and PTH was carried out in 15 participants who experienced BMD loss of > or = 5% during DMPA use. At initiation of DMPA, participants had mean (+SE) age 17+1 years, gynecologic age 61+4 months, and body mass index 24+1.5 kg/m2. Racial/ethnic distribution was: Caucasian--7 girls, Hispanic--4 girls, African-American--3 girls, and other--1 girl. Six participants had BMD loss of >5% after 2 DMPA injections, five after 3 injections, one after 5 injections, one after 8 injections, one after 10 injections, and one after 13 injections. Only one girl (7%) had sufficient vitamin D. The other participants had vitamin D insufficiency (50%) or deficiency (43%). Participants' mean (+SE) PTH was 22+4 pg/mL (reference range 7-53 pg/mL), and mean (+SE) 1,25-dihydroxyvitamin D was 56+5 pg/mL (reference range 22-67 pg/mL).

CONCLUSIONS

Inadequate vitamin D status was evident among the majority of female adolescents who experienced a substantial BMD loss while using DMPA.

Biopsychosocial variables associated with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate in adolescents: adolescents who lost 5% or more from baseline vs. those who lost less than 5%

BACKGROUND

It is unclear why some adolescents experience substantial bone mineral density (BMD) loss, while others experience a minimal decrease during depot medroxyprogesterone acetate (DMPA) use. We examined biopsychosocial factors in adolescents who experienced ≥5% BMD loss from baseline compared with adolescents who experienced <5% BMD loss during DMPA use.

STUDY DESIGN

A multicenter, prospective, nonrandomized study of 181 female adolescents who initiated DMPA for contraception was conducted. BMD (by dual-energy X-ray absorptiometry) and serum estradiol were measured at initiation and every 6 months for 240 weeks of DMPA use.

RESULTS

Half of participants experienced BMD loss of ≥5% from baseline at the hip, and a quarter experienced BMD loss of ≥5% at the lumbar spine (BMD substantial losers, SL). Hip and lumbar spine BMD-SL received a significantly greater number of DMPA injections than non-SL (p<.001). Decreased estradiol levels did not statistically differ between BMD loss subgroups. Hip BMD-SL had significantly lower baseline body mass index (BMI) than non-SL (p=.002), and there was an inverse relationship between weight gain and degree of BMD loss. Mean calcium intake was significantly lower (p<.05) in hip BMD-SL, and reported alcohol use was significantly higher (p<.05) in lumbar spine BMD-SL compared with non-SL.

CONCLUSIONS

BMD loss of ≥5% was more common at the hip than at the lumbar spine among adolescents using DMPA. Decreased serum estradiol levels did not correlate with magnitude of BMD loss. Lower BMI and calcium intake and greater alcohol use were associated with greater BMD loss in adolescents using DMPA.

Bone density recovery after depot medroxyprogesterone acetate injectable contraception use

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Chronic pelvic pain and endometriosis in adolescents

PURPOSE OF REVIEW

This review will provide a detailed account of chronic pelvic pain and endometriosis, two conditions that frequently occur in adolescents. Current approaches used to evaluate and treat these patients will be addressed.

RECENT FINDINGS

Although previous investigations have established relative rates of disease and basic treatment algorithms for endometriosis in adolescents, its pathogenesis is yet to be explained. Recent scientific works have focused on the interplay of specific genes and the role of host immune response. Despite such progress, we have not yet learned how to apply this knowledge to clinical use. Most innovative treatment strategies are based on algorithms generated primarily for adults, with only a small percentage focusing on adolescents.

SUMMARY

Treating pain associated with endometriosis may be facilitated by early intervention. Future study should focus on identifying adolescents with progressive disease and introducing less invasive therapies that could reverse inflammatory pathways and minimize subsequent morbidity.

Effects of the long-term use of depot medroxyprogesterone acetate as hormonal contraceptive on bone mineral density and biochemical markers of bone remodeling

PURPOSE AND METHOD

Our objective is to evaluate the effects of the long-term use of depot medroxyprogesterone acetate (DMPA) as a method of contraception on bone mineral density (BMD) and bone remodeling. Forty women (21-44 years old) who used DMPA for contraception for <1, 1-2 and >5 years, in addition to 20 age-matched healthy women (nonusers), participated in this study. Lumbar spine BMD (LS-BMD) was measured by dual-energy X-ray absorptionmetry. Serum osteocalcin (OC), a bone formation marker, was measured by enzyme amplification sorbent immunoassay. Urinary deoxypyridinoline (DPD), a bone resorption marker, was determined by enzyme immunoassay.

RESULTS

Serum OC and urinary DPD levels in women who used DMPA for <1, 1-2 and >5 years were significantly increased compared to the corresponding levels in nonusers. The increase of both biomarkers was more pronounced with longer duration of use. LS-BMD was significantly decreased in women on long-term DMPA use compared to LS-BMD in nonusers. The mean percentage decrease of LS-BMD in women who used DMPA for 1-2 and >5 years was 9% and 11.8%, respectively. LS-BMD was negatively correlated with serum OC and urinary DPD in women who used DMPA. On the other hand, LS-BMD and bone turnover were not significantly different between women who used DMPA for <1 year and nonusers.

CONCLUSION

Long-term use of DMPA (>2 years) had a significant adverse effect on BMD and induced increased bone turnover, as evidenced by a significant increase in biochemical indices of bone formation and resorption. The measurement of LS-BMD and of biomarkers of bone turnover may be recommended in women aged above 40 years and who used DMPA for a long duration (2-5 years).

Progestogen-only contraception and bone mineral density: a systematic review

Questions have been raised about the effects of progestogen-only contraceptive use on bone health, particularly among young women who have not yet reached peak bone mass and perimenopausal women who may be starting to lose bone mass. We conducted a systematic review that evaluated the association between progestogen-only contraceptive use and fracture risk or bone mineral density (BMD). We identified 39 articles from MEDLINE and EMBASE, published through July 2005. One study reported that depot medroxyprogesterone acetate (DMPA) users were more likely to experience stress fractures than nonusers; this association was not statistically significant after controlling for baseline bone density. In cross-sectional studies, the mean BMD in DMPA users was usually below that of nonusers, but within 1 SD. In longitudinal studies, BMD generally decreased more over time among DMPA users than among nonusers, but women gained BMD upon discontinuation of DMPA. Limited evidence suggested that use of progestogen-only contraceptives other than DMPA did not affect BMD.

Bone mineral density in lymphangioleiomyomatosis

Estrogen deficiency and pulmonary diseases are associated with bone mineral density (BMD) loss. Lymphangioleiomyomatosis (LAM), a disorder affecting women that is characterized by cystic lung lesions, is frequently treated with antiestrogen therapy, i.e., progesterone and/or oophorectomy. Therefore, we evaluated BMD yearly in 211 LAM patients to determine the prevalence of BMD abnormalities, whether antiestrogen therapy decreased BMD, and if treatment with bisphosphonates prevented bone loss. Abnormal BMD was found in 70% of the patients and correlated with severity of lung disease and age. Greater severity of lung disease, menopause, and oophorectomy were associated with greater decline in BMD. After adjusting for differences in initial lung function and BMD, we found similar rates of BMD decline in progesterone-treated (n = 122) and untreated patients (n = 89). After similar adjustments, we found that bisphosphonate-treated patients (n = 98) had lower rates of decline in lumbar spine BMD (-0.004 +/- 0.003 vs. -0.015 +/- 0.003 gm/cm(2), p = 0.036) and T-scores (-0.050 +/- 0.041 vs. -0.191 +/- 0.041, p < 0.001) than untreated patients (n = 113). We conclude that abnormal BMD was frequent in LAM. Progesterone therapy was not associated with changes in BMD; bisphosphonate therapy was associated with lower rates of bone loss. We recommend systematic evaluation of BMD and early treatment with bisphosphonates for patients with LAM.

Effects of hormonal contraception on bone mineral density after 24 months of use

OBJECTIVE

To measure the effect of 24 months of depot medroxyprogesterone acetate use on bone mineral density compared with oral contraception (pills) and nonhormonal contraception.

METHODS

Women aged 18-33 years self-selected oral contraception, depot medroxyprogesterone acetate, or nonhormonal contraception (controls). Those selecting pills were randomized to formulations containing either 35 microg ethinyl estradiol and norethindrone or 30 microg ethinyl estradiol and desogestrel. Controls were frequency matched on age and race/ethnicity to hormonal contraception users. Dual-energy X-ray absorptiometry of the lumbar spine (L1-L4) was performed at baseline, 12 months, and 24 months. Percent change in bone mineral density was analyzed by using analysis of covariance, adjusting for age, race/ethnicity, weight-bearing exercise, calcium intake, smoking status, and body mass index.

RESULTS

Of the 191 women making up the final sample, 86 used pills, 47 used depot medroxyprogesterone acetate, and 58 used nonhormonal contraception. Women using depot medroxyprogesterone acetate for 24 months experienced, on average, a 5.7% loss in bone mineral density, with a 3.2% loss occurring between months 12 and 24. On average, users of desogestrel pills experienced a 2.6% loss in bone mineral density after 24 months. Bonferroni-adjusted pairwise comparisons demonstrated that bone mineral density changes from baseline to 24 months among depot medroxyprogesterone acetate users differed significantly from changes experienced by either of the pill groups or the control group. Changes in bone mineral density among users of either pill did not significantly differ from each other or from controls.

CONCLUSION

Loss of bone mineral density associated with depot medroxyprogesterone acetate use appears to be linear during the first 2 years of use. Shifts in bone mineral density among pill users were not significant when compared with controls.

Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines

The controversial history of the reproductive rights of the mentally retarded has led to the formulation of laws in the past century designed to protect women from forced sterilization. Significantly, however, in their official ethical guidelines, The American College of Obstetricians and Gynecologists states that "sterilization should not be denied to individuals simply because they also may be vulnerable to coercion" (Int J Gynaecol Obstet 1999; 65:317). Recent advances in medical and surgical methods of contraception and control of menstrual abnormalities have led to a re-evaluation of the management of adolescents with special needs. Physicians, the courts, parents, and caretakers need to be aware of the latest medical and surgical options available, the current applicable laws in each state if such exist, and the ethical guidelines to determine what treatment option is in the best interests of the patient. This review examines the history of the sterilization of the mentally retarded, the latest surgical and pharmacologic treatments available, and the current legal environment and proposes an algorithm to facilitate the management of menstrual hygiene and contraception.