Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety

Establishment of Murine Pregnancy Requires the Promyelocytic Leukemia Zinc Finger Transcription Factor

Using an established human primary cell culture model, we previously demonstrated that the promyelocytic leukemia zinc finger (PLZF) transcription factor is a direct target of the progesterone receptor (PGR) and is essential for progestin-dependent decidualization of human endometrial stromal cells (HESCs). These in vitro findings were supported by immunohistochemical analysis of human endometrial tissue biopsies, which showed that the strongest immunoreactivity for endometrial PLZF is detected during the progesterone (P4)-dominant secretory phase of the menstrual cycle. While these human studies provided critical clinical support for the important role of PLZF in P4-dependent HESC decidualization, functional validation in vivo was not possible due to the absence of suitable animal models. To address this deficiency, we recently generated a conditional knockout mouse model in which PLZF is ablated in PGR-positive cells of the mouse (Plzf d/d). The Plzf d/d female was phenotypically analyzed using immunoblotting, real-time PCR, and immunohistochemistry. Reproductive function was tested using the timed natural pregnancy model as well as the artificial decidual response assay. Even though ovarian activity is not affected, female Plzf d/d mice exhibit an infertility phenotype due to an inability of the embryo to implant into the Plzf d/d endometrium. Initial cellular and molecular phenotyping investigations reveal that the Plzf d/d endometrium is unable to develop a transient receptive state, which is reflected at the molecular level by a blunted response to P4 exposure with a concomitant unopposed response to 17-β estradiol. In addition to a defect in P4-dependent receptivity, the Plzf d/d endometrium fails to undergo decidualization in response to an artificial decidual stimulus, providing the in vivo validation for our earlier HESC culture findings. Collectively, our new Plzf d/d mouse model underscores the physiological importance of the PLZF transcription factor not only in endometrial stromal cell decidualization but also uterine receptivity, two uterine cellular processes that are indispensable for the establishment of pregnancy.

Adjusting Injectable Contraceptive Use for Months Since the Last Injection

Injectables are one of the most popular methods of contraception worldwide, particularly in sub-Saharan Africa. An advantage of injectables over shorter-acting methods is that they provide additional flexibility by not requiring re-supply as frequently. However, there is a risk that injectable users may delay their next injection and may therefore have reduced or no protection from pregnancy. In surveys, women may report that they are using contraception in the form of injectables when the time since they had their last injection (more than four months) would imply that they have reduced protection against the risk of pregnancy. We carried out two field studies in urban Malawi, and we record reported injectable contraceptive use while also asking the number of months since women received their last injection. We observe that 13.8 percent of women who report using injectables also report that they received their last injection more than four months ago, and 11 percent report that they received their last injection more than six months ago. Our analysis highlights the need for additional follow-up with women who report using injectables in surveys to confirm whether they are, in fact, using the method effectively.

Immune Responses in Oral Papillomavirus Clearance in the MmuPV1 Mouse Model

Human papillomavirus (HPV)-induced oropharyngeal cancer now exceeds HPV-induced cervical cancer, with a noticeable sex bias. Although it is well established that women have a more proficient immune system, it remains unclear whether immune control of oral papillomavirus infections differs between sexes. In the current study, we use genetically modified mice to target CCR2 and Stat1 pathways, with the aim of investigating the role of both innate and adaptive immune responses in clearing oral papillomavirus, using our established papillomavirus (MmuPV1) infection model. Persistent oral MmuPV1 infection was detected in Rag1ko mice with T and B cell deficiencies. Meanwhile, other tested mice were susceptible to MmuPV1 infections but were able to clear the virus. We found sex differences in key myeloid cells, including macrophages, neutrophils, and dendritic cells in the infected tongues of wild type and Stat1ko mice but these differences were not observed in CCR2ko mice. Intriguingly, we also observed a sex difference in anti-MmuPV1 E4 antibody levels, especially for two IgG isotypes: IgG2b and IgG3. However, we found comparable numbers of interferon-gamma-producing CD8 T cells stimulated by E6 and E7 in both sexes. These findings suggest that males and females may use different components of innate and adaptive immune responses to control papillomavirus infections in the MmuPV1 mouse model. The observed sex difference in immune responses, especially in myeloid cells including dendritic cell (DC) subsets, may have potential diagnostic and prognostic values for HPV-associated oropharyngeal cancer.

Preconception contraceptive use and miscarriage: prospective cohort study

Objectives

To evaluate the association between preconception contraceptive use and miscarriage.

Design

Prospective cohort study.

Setting

Residents of the United States of America or Canada, recruited from 2013 until the end of 2022.

Participants

13 460 female identified participants aged 21-45 years who were planning a pregnancy were included, of whom 8899 conceived. Participants reported data for contraceptive history, early pregnancy, miscarriage, and potential confounders during preconception and pregnancy.

Main outcome measure

Miscarriage, defined as pregnancy loss before 20 weeks of gestation.

Results

Preconception use of combined and progestin-only oral contraceptives, hormonal intrauterine devices, copper intrauterine devices, rings, implants, or natural methods was not associated with miscarriage compared with use of barrier methods. Participants who most recently used patch (incidence rate ratios 1.34 (95% confidence interval 0.81 to 2.21)) or injectable contraceptives (1.44 (0.99 to 2.12)) had higher rates of miscarriage compared with recent users of barrier methods, although results were imprecise due to the small numbers of participants who used patch and injectable contraceptives.

Conclusions

Use of most contraceptives before conception was not appreciably associated with miscarriage rate. Individuals who used patch and injectable contraceptives had higher rates of miscarriage relative to users of barrier methods, although these results were imprecise and residual confounding was possible.

P. Discovery of novel inhibitor of 11 beta-hydroxysteroid dehydrogenase type 1 using in silico structure-based screening approach for the treatment of type 2 diabetes

Purpose

The current study is aimed to perform structure-based screening of FDA-approved drugs that can act as novel inhibitor of the 11beta- hydroxysteroid dehydrogenase type 1 (11β-HSD1) enzyme.

Methods

Structural analogs of carbenoxolone (CBX) were selected from DrugBank database and their Absorption, Distribution, Metabolism, Excretion, and Toxicity (ADMET) parameters were investigated by SwissADME. Molecular docking of CBX analogs against 11β-HSD1 was performed by AutoDock tool, their binding patterns were visualized using PyMOL and the interacting amino acids were determined by ProteinPlus tool. Molecular dynamics simulation was performed on the docked structure of 11β-HSD1 (Protein Data Bank (PDB) code: 2ILT) using GROMACS 2018.1.

Results

The binding energies of hydrocortisone succinate, medroxyprogesterone acetate, testolactone, hydrocortisone cypionate, deoxycorticosterone acetate, and hydrocortisone probutate were lower than that of substrate corticosterone. The molecular dynamics simulation of 11β-HSD1 and hydrocortisone cypionate docked structure showed that it formed a stable complex with the inhibitor. The Root mean square deviation (RMSD) of the protein (0.37 ± 0.05 nm) and ligand (0.41 ± 0.06 nm) shows the stability of the ligand-protein interaction.

Conclusion

The docking study revealed that hydrocortisone cypionate has a higher binding affinity than carbenoxolone and its other analogs. The molecular dynamics simulation indicated the stability of the docked complex of 11β-HSD1 and hydrocortisone cypionate. These findings indicate the potential use of this FDA approved drug in the treatment of type 2 diabetes. However, validation by in vitro inhibitory studies and clinical trials on type 2 diabetes patients is essential to confirm the current findings.

Dogs for Life: Beagles, Drugs, and Capital in the Twentieth Century

This article tracks the transformation of beagle dogs from a common breed in mid-twentieth century American laboratories to the de jure standard in global toxicological research by the turn of the twenty-first. The breed was dispersed widely due to the expanding use of dogs in pharmacology in the 1950s and a worldwide crisis around pharmaceutical safety following the thalidomide scandal of the 1960s. Nevertheless, debates continued for decades over the beagle's value as a model of carcinogenicity, even as the dogs became legislated stand-ins for human beings in multiple countries. Situating beagles as a biocommodity, the article calls for more sustained attention to the "political economy" of laboratory organism breeding, use, and production. The story of American commercial breeder Marshall Farms offers insight into the role of for-profit companies in contemporary laboratory animal provision, as the article makes a case for the value of a global perspective on transnational corporations as key sites of scientific practice and collaboration.

"I feel empowered": women's perspectives on and experiences with long-acting injectable antiretroviral therapy in the USA and Spain

Long-acting injectable antiretroviral therapy has been shown to be non-inferior to daily oral antiretroviral therapy in clinical trials and may soon become part of clinical care. While most trial participants to date have been men, approximately one quarter of ongoing Phase 3 trial participants are women offering an important opportunity to understand how long-acting antiretroviral therapy is perceived and experienced by women. We conducted in-depth interviews with 80 people living with HIV participating in Phase 2 and 3 clinical trials of long-acting antiretroviral therapy in the USA and Spain. Fifteen percent (12/80) of trial participants interviewed were women. Interviews were audio-recorded, transcribed and coded using content analysis, focused on gender-specific themes. Women shared many of the positive perceptions expressed by men but also had unique perspectives, including finding that long-acting antiretroviral therapy addressed the challenge of remembering pills amidst busy day-to-day realities including multiple roles and responsibilities, is less time consuming and creates less stress compared to oral antiretroviral therapy, and is emotionally freeing and empowering. The gendered nature of women's lives shaped why and how they were satisfied with long-acting antiretroviral therapy. Findings can inform interventions and support systems to facilitate uptake of and adherence to long-acting antiretroviral therapy in women.

Reasons for rejecting hormonal contraception in Western countries: A systematic review

Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading "hormonophobia", i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

Delayed miscarriage inside an infected decidual cast: a rare complication of the Depo medroxyprogesterone acetate injection

Decidualisation of the endometrium is a progesterone-mediated reaction that naturally occurs during a woman's menstrual cycle. The hyperproliferated tissue is then usually dissolved and passed in a menstrual period. Occasionally, the natural dissolution does not happen, and the tissue maintains the shape of the endometrium, forming a decidual cast. These casts are known to be formed secondary to the use and/or cessation of various contraceptive methods. Here, we report a case of a patient presenting with passage of a decidual cast secondary to cessation of the Depo medroxyprogesterone acetate injection. This is the first reported case of the cast becoming infected, and also the first case of a decidual cast containing old products of conception.

A Qualitative Exploration of Women's Interest in Long-Acting Injectable Antiretroviral Therapy Across Six Cities in the Women's Interagency HIV Study: Intersections with Current and Past Injectable Medication and Substance Use

Medications for antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) are currently daily pill regimens, which pose barriers to long-term adherence. Long-acting injectable (LAI) modalities have been developed for ART and PrEP, but minimal LAI-focused research has occurred among women. Thus, little is known about how women's history of injection for medical or nonmedical purposes may influence their interest in LAI. We conducted 89 in-depth interviews at 6 sites (New York, NY; Chicago, IL; San Francisco, CA; Atlanta, GA; Chapel Hill, NC; Washington, DC) of the Women's Interagency HIV study. Interviews occurred with women living with HIV (n = 59) and HIV-negative women (n = 30) from November 2017 to October 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Women's prior experiences with injections occurred primarily through substance use, physical comorbidities, birth control, or flu vaccines. Four primary categories of women emerged; those who (1) received episodic injections and had few LAI-related concerns; (2) required frequent injections and would refuse additional injections; (3) had a history of injection drug use, of whom some feared LAI might trigger a recurrence, while others had few LAI-related concerns; and (4) were currently injecting drugs and had few LAI-related concerns. Most women with a history of injectable medication would prefer LAI, but those with other frequent injections and history of injection drug use might not. Future research needs to address injection-related concerns, and develop patient-centered approaches to help providers best identify which women could benefit from LAI use.

Cabotegravir and rilpivirine for the treatment of HIV

Introduction: Antiretroviral treatment (ART) has led to improved control of HIV infection, giving the opportunity of exploring therapeutic alternatives as new long-acting (LA) regimens, that might improve the quality of life of people living with HIV (PLWH).Areas covered: This article overviews the pharmacokinetic and pharmacodynamic properties of LA cabotegravir and rilpivirine (CR), two nanoformulated drugs of intramuscular administration and focuses on assessing its role on the treatment of HIV infection.Expert opinion: In addition to the advantage of treatment simplification, which could be especially beneficial for population subgroups with significant HIV-related stigma, it also reduces the number of drugs, and probably, the risk of treatment-related toxicity. The similar efficacy when compared to oral triple therapies in clinical trials and the high satisfaction rates among both professionals and patients make LA CR a suitable alternative for the control of HIV infection in the modern era.

Medroxyprogesterone Acetate in Gender-Affirming Therapy for Transwomen: Results From a Retrospective Study

CONTEXT

Medroxyprogesterone acetate (MPA) is a widely used progestin in feminizing hormone therapy. However, the side effects and hormonal changes elicited by this drug have never been investigated in the transgender population.

OBJECTIVE

We evaluated the incidence of self-reported effects among transwomen using MPA and this drug's impact on hormonal and metabolic parameters.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively collected data from 290 follow-up visits (FUVs) of transwomen treated at Rhode Island Hospital from January 2011 to July 2018 (mean duration of therapy 3.4 ± 1.7 years). FUVs followed regimens of estradiol (E) and spironolactone, with MPA (n = 102) or without MPA (n = 188).

MAIN OUTCOME MEASURES

We assessed the incidence of self-reported effects after MPA treatment. We also compared blood levels of E, testosterone, and various laboratory parameters between MPA and non-MPA groups.

RESULTS

Mean weighted E level was 211 ± 57 pg/mL after MPA treatment and 210 ± 31 pg/mL otherwise; this difference was nonsignificant [t(274) = 0.143, P = 0.886]. Mean weighted testosterone level was 79 ± 18 ng/dL after MPA treatment and 215 ± 29 ng/dL otherwise; testosterone levels were significantly lower in the MPA group [t(122) = 32.4, P < 0.001]. There were minimal changes in other laboratory parameters. Of 39 patients receiving MPA, 26 reported improved breast development and 11 reported decreased facial hair. Five patients experienced mood swings on MPA.

CONCLUSIONS

In our cohort of transwomen, we found minimal side effects, unchanged E levels, and a decline in testosterone associated with MPA, outcomes consistent with feminization. Prospective studies are needed to confirm our findings.

Towards a dapivirine and levonorgestrel multipurpose vaginal ring: Investigations into the reaction between levonorgestrel and addition-cure silicone elastomers

With a dapivirine-releasing vaginal ring having successfully completed late-stage clinical testing for HIV prevention and currently undergoing regulatory review, there is now growing interest in next-generation multipurpose prevention technologies that seek to combine antiretroviral and contraceptive drugs within a single product. Here, we focus on ongoing efforts to develop a silicone elastomer vaginal ring releasing both dapivirine and levonorgestrel. Specifically, we evaluate various strategies aimed at both better understanding and reducing the tendency of levonorgestrel to bind with the elastomer, including: (i) formulation and post-manufacturing strategies aimed at reducing the extent of levonorgestrel reaction with addition-cure silicone elastomers; (ii) evaluation of a simple silicone system to model the complex elastomer; (iii) use of model compounds representing the enone and ethinyl moieties of levonorgestrel to probe the mode of addition of levonorgestrel to addition-cure silicone elastomers; and (iv) solution and solid-state ¹³C NMR analysis to probe the structural features of the levonorgestrel-silicone system. The results demonstrate that both the enone and ethinyl groups within levonorgestrel undergo hydrosilylation reactions with the hydrosiloxane groups in the silicone elastomer leading to covalent binding. The results also highlight potential strategies for further optimising the dapivirine + levonorgestrel silicone vaginal ring formulation to ensure that the levonorgestrel is available for release.

Long-Acting Injectable Statins-Is It Time for a Paradigm Shift?

In recent years, advances in pharmaceutical processing technologies have resulted in development of medicines that provide therapeutic pharmacokinetic exposure for a period ranging from weeks to months following a single parenteral administration. Benefits for adherence, dose and patient satisfaction have been witnessed across a range of indications from contraception to schizophrenia, with a range of long-acting medicines also in development for infectious diseases such as HIV. Existing drugs that have successfully been formulated as long-acting injectable formulations have long pharmacokinetic half-lives, low target plasma exposures, and low aqueous solubility. Of the statins that are clinically used currently, atorvastatin, rosuvastatin, and pitavastatin may have compatibility with this approach. The case for development of long-acting injectable statins is set out within this manuscript for this important class of life-saving drugs. An overview of some of the potential development and implementation challenges is also presented.

[Effectiveness and use of hormonal contraceptives (except for intrauterine devices): CNGOF Contraception Guidelines]

Hormonal contraceptives remain among the most popular methods used by women. The purpose of this work is to review the effectiveness and use of these different methods. In addition, some side-effects are feared and/or frequently reported by users of hormonal contraceptives: unscheduled bleeding, acne, catamenial migraines, weight gain, libido and/or mood disorders. In this review of the literature, the accountability of hormonal contraceptives for the occurrence of some of these side-effects was discussed and a management strategy was proposed.

Esters of levonorgestrel and etonogestrel intended as single, subcutaneous-injection, long-lasting contraceptives

An effort with the goal of discovering single-dose, long-lasting (>6 months) injectable contraceptives began using levonorgestrel (LNG)-17-β esters linked to a sulfonamide function purposed as human carbonic anhydrase II (hCA 2) ligands. One single analog from this first series showed noticeably superior anti-ovulatory activity in murine models, and a subsequent structure-activity relationship (SAR, the relationship between a compound's molecular structure and its biological activity) study based on this compound identified a LNG-phenoxyacetic acid ester analog exhibiting longer anti-ovulatory properties using the murine model at 2 and 4 mg dose than medroxyprogesterone acetate (MPA). The same ester function linked to etonogestrel (ENG) furnished a compound which inhibited ovulation at 2 mg for 60 days, the longest duration of all compounds tested at these doses. By comparison, MPA at the same dose inhibited ovulation for 32 days.

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).

Contraceptive knowledge, attitudes, and use among adolescent mothers in the Cook Islands

BACKGROUND

While the adverse health outcomes and broader economic and social factors associated with adolescent motherhood are well documented globally, limited research on unplanned pregnancy and birth among young women in Pacific Island nations exists. The study addresses this gap in the literature by examining the social and contextual factors that inform contraceptive knowledge, attitudes, and use among young women in the Cook Islands.

METHODS

Individual, in-depth interviews were conducted with ten women who became mothers before age twenty. Adolescents' contraceptive knowledge, attitudes, and behaviours were examined while taking into account the context in which they experienced an unplanned birth.

FINDINGS

Five participants were not using a contraceptive method when they became pregnant, believing they would not become pregnant. The remaining participants were using oral contraception but doing so inconsistently. Four participants had a sexual debut prior to age 15. The findings suggest a need to expand comprehensive approaches to sexual and reproductive health education, increase access to long-acting reversible contraceptive methods, and decrease the stigma associated with accessing family planning services in order to more effectively prevent unplanned pregnancy among adolescents in the Cook Islands.

INTERPRETATION

The findings provide insight into the factors contributing to high rates of adolescent pregnancy and birth in the Pacific region and suggest how public health advocates and health care providers might reduce reproductive health disparities in the Cook Islands and similar Pacific Island nations.

Binge eating and biochemical markers of appetite in new users of the contraceptive depot medroxyprogesterone acetate

PURPOSE

Weight gain has been cited by women as one of the main reasons for discontinuation of the contraceptive depot medroxyprogesterone acetate (DMPA). This study aimed to evaluate binge eating and the biochemical markers of appetite in new DMPA users.

METHODS

In this prospective non randomized study with adult healthy women, twenty-eight users of DMPA and twenty-five users of a copper intrauterine device (IUD) were paired for age (±1 year) and body mass index (BMI) (±1 kg/m²). We evaluated binge eating using the Binge Eating Scale (BES), the serum levels of neuropeptide Y, leptin and adiponectin, and the BMI at baseline and after 12 months in both groups. For statistical analysis was used ANOVA for to compare the means of the repeated measurements.

RESULTS

Mean age was 29.6 and 28.6 years and BMI was 23.9 and 24.5 kg/m² for the DMPA and IUD groups, respectively. After 12 months, the frequency of the scores of binge eating remained low in both groups. There were no significant differences between the groups at 12 months with respect to BMI, levels of NPY, leptin, adiponectin, and BES scores.

CONCLUSIONS

Healthy adult women did not present with central stimulation of appetite or binge eating disorder in their first year after starting use of DMPA. This study reinforces the use of the contraceptive DPMA and the need for guidance related to living a healthy lifestyle for women who attribute the increase of body weight to the use of the method.

Depo-Provera (depot medroxyprogesterone acetate) use after bariatric surgery

In the US, obesity rates are increasing greatly. The Centers for Disease Control and Prevention estimates that 68.5% of Americans, including 63.9% of adult women older than 20 years, are overweight (body mass index between 25 kg/m² and 29.9 kg/m²) or obese (body mass index >30 kg/m²). In light of this, it is not surprising that the rates of bariatric surgery have also been increasing. When considering the metabolic changes associated with both bariatric surgery and contraceptive use, in combination with the unique medical considerations of obese women, it is indisputable that clear guidelines are needed when counseling obese patients of reproductive age after bariatric surgery. In this literature review, we focus on depot medroxyprogesterone acetate (DMPA) and the implications of its use in obese women, preweight and postweight loss following bariatric surgery. Both DMPA use and bariatric surgery are known to cause bone loss, but it is still unclear whether there is an additive effect of the two factors on bone loss and whether either of these factors directly leads to an increased risk of bone fracture. The current consensus guidelines do not impose a restriction on the use of DMPA after bariatric surgery. DMPA use is associated with weight gain, and it is unclear whether weight loss blunting occurs with the use of DMPA after bariatric surgery. Prior studies had demonstrated an association with weight gain in adolescents, and therefore, those prescribing DMPA use after bariatric surgery in adolescents should proceed with caution. Adult women do not have a similar response to the use of DMPA. DMPA use has rarely been associated with increased risk of venous thromboembolism (VTE). The obesity-associated increase in VTE should be mitigated by surgically induced weight loss. The concurrent use of DMPA in the post bariatric surgical period should not further increase the risk of VTE.

Scale-up from batch to flow-through wet milling process for injectable depot formulation

Injectable depot formulations are aimed at providing long-term sustained release of a drug into systemic circulation, thus reducing plasma level fluctuations and improving patient compliance. The particle size distribution of the formulation in the form of suspension is a key parameter that controls the release rate. In this work, the process of wet stirred media milling (ball milling) of a poorly water-soluble substance has been investigated with two main aims: (i) to determine the parametric sensitivity of milling kinetics; and (ii) to develop scale-up methodology for process transfer from batch to flow-through arrangement. Ball milling experiments were performed in two types of ball mills, a batch mill with a 30ml maximum working volume, and a flow-through mill with a 250ml maximum working volume. Milling parameters were investigated in detail by methodologies of QbD to map the parametric space. Specifically, the effects of ball size, ball fill level, and rpm on the particle breakage kinetics were systematically investigated at both mills, with an additional parameter (flow-rate) in the case of the flow-through mill. The breakage rate was found to follow power-law kinetics with respect to dimensionless time, with an asymptotic d₅₀ particle size in the range of 200-300nm. In the case of the flow-through mill, the number of theoretical passes through the mill was found to be an important scale-up parameter.

Self-administration of injectable contraceptives: a systematic review

Background

The contraceptive injectable is a safe and effective method that is used worldwide. With the variety of injectable delivery systems, there is potential for administration by the woman herself. Self‐administration of the contraceptive injectable is the subject of this systematic review.

Objectives

To assess how effective and safe the contraceptive injectable method is when women themselves perform/administer it, compared with when the usual healthcare providers administer it.

Search strategy

We searched PubMed, Popline, Cochrane, CINAHL, and Embase for articles with subject headings or text words related to ‘self‐administration’ and ‘contraception’.

Selection criteria

Studies that compared the administration of the contraceptive injectable by the woman herself versus administration by the healthcare provider were included. Outcomes of interest were continuation rates, safety, and the women's overall satisfaction with the contraceptive provider and method.

Data collection and analysis

We undertook data extraction, descriptive analysis, and assessment of risk of bias.

Main results

Three studies met the inclusion criteria. The best available evidence shows that there may be little or no difference in continuation rates when women self‐administer contraceptive injections (326 per 1000 women; 95% CI 192–554 per 1000 women) compared with administration by healthcare providers (304 per 1000 women). Safety was not estimable as no serious adverse events were reported in any of the studies. With regards to overall satisfaction towards the provider and the method, the effect of the intervention was uncertain.

Authors’ conclusions

Findings suggest that with appropriate information and training the provision of contraceptive injectables for the woman to self‐administer at home can be an option in some contexts.

Tweetable abstract

This review assessed the continuation rates and safety of self‐administration of the contraceptive injection.

This review assessed the continuation rates and safety of self‐administration of the contraceptive injection.

Strengths, weaknesses, opportunities and challenges for long acting injectable therapies: Insights for applications in HIV therapy

Advances in solid drug nanoparticle technologies have resulted in a number of long-acting (LA) formulations with the potential for once monthly or longer administration. Such formulations offer great utility for chronic diseases, particularly when a lack of medication compliance may be detrimental to treatment response. Two such formulations are in clinical development for HIV but the concept of LA delivery has its origins in indications such as schizophrenia and contraception. Many terms have been utilised to describe the LA approach and standardisation would be beneficial. Ultimately, definitions will depend upon specific indications and routes of delivery, but for HIV we propose benchmarks that reflect perceived clinical benefits and available data on patient attitudes. Specifically, we propose dosing intervals of ≥1week, ≥1month or ≥6months, for oral, injectable or implantable strategies, respectively. This review focuses upon the critical importance of potency in achieving the LA outcome for injectable formulations and explores established and emerging technologies that have been employed across indications. Key technological challenges such as the need for consistency and ease of administration for drug combinations, are also discussed. Finally, the review explores the gaps in knowledge regarding the pharmacology of drug release from particulate-based LA injectable suspensions. A number of hypotheses are discussed based upon available data relating to local drug metabolism, active transport systems, the lymphatics, macrophages and patient-specific factors. Greater knowledge of the mechanisms that underpin drug release and protracted exposure will help facilitate further development of this strategy to achieve the promising clinical benefits.

Injectable agents for pre-exposure prophylaxis: lessons learned from contraception to inform HIV prevention

PURPOSE OF REVIEW

Long-acting injectable (LAI) forms of preexposure prophylaxis (PrEP) are in clinical trials, generating much hope for HIV prevention. But this is not the first time that an injectable form of preventive medication has emerged: the contraceptive agent depomedroxyprogesterone acetate (DMPA) has an important precedent. DMPA's long journey, its initial reception, and ongoing implementation challenges can help inform the field of HIV prevention as we plan for approval, acceptance, and scale-up of LAI-PrEP.

RECENT FINDINGS

DMPA faced a long regulatory journey in the USA, with a lag of 25 years from initial application (1967) to approval (1992). Acceptance after introduction was rapid, but challenges hampered scale-up. Specific lessons learned include that extensive acceptability work is needed in parallel to product development. Also, low continuation rates, challenges with timing of initiation, and difficulty ensuring access for the most vulnerable populations have limited DMPA's impact. A new subcutaneous formulation presents opportunities for administration outside of clinical settings and for self-administration.

SUMMARY

Those involved in LAI-PrEP development and those who plan to be involved in its future implementation must consider these lessons and possible solutions from DMPA to ensure a successful future for this new HIV prevention modality.

The safety of subcutaneously administered depot medroxyprogesterone acetate (104mg/0.65mL): A systematic review

CONTEXT

Depot medroxyprogesterone acetate (DMPA), a progestogen-only contraceptive injectable, has traditionally been formulated as a crystalline suspension delivered intramuscularly (IM) at a dose of 150mg/1.0mL. A new, lower dose formulation of DMPA (104mg/0.65mL) has been developed for subcutaneous administration (SC). Given its increasing global availability and public health relevance, DMPA-SC was prioritized for inclusion as a new method referenced in the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC), 5th Edition.

OBJECTIVE

This systematic review evaluated the published peer-reviewed literature regarding the safety of DMPA-SC among women with various characteristics or medical conditions. Results of this review informed the decision-making of a WHO Guideline Development Group in order to include recommendations on contraceptive eligibility within the revised MEC.

METHODS

We searched PubMed and Cochrane Library databases to identify all relevant evidence published in peer-reviewed journals regarding the safety of DMPA-SC when used by women of reproductive age, particularly those with select characteristics or conditions specified in the MEC, from inception through June 2015. The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force.

RESULTS

Fourteen studies met criteria for inclusion. Ten reported results relevant to DMPA users of varying age or with obesity, endometriosis or HIV; four compared the safety of DMPA-SC and DMPA-IM when used by general populations of healthy women. A randomized trial evaluating changes in bone mineral density among adult DMPA-SC and DMPA-IM users demonstrated no differences at 2years of follow-up. Limited evidence reported no consistent differences in weight change or bleeding patterns according to age; however, adolescents (<18years) were not included in any studies. Similar contraceptive efficacy, weight change, bleeding patterns and occurrence of other adverse effects among obese and nonobese DMPA-SC users were observed. Women with endometriosis using DMPA-SC over 6months had minimal decreases in bone mineral density, weight gain, few serious adverse events and experienced improved pain symptoms. Women living with HIV tolerated injection of DMPA-SC with rare complications. DMPA-SC and DMPA-IM also show therapeutic equivalence and similar effects on weight gain, changes in bleeding patterns and reports of other adverse effects when these different delivery systems were used by general populations of women.

CONCLUSION

Evidence for use of DMPA-SC by women with select conditions and characteristics including age, obesity, endometriosis or HIV demonstrates that this method can generally be used safely in these contexts. Further, DMPA-SC and DMPA-IM appear to be therapeutically equivalent with similar safety profiles when used by healthy women.

Drug delivery strategies and systems for HIV/AIDS pre-exposure prophylaxis and treatment

The year 2016 will mark an important milestone - the 35th anniversary of the first reported cases of HIV/AIDS. Antiretroviral Therapy (ART) including Highly Active Antiretroviral Therapy (HAART) drug regimens is widely considered to be one of the greatest achievements in therapeutic drug research having transformed HIV infection into a chronically managed disease. Unfortunately, the lack of widespread preventive measures and the inability to eradicate HIV from infected cells highlight the significant challenges remaining today. Moving forward there are at least three high priority goals for anti-HIV drug delivery (DD) research: (1) to prevent new HIV infections from occurring, (2) to facilitate a functional cure, i.e., when HIV is present but the body controls it without drugs and (3) to eradicate established infection. Pre-exposure Prophylaxis (PrEP) represents a significant step forward in preventing the establishment of chronic HIV infection. However, the ultimate success of PrEP will depend on achieving sustained antiretroviral (ARV) tissue concentrations and will require strict patient adherence to the regimen. While first generation long acting/extended release (LA/ER) DD Systems (DDS) currently in development show considerable promise, significant DD treatment and prevention challenges persist. First, there is a critical need to improve cell specificity through targeting in order to selectively achieve efficacious drug concentrations in HIV reservoir sites to control/eradicate HIV as well as mitigate systemic side effects. In addition, approaches for reducing cellular efflux and metabolism of ARV drugs to prolong effective concentrations in target cells need to be developed. Finally, given the current understanding of HIV pathogenesis, next generation anti-HIV DDS need to address selective DD to the gut mucosa and lymph nodes. The current review focuses on the DDS technologies, critical challenges, opportunities, strategies, and approaches by which novel delivery systems will help iterate towards prevention, functional cure and eventually the eradication of HIV infection.

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

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

Long-acting injectable antiretrovirals for HIV treatment and prevention

PURPOSE OF REVIEW

Long-acting antiretroviral (ARV) drugs may improve adherence to therapy and extend opportunities for therapeutic or prophylactic intervention to underserved patient populations. This review focuses on recent advances in the development of small molecule long-acting injectable ARV agents.

RECENT FINDINGS

The need for combination ART and physicochemical and dosing limitations of current ARV drugs impede attempts to redevelop them as long-acting injectable formulations. However, the intrinsic properties of rilpivirine, a nonnucleoside reverse transcriptase inhibitor, and GSK1265744, an HIV-1 integrase strand transfer inhibitor, have enabled crystalline nanoparticle formulations to progress to clinical trials.

SUMMARY

Investigational long-acting injectable nanoformulations of rilpivirine and GSK1265744 are clinical-stage development candidates. Complementary pharmacologic properties of both agents - different mechanisms of action, resistance profiles, metabolic pathways, lack of drug interactions and low daily oral doses - offer the potential for combination use. Phase I studies of the pharmacokinetics and safety of each long-acting formulation alone and in combination indicate that a monthly dosing regimen is possible for HIV treatment. An ongoing phase IIb trial of oral GSK1265744 and oral rilpivirine is evaluating this two-drug regimen for maintenance of virologic suppression; results will inform future studies using the injectable formulations. Additional preclinical and clinical studies indicate a potential use of each agent for HIV pre-exposure prophylaxis.

Medroxyprogesterone acetate and estradiol cypionate injectable suspension (Cyclofem) monthly contraceptive injection: steady-state pharmacokinetics

BACKGROUND

Cyclofem is a combined injectable contraceptive, containing medroxyprogesterone acetate (MPA) and estradiol cypionate. The objective was to characterize the steady-state pharmacokinetics (PK) using tandem liquid chromatography/mass spectrometry and compare these data to a previous PK study of this formulation in US women.

STUDY DESIGN

Fifteen ovulatory, surgically sterile women received three Cyclofem injections, once every 28 days, with serum PK measurements on 23 separate days. Trough levels of estradiol and MPA were obtained on Days 1, 29 and 57, prior to each of the three injections. Steady-state concentrations of MPA and estradiol were assessed during the third treatment month on Days 58, 60, 62, 64, 67, 69, 71, 75, 78 and 85. MPA and serum progesterone levels were measured during the follow-up phase to assess MPA clearance (Days 92, 99, 106, 113, 120, 127, 134 and 141) and return of ovulation (Days 103, 106, 131 and 134).

RESULTS

In the steady state, mean serum MPA concentrations peaked at 1.31 ng/mL at 4.1 days. Mean estradiol levels peaked at 254 pg/mL by 3.3 days. Ovulation was suppressed for at least 77 days post third injection in all but one woman.

CONCLUSIONS

Once monthly injections of Cyclofem resulted in contraceptive levels of MPA without accumulation of hormones, consistent with a previous US study.

Initiation of progestogen-only injectables on different days of the menstrual cycle and its effect on contraceptive effectiveness and compliance: a systematic review

BACKGROUND

Initiation of contraceptive progestogen-only injections conventionally require that women delay starting them until menses begin, during which time interval a woman may be at risk of unintended pregnancy. Our objective was to determine from the literature when a woman can initiate progestogen-only injectables for contraception.

STUDY DESIGN

We searched MEDLINE and Cochrane databases for all articles (in all languages) published in peer-reviewed journals between database inception to February 2012, for evidence relevant to starting injectables on different days of the menstrual cycle and its impact upon contraceptive effectiveness or those that examined different strategies for initiation and their effects on compliance and continuation.

RESULTS

Eight articles met our criteria for inclusion. All studies examined initiation of depot medroxyprogesterone (DMPA); no studies of norethisterone enantate were identified. Three articles, reported that when DMPA was initiated later than Cycle Day 7, ovulation occurred in some women. Approximately 90% of women had poor quality cervical mucus within 24 h after they received an injection. Five studies of compliance and continuation demonstrated that the use of another contraceptive method as a "bridging option" was not successful in helping women initiate DMPA. When DMPA was given throughout the menstrual cycle, more women were eligible to receive their first injection but only about half returned on time for their subsequent injection and some pregnancies occurred.

CONCLUSION

Ovulation is rare when DMPA is provided within the first 7 days of the menstrual cycle. Use of another contraceptive as a "bridging option" until DMPA can be initiated has been unsuccessful in helping women initiate DMPA and is associated with higher rates of pregnancy.

Associations between recent contraceptive use and quality of life among women

BACKGROUND

Whether contraception affects health-related quality of life (HRQoL) is unclear.

STUDY DESIGN

We conducted a cross-sectional analysis of routine intake data collected from women aged 18-50 years, including the RAND-36 (Research and Development Corporation) measure of HRQoL, pregnancy intentions and recent contraceptive use. We used multivariable logistic regression to test the relationship between HRQoL and use of any and specific contraceptives. Physical and mental HRQoLs were dichotomized based on US population averages. Models were adjusted for age, race, marital status, education and pregnancy intentions.

RESULTS

Among the 726 women, those using any form of contraception were more likely to have average or better mental HRQoL than women using no contraception [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI) 1.01-2.53]. Women using injectable contraception were less likely than those using combined hormonal methods to have average or better physical HRQoL (aOR=0.26, 95% CI 0.09-0.80) and mental HRQoL (aOR=0.24, 95% CI 0.06-0.86).

CONCLUSIONS

Measures of women's HRQoL differ with contraceptive use.

Depot-medroxyprogesterone acetate contraception use among Salvadoran women: an in-depth analysis of attitudes and experiences

OBJECTIVE

To survey a cross-section of reproductive-age Salvadoran women in order to assess the factors that influence their decision to use depot-medroxyprogesterone acetate (DMPA), an injectable form of contraception.

METHODS

Reproductive-age women at three rural Salvadoran health clinics were asked to participate in a study to assess their current and past experiences using DMPA contraception. Verbal informed consent was obtained, and research coordinators administered a 23-question survey.

RESULTS

Surveys were completed in 425 women with an average age of 27.36 years. Average duration of DMPA contraception use was 2.89 years. The majority (84%) of past and present users were very satisfied with DMPA contraception, most commonly because they did not have to remember to use it daily (44.9%). The side effects of DMPA appear to be a significant indicator of whether women heard about and wanted to use other forms of long-term reversible contraception, such as an intrauterine device (IUD) or implant.

CONCLUSIONS

The main reason Salvadoran women chose to use DMPA is because they do not have to think about it on a daily basis. However, many women do not like the side effects and may be open to explore using other long-term reversible methods of contraception, such as IUDs or implants. It is possible that with increased access to educational information about IUD use, safety, and effectiveness, more women would use this form of long-term contraception as opposed to sterilization.

Steroidal contraceptives: effect on bone fractures in women

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

To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women

SEARCH STRATEGY

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 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 in women with hormonal contraceptive use prior to menopause. Interventions could include comparing a hormonal contraceptive with a placebo or another hormonal contraceptive or could compare providing a supplement versus a placebo.

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 different interventions, no trials could be combined for meta-analysis.

MAIN RESULTS

Of the 16 RCTs we found, 2 used a placebo and 1 used a non-hormonal method as the comparison, while 13 compared two hormonal contraceptives. No trial had fracture as an outcome. Most measured BMD and several assessed bone turnover. Depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density. The placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo. Combination contraceptives did not appear to negatively affect bone health, but none were placebo-controlled. For implants, the single-rod etonogestrel group showed a greater BMD decrease versus the two-rod levonorgestrel group. However, results were not consistent across all implant comparisons.

AUTHORS' CONCLUSIONS

Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Many trials had small numbers of participants and some had large losses to follow up. 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.

Molecular mechanisms of steroid receptor-mediated actions by synthetic progestins used in HRT and contraception

Synthetic progestins are used by millions of women as contraceptives and in hormone replacement therapy (HRT), although their molecular mechanisms of action are not well understood. The importance of investigating these mechanisms, as compared to those of progesterone, has been highlighted by clinical evidence showing that medroxyprogesterone acetate (MPA), a first generation progestin, increases the risk of breast cancer and coronary heart disease in HRT users. A diverse range of later generation progestins with varying structures and pharmacological properties is available for therapeutic use and it is becoming clear that different progestins elicit beneficial and adverse effects to different extents. These differences in biological activity are likely to be due to many factors including variations in dose, metabolism, pharmacokinetics, bioavailability, and regulation of, and/or binding, to serum-binding proteins and steroidogenic enzymes. Since the intracellular effects on gene expression and cell signaling of steroids are mediated via intracellular steroid receptors, differential actions via the progesterone and other steroid receptors and their isoforms, are likely to be the major cause of differential intracellular actions of progestins. Since many progestins bind not only to the progesterone receptor, but also to the glucocorticoid, androgen, mineralocorticoid, and possibly the estrogen receptors, it is plausible that synthetic progestins exert therapeutic actions as well as side-effects via some of these receptors. Here we review the molecular mechanisms of intracellular actions of old (MPA, norethisterone, levonorgestrel, gestodene) vs. new (drospirenone, dienogest, trimegestone) generation progestins, via steroid receptors.

Gynecologic care in hematopoietic stem cell transplant patients: a review

Over 4500 hematopoietic stem cell transplants (HSCT) are performed on patients in the United States each year. As HSCT patients shift their survivorship care from large transplant centers to community health care providers, many gynecologists are assuming their pre- and post-HSCT gynecologic care. This article reviews recommendations, current research, and expert opinions on the gynecologic care of HSCT patients.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completing this educational activity, the physician should be better able to implement strategies for the prevention and management of menstrual bleeding during hematopoietic stem cell transplants; educate female patients regarding Fertility Preservation options before hematopoietic stem cell transplantation; and apply posthematopoietic stem cell transplant reproductive care screening and treatment recommendations for bone health, sexual health, and secondary cancer development.

Transvaginal Doppler sonography for evaluation of irregular uterine bleeding with DMPA

BACKGROUND

The main cause for discontinuation of depot medroxyprogesterone acetate (DMPA) use is irregular menstrual bleeding. The exact pathophysiological mechanisms of irregular bleeding have remained unclear. Transvaginal Doppler is a non-invasive method for studying changes in blood flow which may highlight the underlying pathology in those cases with irregular uterine bleeding. The aim of this study was to quantify the uterine and subendometrial microvasculature in DMPA users with irregular bleeding pattern in comparison to DMPA users with amenorrhea.

STUDY DESIGN

This is a case control study. Forty users of DMPA were divided into two groups: one group included 20 users with irregular uterine bleeding and the second group included 20 amenorrheic users. Pulsatility index (PI) and resistance index (RI) of uterine and subendometrial blood vessels were determined. Power Doppler Energy was used to quantify the signal percentage of the subendometrial area.

RESULTS

There is significant reduction of PI and RI in the uterine artery and subendometrial microvasculature in cases of irregular uterine bleeding.

CONCLUSION

Irregular uterine bleeding with DMPA associated with increased perfusion of uterine and subendometrial blood vessels.

Bone mineral density in women of a low socioeconomic level using DMPA for contraception in rural Upper Egypt

OBJECTIVE

To evaluate the effect of long-term use of depot medroxyprogesterone acetate (DMPA) on bone mineral density (BMD).

METHODS

A cross-sectional study was performed with 150 women using DMPA and 136 women using nonhormonal methods of contraception in rural Sohag Governorate, Upper Egypt. Socioeconomic scores were measured using the 1983 Fahmy and El Sherbeny system, model II. The mineral density of the left calcaneus was measured by ultrasonographically.

RESULTS

If the overall mean T score was significantly lower for the DMPA than for the control group, osteopenia and osteoporosis were more prevalent among DMPA users only for participants of the lowest socioeconomic level. There was a mild negative correlation between duration of DMPA use and T score, and when contraception duration was considered the differences in T scores between the DMPA and control groups were significant.

CONCLUSION

Prescribing DMPA only for the short term to women of a low socioeconomic level and counseling them about its effect on bone density may be a practical approach.

Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections

BACKGROUND

Depot medroxyprogesterone acetate (DMPA) is a highly effective progestin-only contraceptive that is widely used by adolescents. We investigated bone mineral density (BMD) changes in female adolescents during and following use of this method.

STUDY DESIGN

A multicenter, prospective, non-randomized observational study in 98 healthy female adolescents aged 12-18 years who initiated DMPA intramuscular injections for contraception and provided BMD data for up to 240 weeks while receiving DMPA and for up to 300 weeks after DMPA cessation. BMD at the lumbar spine (LS), total hip (TH) and femoral neck (FN) was assessed by dual-energy X-ray absorptiometry. A mixed model analysis of variance was used to examine BMD changes.

RESULTS

At the time of their final DMPA injection, participants had mean BMD declines from baseline of 2.7% (LS), 4.1% (TH) and 3.9% (FN) (p<.001 at all three sites). Within 60 weeks of discontinuation of DMPA, mean LS BMD had returned to baseline levels, and 240 weeks after DMPA discontinuation, the mean LS BMD was 4.7% above baseline. Mean TH and FN BMD values recovered to baseline values more slowly: 240 weeks and 180 weeks, respectively, after the last DMPA injection.

CONCLUSIONS

BMD loss in female adolescents receiving DMPA for contraception is substantially or fully reversible in most girls following discontinuation of DMPA, with faster recovery at the LS than at the hip.