Physical findings and symptoms of depot medroxyprogesterone acetate use in adolescent females

Why Didn't You Text Me? Poststudy Trends From the DepoText Trial

OBJECTIVE

To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT).

STUDY DESIGN

Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention.

RESULTS

Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015).

CONCLUSION

Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.

The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial

BACKGROUND

Depot medroxyprogesterone acetate (DMPA) is the most commonly used hormonal contraceptive method in South Africa. It is frequently administered in the immediate postnatal period, yet it is unclear whether it affects the risk of postnatal depression (PND).

AIM

To determine whether DMPA increases the risk of PND compared with the copper-containing intrauterine device (IUD) when administered after delivery.

DESIGN AND SETTING

A single-blind randomised controlled trial conducted at two teaching hospitals in East London, South Africa.

METHODS

Eligible, consenting women (N=242) requiring postnatal contraception were randomised to receive DMPA or an IUD within 48 hours of childbirth and interviewed at 1 and 3 months postpartum. Depression was measured using the Beck Depression Inventory (BDI-II) and the Edinburgh Postnatal Depression Scale (EPDS). Resumption of sexual intercourse, menstrual symptoms and breastfeeding rates were also assessed.

RESULTS

One-month EPDS depression scores were statistically significantly higher in the DMPA arm compared with IUD arm (p=0.04). Three-month BDI-II scores were significantly higher in the DMPA arm than in the IUD arm (p=0.002) and, according to the BDI-II but not the EPDS, more women in the DMPA arm had major depression at this time-point (8 vs 2; p=0.05). There were no statistically significant differences in other outcome measures except that fewer women had resumed sexual activity by 1 month postpartum in the DMPA arm (13% vs 26%; p=0.02).

CONCLUSIONS

The possibility that immediate postnatal DMPA use is associated with depression cannot be excluded. These findings justify further research with longer follow-up.

CLINICAL TRIAL NUMBER

PACTR201209000419241.

Dietary Intake and Weight Gain Among Adolescents on Depot Medroxyprogesterone Acetate

STUDY OBJECTIVE

To examine the relationship between dietary intake and weight gain among adolescent females initiating depot medroxyprogesterone acetate (DMPA).

DESIGN

Prospective observational study.

SETTING

Two urban Adolescent Medicine clinics.

PARTICIPANTS

45 postmenarchal females, age 12 to 21, enrolled after self-selecting to initiate DMPA.

INTERVENTION

Participants received 150 mg DMPA intramuscularly every 12 weeks. Height, weight, and 24-hour dietary recall were collected at baseline, 3, 6, and 12 months.

MAIN OUTCOME MEASURE

Body mass index (BMI) over time calculated as weight (kg)/height (m(2)). Associations between dietary variables and BMI were evaluated with repeated measures analysis of variance modeling.

RESULTS

Mean chronological and gynecologic ages were 16.2 ± 1.5 and 4.2 ± 1.8 years, respectively. Mean BMI increased from 23.7 ± 5.3 to 25.3 ± 5.7 over 12 months. Average dietary intake included: 1781.4 ± 554.1 total kilocalories, 228.5 g ± 69.8 carbohydrates, 71.0 g ± 27.3 fat, and 61.0 g ± 20.2 protein. These diet measures were not associated with BMI over time. Dietary fiber, magnesium, and linoleic acid were inversely associated with increased BMI over time (P < .05) CONCLUSION: We found no evidence that general measures of diet (energy, carbohydrates, fat, and protein), as assessed by 24-hour recall, were predictive of weight gain on DMPA. Several nutrients abundant in foods that benefit overall health were inversely associated with increased BMI over time, suggesting that diet quality, rather than quantity, is a more important predictor of DMPA-associated weight gain.

Satisfaction with and intention to continue Depo-Provera versus the Mirena IUD among post-partum adolescents through 12 months of follow-up

STUDY OBJECTIVE

No prior study has directly compared satisfaction with Depo-Provera to the Mirena intra-uterine device (IUD) among post-partum parous adolescents. Our aim was to make this comparison among post-partum adolescents at 3, 6, and 12 months of follow-up.

PARTICIPANTS

Post-partum/parous adolescents (aged 20 and younger) choosing either Depo-Provera or the Mirena IUD as their method of contraception.

DESIGN

Prospective longitudinal survey.

SETTING

The adolescent clinic at the Truman Medical Center, Kansas City Missouri.

MAIN OUTCOME MEASURE

Satisfaction with and intention to continue the chosen method at 3, 6, and 12 months of follow-up.

INTERVENTIONS

None.

RESULTS

Sixty-six post-partum/parous adolescents were recruited, 37 choosing the Mirena IUD and 29 choosing Depo-Provera for contraception. The 2 groups had similar baseline characteristics. There was no statistically significant difference in overall satisfaction with Depo-Provera versus the Mirena IUD at 3, 6, or 12 months of follow-up. For both contraceptive methods, unpredictable bleeding was most unacceptable at 6 months of follow-up but the trend was only statistically significant for Depo-Provera. For Depo-Provera, there was a significantly lower proportion of participants actually continuing the method at 12 months (42.9%) relative to the proportion who at 6 months had expressed an intention to continue (80.0%; P = .01). This trend was not seen for the Mirena IUD.

CONCLUSION

Among post-partum/parous adolescents, overall subjective satisfaction with Depo-Provera and the Mirena IUD is similarly high over 12 months of follow-up. With Depo-Provera, however, there appears to be a disconnect between intention to continue at 6 months and actual continuation at 12 months.

Oral contraceptives vs injectable progestin in their effect on sexual behavior

OBJECTIVE

We sought to compare sexual function and hormone concentrations in combined oral contraceptive (COC) and injectable progestin users.

STUDY DESIGN

Sexually active COC and depot medroxyprogesterone acetate (DMPA) users completed the Female Sexual Function Index (FSFI) questionnaire, a demographic data form, and had serum testosterone and estradiol levels measured. Multiple linear regression was used to measure associations of interest.

RESULTS

Among 50 subjects enrolled, COC users had lower levels of free testosterone compared to DMPA users (0.2 vs 0.6 pg/mL; P < .0001) and higher levels of estradiol (75.8 vs 62.8 pg/mL; P = .0057), but scores of desire (4.2 vs 3.8; P = .27), scores of arousal (5.0 vs 4.8; P = .46), or total scores (30.1 vs 28.8; P = .28) were no different. Demographic characteristics were similar except for ethnicity, level of education, gravidity, parity, and frequency of intercourse. In multivariate analysis, birth control type was not significantly associated with desire score or total FSFI score.

CONCLUSION

While users of COC and DMPA have significantly different sex hormone levels, they are not different in sexual function as measured by the FSFI.

Prospective study of weight change in new adolescent users of DMPA, NET-EN, COCs, nonusers and discontinuers of hormonal contraception

BACKGROUND

Weight gain is commonly reported as a side effect of hormonal contraception and can lead to method discontinuation or reluctance to initiate the method. The purpose of this study was to investigate weight change in adolescent (aged 15-19 years) users of depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN), combined oral contraceptives (COCs) and discontinuers of these methods as compared to nonusers of hormonal contraception.

STUDY DESIGN

This longitudinal study recruited initiators of DMPA (n=115), NET-EN (n=115), COCs (n=116) and nonusers of contraception (n=144). Participants were followed up for 4-5 years, and details of current contraceptive method, including switching, discontinuing and/or starting hormonal methods were documented at each 6-monthly visit. Women were classified according to their contraceptive histories on completion of the study, and injectable users were combined into one group for analysis. Height, weight and self-reported dieting were recorded at each visit.

RESULTS

There was no difference in mean age or weight between the groups at baseline. Women using DMPA or NET-EN throughout, or switching between the two, had gained an average of 6.2 kg compared to average increases of 2.3 kg in the COC group, 2.8 kg in nonusers and 2.8 kg among discontinued users of any method (p=.02). There was no evidence of a difference in weight gain between women classified as nonobese or classified as overweight/obese in any of the four study groups at baseline.

CONCLUSION

There is fairly strong evidence that adolescent contraceptive hormonal injectable users appear to gain more weight than COC users, discontinuers and nonusers of contraception.

Physiologic and psychologic symptoms associated with use of injectable contraception and 20 microg oral contraceptive pills

OBJECTIVE

The objective of the study was to compare menstrual, physiologic, and psychologic symptoms over 2 years among women initiating use of depot medroxyprogesterone acetate or an oral contraceptive pill with a reduced pill-free interval and those not using hormonal contraception.

STUDY DESIGN

A total of 608 women reported their experience regarding 17 symptoms prior to initiating contraception and every 6 months thereafter for 24 months. Longitudinal relationships between symptoms and contraceptives were assessed after adjusting for age, visits, and baseline status of symptoms.

RESULTS

Oral contraceptive pills were protective against mastalgia (odds ratio [OR], 0.7), cramping (OR, 0.5), hair loss (OR, 0.6), acne (OR, 0.4), nervousness (OR, 0.5), and mood swings (OR, 0.7). Depot medroxyprogesterone acetate (DMPA) was protective against bloating (OR, 0.5) and mood swings (OR, 0.7) but caused weight gain (OR, 2.3), bleeding episodes more than 20 days (OR, 13.4), and missed periods (OR, 96.9). Both methods caused intermenstrual bleeding.

CONCLUSION

Evidence-based data regarding beneficial and adverse symptoms associated with these methods may help clinicians counsel patients appropriately prior to contraceptive initiation.

The influence of hormonal contraception on mood and sexual interest among adolescents

Mood and sexual interest changes are commonly cited reasons for discontinuing hormonal contraceptives. Data, however, are inconsistent and limited to adult users. We examined associations of hormonal contraceptive use with mood and sexual interest among adolescents. We recruited 14-17-year-old women from primary care clinics and followed them longitudinally for up to 41 months. Participants completed face-to-face interviews quarterly and two 12-week periods of daily diary collection per year. On daily diaries, participants recorded positive mood, negative mood, and sexual interest. We classified 12-week diary periods as "stable OCP use," "non-use," "initiated use," "stopped use," and "DMPA use" based on self-report of oral contraceptive pill (OCP) use and depot medroxyprogesterone acetate (DMPA) use from medical charts. Diary periods were the unit of analysis. Participants could contribute more than one diary period. We analyzed data using linear models with a random intercept and slope across weeks in a diary period, an effect for contraceptive group, and an adjustment for age at the start of a diary period. Mean weekly positive mood was higher in diary periods characterized by stable OCP use, compared to other groups. Mean weekly negative mood was lower in diary periods characterized by stable OCP use and higher in periods characterized by DMPA use. Periods characterized by stable OCP use additionally showed less mood variation than other groups. Changes in mood among adolescent hormonal contraceptive users differed from those anticipated for adult users. Attention to adolescent-specific changes in mood and sexual interest may improve contraceptive adherence.

Pharmacological effects on sexual function

Many drugs may have effects on sexual function. Sexual function is complex and psychological and relationship issues are likely to have greater impacts on sexual function in women than drugs. Although it is important to understand the effects of drugs on sexual function, physicians should use caution in "medicalization" of sexual function in women [106].

Depo Now: preventing unintended pregnancies among adolescents and young adults

PURPOSE

We compared the immediate administration of DMPA (Depo Now) to the immediate use of short-term hormonal methods that served as a "bridge method" until later DMPA initiation. We examined whether Depo Now, as compared to initiating with a bridge method (pills, transdermal patch, or vaginal ring), resulted in greater DMPA continuation at six months.

METHODS

Young women aged 14 to 26 years seeking to use DMPA were randomized (nonblinded) after meeting eligibility criteria to either the Depo Now (n = 101) or bridge method (n = 232) group. Depo Now subjects received their first injection of DMPA at the conclusion of their first visit provided each was medically suitable and had a negative urine pregnancy test regardless of menstrual cycle day. Those assigned to the bridge method group were allowed to choose their starting contraceptive method and it was provided at the first visit. All subjects were told to return to the clinic in 21 days to repeat the urine pregnancy test, and among those who were assigned to use a bridge method, to receive their first injection of DMPA. All subjects were followed to their third injection, or about 6 months later.

RESULTS

Those randomized to a bridge method were 1.8 (1.1, 2.9) times more likely than Depo Now subjects to return for their 21-day repeat pregnancy test, but only 55% (n = 125) of these young women actually received their first DMPA injection. Continuation rates at the third injection were 29.7% (n = 30) for those in the Depo Now group and 21.1% (n = 49) for those assigned to the bridge method (p = .09). Three factors were significantly associated with adherence to the third injection: randomized to Depo Now group, knowing more women who use DMPA, and returning to clinic for the 21-day repeat pregnancy test visit. Finally, 28 pregnancies were diagnosed during the study period, and those in the bridge method group were almost 4.0 (1.2, 13.4) times more likely to be diagnosed with a pregnancy than those in the Depo Now group.

CONCLUSIONS

Immediate administration of DMPA is associated with improved adherence to DMPA continuation and fewer pregnancies.

Hormonal contraception in adolescents: special considerations

With the rates of unintended pregnancies in teenagers remaining high, it is crucial to present adolescents with all of the contraceptive options available to them. While barrier methods, for example, male condoms, are easily accessible and do not have adverse effects, their use must be consistent and correct with each act of intercourse. Hormonal contraception affords much better efficacy in preventing pregnancy when used with full compliance. Oral contraceptives are a popular method of contraception among adolescents and offer many non-contraceptive benefits along with the prevention of pregnancy. They have very few significant adverse effects, which are outweighed by the significant morbidity associated with teenage pregnancies, and can be used by most adolescent females. However, their minor bothersome effects do contribute to the high discontinuation rates seen. In addition, many girls find it difficult to remember to take a pill every day, leading to higher failure rates in teenagers than in adult women. The advent of long-acting, progestogen (progestin)-only methods, such as injectables and implantables, has been generally accepted by adolescents and these methods have proven to be more efficacious by avoiding the need for daily compliance. However, progestogen-only methods cause irregular bleeding and amenorrhea, which is not acceptable to many teenagers. In addition, the most widely used implant was taken off the market a few years ago and newer forms are not yet widely accessible. Other novel methods are currently available, including the transdermal patch and the vaginal ring. Both are combinations of estrogen and progestogen and have similar efficacy and adverse effect profiles to oral contraceptives. Their use may be associated with greater compliance by adolescents because they also do not require adherence to a daily regimen. However, there may be some drawbacks with these newer methods, for example, visibility of the patch and difficulty with insertion of the vaginal ring. When regular contraceptive modalities fail, emergency contraception is available. Choices include combination oral contraceptives, progestogen-only pills, mifepristone, or placement of a copper-releasing intrauterine device. These methods can be very useful for preventing pregnancy in adolescents as long as adolescents are aware of their existence and have easy access to them.

Weight, fat mass, and central distribution of fat increase when women use depot-medroxyprogesterone acetate for contraception

OBJECTIVE

To compare longitudinal changes in weight, body fat, and ratio of central to peripheral fat mass among first-time depot-medroxyprogesterone acetate (DMPA) users to women using no hormonal contraception, and to evaluate user characteristics associated with that change.

DESIGN

Prospective longitudinal study.

SUBJECTS

Healthy women, aged 18-35 y, using DMPA for contraception (n=178) and women using no hormonal contraception (n=145).

MEASUREMENTS

Weight, body fat, and the central distribution of fat, measured at 3-month intervals for 30 months, by electronic scale and dual-energy X-ray absorptiometry (DEXA). The ratio of central to peripheral distribution of body fat was computed by dividing the body fat in the conventional DEXA trunk region of interest (ROI) by the ROI's that encompass the arms, hips and legs.

RESULTS

Women using DMPA had a significantly greater increase in all measures of fatness than women using no hormonal method of contraception (P<0.03). The observed weight of DMPA users increased from a mean of 69.4 kg (s.d.=16.9) at baseline to 75.5 kg (s.d.=25.0) at 30 months; an increase of 6.1 kg (8.8.%). Fat mass increased from a mean of 25.3 kg (s.d.=12.6 kg) at baseline to 31.4 kg (s.d.=17.8); an increase of 6.1 kg (23.6%) in DMPA users. The ratio of central to peripheral fat mass in DMPA users changed from 0.95 (s.d.=0.155) at baseline to 1.01(s.d.=0.198) at 30 months. In contrast, weight, fat mass and the ratio of central to peripheral fat mass of control participants remained virtually unchanged over the same time period. Women with higher baseline physical activity levels had a smaller increase in body fat (P=0.003) and the fat ratio (P=0.03), but not weight (P=0.48). No other user characteristics including, smoking, past oral contraceptive use or previous pregnancies predicted change in level of fatness.

CONCLUSIONS

This study has demonstrated a change in body composition toward greater fatness and toward a central redistribution of fat among DMPA users as compared to controls and provides important information to be used when counseling women regarding contraceptive methods. Given the potential long-term implication of these changes, further study is recommended to determine whether the gains in fatness are reversed following DMPA discontinuation and to examine the role of progestins in the development and maintenance of obesity.

Concentration of depot medroxyprogesterone acetate and pain scores in adolescents: a randomized clinical trial

A prospective, single-blinded, randomized trial was initiated to determine whether injection site pain differed in adolescents receiving two concentrations of 150 mg of depot medroxyprogesterone acetate (DMPA). Ninety-five adolescents seeking injectable contraception were randomized to receive 150 mg of DMPA as follows: a deltoid injection of 1.0 mL from a single-unit-dose vial containing 150 mg/mL or 0.38 mL from a multidose vial containing 400 mg/mL of DMPA. A visual analogue scale was measured at each visit and cumulatively compared between the groups. Continuation rates were tabulated. The report of pain for the multidose vial group was significantly higher than for the unit-dose vial group (p<.003). The dropout rates for both groups were high at 1 year and were not statistically different (multidose group=64% and unit-dose group=77%). Twenty percent of the subjects in the multidose group vs. 22% in the unit-dose group discontinued due to bleeding irregularities. The concentrated form of DMPA led to greater pain at the injection site than did the less concentrated form, but this did not lead to higher discontinuation rates among adolescents.

Benefits and risks of pharmacological agents used for the treatment of menorrhagia

Menorrhagia affects the lives of many women. The assessment of menstrual flow is highly subjective and gauging the severity of the condition by objective assessment of menstrual blood loss is impractical. In treating menorrhagia, the primary aim should be to improve quality of life. Women are willing to undergo quite invasive treatment in order to achieve this. Drug therapy is the initial treatment of choice and the only option for those who wish to preserve their reproductive function. Despite the availability of a number of drugs, there is a general lack of an evidence-based approach, marked variation in practice and continuing uncertainty regarding the most appropriate therapy. Adverse effects and problems with compliance also undermine the success of medical treatment. This article reviews the available literature to compare the efficacy and tolerability of different medical treatments for menorrhagia. Tranexamic acid and mefenamic acid are among the most effective first-line drugs used to treat menorrhagia. Despite being used extensively in the past, oral luteal phase norethisterone is probably one of the least effective agents. Women requiring contraception have a choice of the combined oral contraceptive pill, levonorgestrel-releasing intrauterine system (LNG-IUS) or long-acting progestogens. Danazol, gestrinone and gonadotropin-releasing hormone analogues are all effective in terms of reducing menstrual blood loss but adverse effects and costs limit their long-term use. They have a role as second-line drugs for a short period of time in women awaiting surgery. While current evidence suggests that the LNG-IUS is an effective treatment, further evaluation, including long-term follow up, is awaited. Meanwhile, the quest continues for the ideal form of medical treatment for menorrhagia--one that is effective, affordable and acceptable.

Weight gain, adiposity, and eating behaviors among adolescent females on depot medroxyprogesterone acetate (DMPA)

OBJECTIVE

To identify risk factors for weight gain and explore body composition and eating behaviors among adolescent females initiating depot medroxyprogesterone acetate (DMPA).

METHODS

A longitudinal study was conducted in 43 adolescent females beginning DMPA. Data collection at baseline, 3, and 6 months included structured interview; measurement of height, weight, and percent body fat; and assessment of dietary restraint, disinhibition, and appetite.

RESULTS

Black and white subjects did not differ in baseline weight or body composition. At 6 months, black subjects had a 4.2% increase in weight (mean weight gain=2.9 kg; P=0.003) and a 12.5% increase in body fat (mean fat gain =2.5 kg; P<0.001). In contrast, white subjects had a 1.2% increase in weight (mean weight gain=0.9 kg; P=0.32) and a 1.2% increase in body fat (mean fat gain of 0.5 kg; P=0.54). Baseline weight (P<0.001), study visit (P=0.005), age (P=0.006), eating restraint (P=0.005), eating disinhibition (P<0.001), and other medications (P<0.001) were predictive of weight gain in black subjects. Only baseline weight (P<0.001) was predictive in white subjects. Higher baseline weight (adjusted odds ratio (AOR)=1.2, 95% confidence interval (CI)=1.1,1.3) was a risk factor for gaining >2.2 kg the first 3 months. Black race (AOR=7.8, 95% CI=1.5, 66.2) and younger age at menarche (AOR=0.6, 95% CI=0.3, 0.9) were risk factors for gaining >2.2 kg the second 3 months. Appetite decreased in the study sample reaching statistical significance in black subjects.

CONCLUSIONS

Our data suggest that black and white adolescents differ in the quantity, timing, and predictors of weight gain on DMPA. DMPA-associated weight gain is paralleled by increases in total body fat, while appetite decreases on DMPA.

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

Depot-medroxyprogesterone acetate (Depo-Provera(R)) is a highly effective, nondaily hormonal contraceptive option that has been available in the United States for a decade, and worldwide for 40 years. Benefits and risks of hormonal therapy are often under scrutiny; however, long-term clinical experience has established the safety of this long-acting contraceptive. This article reviews the contraceptive efficacy, potential noncontraceptive health benefits and long-term safety of with regard to risk of cardiovascular events, breast and gynecologic malignancy and osteopenia. Comparisons with other hormonal contraceptives are made as clinically appropriate. Common patient management issues, including effects on menstrual cycle, body weight and mood, are also addressed. Finally, this review provides recommendations for appropriate patient selection.

Evidence for serotonergic modulation of progesterone-induced hyperphagia, depression and algesia in female mice

The acute administration of the neurosteroid precursor, progesterone (10 mg/kg, s.c.) produced significant hyperphagia in female mice as observed at 0.5-, 1-, 2- and 3-h time intervals. At this dose progesterone also produced significant increase in immobility period duration in Porsolt's forced swim test and nociceptive response in hot-plate and tail-flick tests. Treatment with direct (quipazine, 5 mg/kg, i.p.) and indirect (fluoxetine, 10 mg/kg, i.p.) acting serotonergic agents per se produced significant hypophagia, decrease in immobility period and induced analgesic effect in hot-plate and tail-flick test. Further, treatment with both fluoxetine (10 mg/kg, i.p.) and quipazine (5 mg/kg, i.p.) significantly reversed progesterone-induced hyperphagia, depression and algesia in the female mice. Pretreatment with seganserin, a 5-HT(2) receptor antagonist (2 mg/kg, i.p.) significantly reversed fluoxetine and quipazine-induced antidepressant and analgesic effects. Seganserin reversed quipazine-induced hypophagia but in a replicate study it failed to reverse fluoxetine-induced hypophagia. Further, seganserin, 2 mg/kg, i.p., significantly reversed the suppressive effect of fluoxetine and quipazine on progesterone-induced hyperphagia, depression and algesia in hot-plate test. Seganserin also reversed the suppressive effect of fluoxetine and quipazine on progesterone-induced algesia in hot-plate test. These data suggest that the modulation of progesterone-induced effects by these serotonergic agents possibly involve 5-HT(2) receptor mechanisms. Further, the study underscores the use of serotonergic agents for the treatment of eating and affective disorders caused by the regular changes or disturbances of ovarian steroid levels in females.

Overweight teens at increased risk for weight gain while using depot medroxyprogesterone acetate

STUDY OBJECTIVE

To determine if factors such as body mass index (BMI), race, and age are associated with weight gain in adolescents receiving depot medroxyprogesterone acetate (DMPA).

DESIGN/SETTING

Retrospective chart review at three rural health department family planning clinics and a university-based adolescent clinic in rural eastern North Carolina.

PARTICIPANTS

Adolescent females, aged 12-19, who used either oral contraceptive pills (OCPs) or DMPA consistently for the first year of use.

MAIN OUTCOME MEASURE

Weight change at one year.

RESULTS

A total of 239 adolescent females were included in the analysis; 117 were DMPA users and 122 were OCP users. The mean weight gain for the DMPA group was 8.9 lbs. compared with 4.79 lbs. in the OCP group (P =.002). The change in BMI from baseline was greater among the DMPA group (1.51 +/- 1.94) than the OCP group (.75 +/- 1.65), P =.001. After adjusting for age, race, and contraceptive method, initial BMI was associated with weight gain (P =.009).

CONCLUSIONS

Adolescent females using DMPA gained significantly more weight over one year than those girls using OCPs. Adolescent females who are overweight at the initiation of DMPA may be more likely to have significant weight gain during the first year of use.

Sex hormones and chronic headache in women

Women experience changes in headache pattern in relation to changes in their reproductive cycles. Menarche, menses, pregnancy, menopause and the use of exogenous oestrogen-containing medications frequently alter baseline headache patterns. Changing patterns of headache in women may be linked to alterations in levels of sex hormones. Sex hormones directly influence headache by affecting the activity of a variety of neurochemicals important for headache, including serotonin (5HT). Treating headache alterations in women may include therapies that modify sex hormones or neurochemicals.

Comparison of weight increase in users of depot medroxyprogesterone acetate and copper IUD up to 5 years

The objective of this study was to evaluate retrospectively the weight variation in long-term users of depot medroxyprogesterone acetate (DMPA) compared to users of the TCu380A intrauterine device (IUD). A cohort of 206 healthy women allocated in two groups of 103 women according to the contraceptive method used was evaluated through 5 years. Each user of DMPA was paired with an IUD user by age (+/- 1 year) and weight (+/- 1 kg) at the beginning of the study. Weight was evaluated yearly during 5 years. The mean age at the beginning of the study was 33.1 years in both groups, and the mean weight was 59.4 kg in the IUD users and 60.4 kg in the DMPA group. Both cohorts of women presented significant weight increase at the end of the 5 years of observation (p < 0.001). However, DMPA users presented higher weight increase when compared to IUD users from the second through the fifth year of observation. The DMPA users increased weight by 4.3 kg during the 5 years, and IUD users increased 1.8 kg. In conclusion, DMPA users had a significantly higher weight increase when compared to IUD users. In addition, this cohort of women increased weight throughout the 5 years with the use of DMPA or IUD.

Injectable contraception. New and existing options

DMPA and MPA/E2C contraception offer women safe, effective, convenient, and reversible birth control choices. The use of DMPA, a 3-month injectable, is characteristically associated with amenorrhea. Lactating women and women in whom contraceptive doses of estrogen are contraindicated can use this progestin-only birth control method. Return of fertility can be delayed in women discontinuing DMPA to become pregnant. In some cases, the use of DMPA also confers important noncontraceptive and therapeutic benefits. A monthly estrogen/progestin injectable contraceptive, MPA/E2C should appeal to women who are concerned about daily pill taking, who prefer regular cycles to amenorrhea, and who find monthly injections acceptable and accessible. As is true for oral contraceptives, MPA/E2C represents an appropriate choice for women who prefer a rapidly reversible contraceptive. Currently, the proposed contraindications for MPA/E2C parallel those for combined oral contraceptives. As MPA/E2C contraception becomes available for American women, clinicians will learn how to best include this new method among the array of contraceptive choices. By individualizing contraceptive selection, counseling, and management approaches based on the relevant behavioral and medical considerations reviewed herein, clinicians can maximize their patients' success with injectable contraceptives. The more innovative that clinicians, family planning agencies, and insurers are in facilitating access to care (including reinjections), the more women will be able to avail themselves of safe, effective, and reversible methods of contraception. In addition to the physician's office or health clinic, other sites at which women might receive contraceptive injections include employee health clinics, college health clinics, or perhaps the pharmacy where the prescription is filled. Self-administration may become an appropriate option for some users of injectable contraception.

Use of depot medroxyprogesterone acetate in Thai adolescents

Depot medroxyprogesterone acetate (DMPA) has been available for several decades in many parts of the world including Thailand, but few data have been reported concerning adolescents. The aim of the study was to determine the use of DMPA for contraceptive use among Thai adolescents. A cross-sectional study has been designed. A total of 108 adolescents who used DMPA as contraception between January 1, 1996, and December 31, 1997, at King Chulalongkorn Hospital were reviewed by chart. Most of the participants were in late adolescence and average age was 17.6 years of age. Six-month continuation rate was 69.4%, and at 9 months and 1 year were 42.6 and 30.6%, respectively. Irregular bleeding, amenorrhea, and weight gain were the side effects frequently reported. The most common side effect that caused discontinuation within 1 year was irregular bleeding. With prolonged use, the number of cases with irregular bleeding decreased and the duration of bleeding was shortened, whereas the rate of amenorrhea increased. No pregnancy occurred during the study period. In conclusion, DMPA is an effective contraception in adolescents. However, the continuation rate is lower than that for adult women. The main reason for discontinuation is irregular bleeding.

The use of long-acting contraceptives in adolescents

DMPA and implants have played an important role in the attempt to prevent teenage pregnancies. Adolescent health care providers should provide continued counseling to girls using DMPA or implants and should promptly address any concern associated with these methods. Future studies are warranted to explore ways to prevent or reduce the side effects of DMPA and implants, as well as to develop new, optimal, long-acting contraceptives. Detailed baseline information should be obtained in every future study that explores the presence of side effects during the use of long-acting contraceptives.

Focus on primary care diagnosis and management of headache in women

Women experience unique changes in headache pattern related to changes in their reproductive cycles. Changes predictably occur in association with menarche, menstrual cycling, the use of oral contraceptives, pregnancy, and menopause. These predictable headache changes are linked to changing levels of sex hormones. This article describes important relationships between estradiol and neurotransmitters involved in the pathogenesis of headache, such as serotonin. Treatment of headache in women includes the use of acute care and preventive treatments. The effectiveness of both medication and nonmedication treatments is reviewed. Also, unique aspects of treating headache with menstruation, pregnancy, and menopause are described.

Adolescent contraception

Adolescent pregnancy rates have declined modestly, most likely because of the increased use of condoms, especially at first intercourse. Condom distribution in schools appears to be effective in promoting condom use without increasing sexual activity. Although, to date, no contraceptive has been as effective as Norplant in reducing teen pregnancy, use of the method has declined dramatically. Depo-Provera use is increasing, but continuation rates are disappointing and the impact on teen pregnancy rates is as yet unknown. Emergency contraception remains underutilized, and interventions to improve oral contraceptive compliance are beginning to be explored. School-based programs that provide contraception without adding a strong educational component fail to improve contraceptive use or reduce pregnancy rates. Use of any contraceptive by teens is cost effective.

The pediatrician and the sexually active adolescent. Sexual activity and contraception

Sexuality and its resultant consequences continue to be major issues for adolescents and for those who provide their health care. This article discusses current sexual behavior in adolescents and describes the various forms of hormonal contraception that sexually active adolescents should use.