A prospective study on the effects of depot medroxyprogesterone acetate on trabecular and cortical bone after attainment of peak bone mass

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.

Contraception for the older woman: an update

Although fertility declines with advancing age as the woman approaches the menopause, some risk of pregnancy persists, and effective contraception needs to be offered to avoid an unintended pregnancy. An older woman may have menstrual dysfunction or climacteric symptoms and these factors would need consideration when making the choice of contraception. Low-estrogen dose combined oral contraceptives may be prescribed to healthy non-smoking women up to about 50 years of age. The progestogen-only pill may be an appropriate option in an older woman with declining fertility. The copper intrauterine device is an optimal method for parous women free of pre-existing menstrual problems. The levonorgestrel-releasing intrauterine system is considered the contraceptive method of choice for perimenopausal women with menstrual dysfunction. The woman should be provided with individualized advice so that she has a choice between the newer, effective, largely safe, reversible methods and sterilization.

Forearm bone mineral density in postmenopausal former users of depot medroxyprogesterone acetate

BACKGROUND

The aim of the study was to compare the bone mineral density (BMD) of postmenopausal women who had used depot-medroxyprogesterone acetate (DMPA) or a copper intrauterine device (IUD) as a comparison group until menopause.

STUDY DESIGN

BMD was measured using dual-energy X-ray absorptiometry at the nondominant forearm for up to 3 years following menopause in 135 women aged 43-58 years: 36 former DMPA users and 99 former IUD users.

RESULTS

Mean duration of use was (mean+/-SEM) 9.4+/-3.8 and 14.7+/-6.2 years for the DMPA and IUD groups, respectively. One year after menopause, mean distal radius BMD was 0.435 and 0.449 in DMPA and IUD users, respectively, and 0.426 and 0.447 at 2-3 years following menopause. Ultra-distal BMD was 0.369 and 0.384 in DMPA and IUD users, respectively, at 1 year, and 0.340 and 0.383 at 2-3 years.

CONCLUSIONS

At 1 and 2-3 years following menopause, no significant differences were observed in the BMD of postmenopausal women aged 43-58 years, who had used DMPA or an IUD until menopause.

Bone density recovery after depot medroxyprogesterone acetate injectable contraception use

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Bone status after cessation of use of injectable progestin contraceptives

BACKGROUND

Women using injectable progestin contraceptives (IPCs) have lower bone mineral density than nonusers. We assessed whether bone loss is completely reversible after cessation of IPC use, whether different IPCs have different effects and whether effects vary by age at first use.

STUDY DESIGN

In a cross-sectional study in Cape Town, South Africa, 3487 premenopausal black and mixed race women aged 18-44 years were interviewed for information on contraceptive history and risk factors for decreased bone mineral density, and ultrasound measurements of the left calcaneus were taken. Adjusted means of the ultrasound measures for categories of IPC use were obtained using multivariable linear regression.

RESULTS

Current users of IPCs had the lowest ultrasound measures, while the measures of women who had ceased IPC use at least 2-3 years previously were similar to or greater than those of never users of IPCs. The effects of depot medroxyprogesterone acetate and norethisterone enanthate were similar. The calcaneus measures were unrelated to age at which use began after control for confounding factors.

CONCLUSION

The data suggest that bone loss during IPC use is reversible and that this loss of bone is completely recovered several years after cessation of use.

Bone mineral density loss and recovery during 48 months in first-time users of depot medroxyprogesterone acetate

OBJECTIVE

To compare changes in bone mineral density (BMD) during 48 months between first-time depot medroxyprogesterone acetate (MPA) users, during use and after discontinuation, to controls.

DESIGN

Longitudinal study.

SETTING

Academic community.

PATIENT(S)

Women 18-35 years, newly initiating depot MPA (n = 178) and controls (n = 145) not using hormonal contraception.

MAIN OUTCOME MEASURE(S)

The BMD of the hip and spine, measured at 3-month intervals, by dual energy roentgen absorptiometry.

RESULTS

Hip and spine BMD declined during 48 months of depot MPA use by 7.7% +/- 0.11% (mean +/- SE) and 6.4% +/- 0.36%, respectively. The BMD of controls declined <or=1.6% +/- 0.30%. Hip and spine BMD loss slowed to <0.6% after 48 months of depot MPA use. After discontinuation, BMD increased from 0.3% to 2.0% per year depending on length of depot MPA use and bone site. The longest depot MPA users remained 4.7% and 2.9% lower than hip and spine baseline values, respectively, 18 months after discontinuation.

CONCLUSION(S)

Depot MPA-related BMD loss is substantial but occurs mostly during the first 2 years of DMPA use. Therefore, longer use may not substantially increase the risk of osteoporosis. The prolonged recovery time suggests the need to consider timing of use in relation to menopause or other factors that may impede bone remodeling.

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

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

Bone mineral density changes over two years in first-time users of depot medroxyprogesterone acetate

OBJECTIVE

To compare longitudinal changes in bone mineral density (BMD) among first-time depot medroxyprogesterone acetate (DMPA) users to women using no hormonal contraception, and evaluate user characteristics associated with that BMD change.

DESIGN

Prospective longitudinal study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Women, aged 18 to 35, choosing DMPA for contraception (n = 178) and women using no hormonal contraception (n = 145).

MAIN OUTCOME MEASURE(S)

Hip and spine BMD measured, at three-month intervals for 24 months, by dual energy x-ray absorptiometry.

RESULT(S)

Mean hip BMD declined 2.8% (SE = 0.034) 12 months following DMPA initiation and 5.8% (SE = 0.096) after 24 months. Mean spine (L1-L3) BMD declined 3.5% (SE = 0.022) and 5.7% (SE = 0.034), respectively, after one and two years of DMPA use. Mean hip and spine BMD of control participants changed less than 0.9% over the same period. Among DMPA users, body mass index (BMI) change was inversely associated with BMD change at the hip, but not at the spine. Calcium intake, physical activity, and smoking did not influence BMD change in either group.

CONCLUSION(S)

Hip and spine BMD declined after one DMPA injection and this decline continued with each subsequent injection for 24 months. With the exception of increasing BMI among DMPA users, no user characteristics offered protection against DMPA-related BMD loss.

Bone mineral density in lymphangioleiomyomatosis

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

Bone Mineral Density in Adolescent Women Using Depot Medroxyprogesterone Acetate

PURPOSE

To present current data on bone mineral density (BMD) in adolescent women using the long-acting contraceptive depot medroxyprogesterone acetate (DMPA) and also to discuss the importance of developing maximal bone mass during adolescence to offset bone demineralization later in life.

DATA SOURCES

Research-based articles in the medical literature, review articles, and recommendations from the American Academy of Pediatrics and the National Osteoporosis Foundation.

CONCLUSIONS

Osteoporosis is a preventable disease that affects millions of Americans, particularly older women. Factors influencing the attainment and maintenance of peak bone mass during childhood and adolescence affect the future risk of fractures. Although longitudinal studies conducted on adolescent women using DMPA are very limited, findings suggest that adolescents are losing bone density during a time of expected bone accretion.

IMPLICATIONS FOR PRACTICE

Clinicians must consider all the risks and benefits when prescribing contraceptives to adolescents. By themselves, the findings related to BMD and DMPA use by adolescents are not sufficient to limit the use of DMPA as a contraceptive method. However, clinicians must take into account the addition of other modifying factors associated with BMD that may contribute to overall bone loss in adolescent females. More prospective data on the long-term use of DMPA by adolescents are needed to determine DMPA's effect on bone loss and to determine if bone loss is transient in adolescents.

Controversies in adolescent hormonal contraception

Unintended pregnancy and abortion rates among US adolescents remain high although hormonal contraception is safe and effective in this population. Controversies affecting the provision of hormonal contraception for adolescents include the side effects of oral contraceptives, the possibility that progestin-only injectables lead to decreased bone health, and debate as to whether emergency contraception should be available to teens without a prescription. Each of these issues is addressed with a review of relevant literature.

Injectable hormone contraception and bone density: results from a prospective study

BACKGROUND

Depot medroxyprogesterone acetate (DMPA) injectable contraception may decrease bone density and increase the risk for osteoporosis in later life. Prospective data are scarce, especially of the effects of DMPA discontinuation on bone.

METHODS

Between 1994 and 1999, we conducted a population-based prospective cohort study among women enrollees of a Washington State health maintenance organization. We enrolled 457 nonpregnant women, ages 18-39 years (183 DMPA users and 274 non-users). Bone density was measured by dual-energy x-ray absorptiometry every 6 months for 3 years.

RESULTS

Bone density decreased notably among DMPA-exposed women at the spine (adjusted mean bone density was -0.0053 gm/cm for DMPA users compared with +0.0023 gm/cm for non-users for each 6-month interval) and total hip (-0.0060 compared with -0.0002 gm/cm ). This represents an annualized mean rate of change at the spine of -0.87% compared with +0.40% and, at the hip, -1.12% compared with -0.05%. Discontinuers of this method (N = 110) showed sizable increases in bone density over comparison women (for each 6-month interval, adjusted mean spine bone density was +0.0067 gm/cm compared with +0.0023 gm/cm, respectively; adjusted mean hip bone density was +0.0035 compared with -0.0002 gm/cm ). Estimated annualized mean rates of change were +1.41% compared with +0.40% [corrected] at the spine and +1.03% [corrected] compared with -0.05% at the hip. After 30 months, mean bone density for discontinuers was similar to that of non-users.

CONCLUSIONS

In this study, DMPA use was strongly associated with bone density loss. Substantial postdiscontinuation recovery of bone provides evidence that the effects may be largely reversible.

Bone mineral density at various anatomic bone sites in women receiving combined oral contraceptives and depot-medroxyprogesterone acetate for contraception

The association between users of combined oral contraceptives and depot-medroxyprogesterone acetate (DMPA) for contraception and bone mineral density (BMD) has been controversial because of variations among studies. Like other studies, this cross-sectional study compares BMD in users of combined oral contraceptives and DMPA with that in nonusers. Unlike previous studies, we defined long-term use as >2 years, and we measured more bone sites than previous studies including lumbar spines, femurs, and forearms. The study group consisted of 59 women aged 30 years to 34 years who had been using combined oral contraceptives for 57.36 +/- 27.02 months with a minimum period of 24 months, 34 women of the same age who had been using DMPA as contraceptive for 55.76 +/- 35.31 months, and 62 women of the same age who had not used any steroid hormonal contraceptives for more than 6 months. BMD was measured by dual energy photon absorptiometer at lumbar spine 2-4, neck of femur, Ward's triangle of femur, greater trochanter of femur, ultradistal radius, and distal ulnar, respectively. Age, body mass index, and lifestyles of both groups were matched with nonusers. Mean BMD at lumbar spine (L2-4) in the DMPA users was significantly lower than in the controls (1.031 +/- 0.090 vs. 1.096 +/- 0.116, p = 0.007). There were no significant differences in BMD values at bone sites other than lumbar spine between DMPA users and the controls. There were no significant differences in BMD values at all bone sites between combined oral contraceptives users and the controls. We conclude that combined oral contraceptives are not associated with changes in values of BMD, while DMPA is associated with decreased BMD only at lumbar spine. We comment that steroid hormonal contraceptives are safe to use for long-term contraception regarding bone mass effects.