Depo-Provera® and bone density

Alcohol Consumption and Bone Mineral Density in People with HIV and Substance Use Disorder: A Prospective Cohort Study

BACKGROUND

People living with HIV (PLWH) commonly have low bone mineral density (BMD) (low bone mass and osteoporosis) and are at high risk for fractures. Fractures and low BMD are significant causes of morbidity and mortality, increasingly relevant as PLWH age. Alcohol use is common among PLWH and known to affect bone health. The association between alcohol use and changes in BMD among PLWH is not well understood.

METHODS

We conducted a 3.5-year prospective cohort study of 250 PLWH with substance use disorder or ever injection drug use. Annual alcohol consumption was measured as a mean of grams per day of alcohol, mean number of heavy drinking days per month, mean number of days abstinent per month, and any heavy drinking, using the 30-day Timeline Followback method twice each year. The primary outcome was annual change in BMD measured each year by dual energy X-ray absorptiometry in grams per square centimeter (g/cm2 ) at the femoral neck. Additional dependent variables included annual change in total hip and lumbar spine BMD, >6% annual decrease in BMD at any site, and incident fractures in the past year. Regression models adjusted for relevant covariates.

RESULTS

The median age of participants was 50 years. The median duration of HIV infection was 16.5 years and the mean time since antiretroviral therapy initiation was 12.3 years. At study entry, 67% of participants met criteria for low BMD (46% low bone mass, 21% osteoporosis). Median follow-up was 24 months. We found no significant associations between any measure of alcohol consumption and changes in BMD (g/cm2 ) at the femoral neck (adjusted β for g/d of alcohol = -0.0032, p = 0.7487), total hip, or lumbar spine. There was no significant association between any measure of alcohol consumption and >6% annual decrease in BMD at any site, or incident fractures.

CONCLUSIONS

In this sample of PLWH and substance use disorders or ever injection drug use, we detected no association between any of the alcohol measures used in the study and changes in BMD or incident fractures.

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.

Contraception, communication and counseling for sexuality and reproductive health in adolescents and young adults with CF

With survival now into the fourth decade and rapid growth of the adolescent and adult population of people with cystic fibrosis CF sexual and reproductive health issues are integral to the management of adolescents and adults with CF. Education and counseling for sexual health related issues must be included in the daily routine of CF care. With advances in genetic counseling, contraception, assisted reproductive technology and collaborative management adolescents and young adults with CF realizing their sexual and reproductive potentials safely and realistically can be possible .

Effect of depot medroxyprogesterone acetate on bone density in a Scottish industrial city

OBJECTIVE

To determine if long-term users of depot medroxyprogesterone acetate injectable contraception (DMPA) were more likely than their peers to have low bone density.

DESIGN

Cross-sectional observational study.

SETTING

The Domiciliary Family Planning Service, Glasgow, Scotland.

SUBJECTS

Clients of the Domiciliary Service who had used DMPA for contraception for longer than 5 years (mean 12 years) were invited to participate and select their own control, a friend or relative who had never used this method of contraception.

MAIN OUTCOME MEASURES

Bone density measured at the hip and lumbar spine by dual X-ray absorptiometry (DXA).

RESULTS

DMPA users had a significantly lower bone density than controls, 12-13% less at both hip and lumbar spine. This difference remained even when controlling for parity, smoking, family history of kyphosis or hip fracture, and body mass index.

CONCLUSIONS

DMPA significantly decreases bone density in a group of long-term users with significant social deprivation. The long-term significance of this remains uncertain.

Subcutaneous DMPA vs. intramuscular DMPA: a 2-year randomized study of contraceptive efficacy and bone mineral density

BACKGROUND

A formulation of depot medroxyprogesterone acetate (DMPA) has been developed that allows subcutaneous injection (104 mg/0.65 mL; DMPA-SC) and achieves highly effective contraception with a similar tolerability profile to intramuscular DMPA (150 mg/mL; DMPA-IM).

STUDY DESIGN

This randomized, evaluator-blinded study was designed to compare efficacy, safety, and user satisfaction in women receiving DMPA-SC (n=266) or DMPA-IM (n=268) for 2 years with an option to continue for a third year. The primary objectives were to evaluate bone mineral density (BMD) changes and contraceptive efficacy after 2 years.

RESULTS

A total of 225 women completed the first 2 years of this study (DMPA-SC, n=116; DMPA-IM, n=109). After 2 years of DMPA use, BMD loss was marginally smaller in the DMPA-SC group than in the DMPA-IM group at both the total hip (-3.3% and -3.6%, respectively) and lumbar spine (-4.3% and -5.0%, respectively). In those women who received DMPA during the third year, there were no statistically significant differences in BMD loss between DMPA-SC and DMPA-IM groups at the end of Year 3. Recovery of BMD was observed in the small subpopulation of women who had discontinued DMPA-SC or DMPA-IM after the second year. The 2-year treatment-failure cumulative pregnancy rate was 0% in the DMPA-SC group and 0.8% (95% confidence interval, 0.00-2.37%) in the DMPA-IM group (life-table method). Adverse events were similar in the two groups except that injection site reactions were more common in the DMPA-SC group.

CONCLUSION

DMPA-SC is an effective and well-tolerated contraceptive option, providing comparable efficacy and BMD safety to DMPA-IM.

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.

Long-acting contraceptives in adolescents

PURPOSE OF REVIEW

To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed.

RECENT FINDINGS

The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits.

SUMMARY

The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.

Bone mineral density and depot medroxyprogesterone acetate

INTRODUCTION

Depot medroxyprogesterone acetate (DMPA) suppresses pituitary gonadotrophin output, thus, suppressing ovulation. Estrogen production from the ovary is also strongly inhibited, and the resulting estrogen deficiency has a detrimental impact on bone. Depot medroxyprogesterone acetate may be particularly detrimental in young women, as it may impede attainment of peak bone mass, and switching to a different contraceptive is recommended. However, the effect of sequential use of DMPA with other contraceptives in this age group has not been investigated.

METHODS

This was a cross-sectional analysis of 218 DMPA users who were 20 years or older (mean, 31 years, +/-8.9 SD) at the time of bone mineral density (BMD) estimation. The majority of women had used one or more contraceptive beside DMPA. The most commonly used alternative contraceptive was the oral combined pill (OCP). It was used by 65% of women (n=143) and for an average duration of 6 years. A logistic regression model was used to estimate the association between potential risk factors and low bone mass.

RESULTS

The prevalence of low bone mass at either hip or spine (T< or =1) was 41%. The prevalence of a T score below -2.5 was 5%, and 45% of women had already sustained one fracture. Younger age was associated with higher BMD [odds ratios (ORs), 0.054; 95% confidence interval (CI), 0.007-0.431]. However, this protective effect of age was lost once the interaction between the duration of both DMPA and OCP was introduced into the model (OR for low BMD, 1.42; 95% CI, 1.09-1.8). The use of DMPA first before ever use of OCP was particularly detrimental to BMD (OR, 3.94; 95% CI, 1.08-14.0). On the contrary, body mass index was positively associated with BMD (OR, 0.86; 95% CI, 0.8-0.9). No other demographic or anamnestic variables significantly predicted the presence of low BMD in this group of young women. This group of DMPA users appear to be at a very high risk of both low BMD and fractures, possibly independently of DMPA use. This needs to be considered when writing guidelines for risk assessment.

CONCLUSION

The use of DMPA before achievement of peak bone mass may be particularly detrimental to bone, but switching DMPA with the OCP in these women does not seem to confer specific benefit in terms of bone density. This needs to be taken into consideration when a change in contraceptive is considered purely for the sake of bone protection.