Snapshot: Shot remains as long-acting option
The next patient in your examination room is an 18-year-old female who is seeking effective contraception. She has tried oral contraceptives (OCs), but she hasn't been successful in sticking with the dosing regimen. What options can you offer her?
Consider the contraceptive injection (DMPA, Depo-Provera; Pfizer, New York City; or Medroxyprogesterone Acetate Injection, Teva Pharmaceuticals USA, North Wales, PA).
According to results of the 2007 Contraceptive Technology Update Contraception Survey, many family planning providers continue to prescribe the drug, 15 years after it debuted on the U.S. market. The shot remains a popular option for younger women: About 86% say they are in favor of prescribing the drug for teens, similar to 2006's survey results.
Not only is Depo-Provera a popular choice, it is a wise choice for young teens, says Beth Sperring, ARNP, a nurse practitioner at Suwannee County Health Department in Live Oak, FL. When the teen's parents are involved in the birth control process, they often express preference to Depo-Provera over the pill, she says. "I still deliver the message about sexually transmitted disease [STD] risks, cervical cancer risks, and encourage abstinence and safe sex," says Sperring. "The dosing schedule of Depo allows elimination of one more topic of contention between the parent and adolescent that will often occur with daily reminders about taking the pill."
Check Same Day Start
If your clinic offers DMPA, consider the use of same-day start of the injection. More clinicians are now eyeing this form of contraceptive initiation, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the University of California in Los Angeles (UCLA) and medical director of the women's health care programs at Harbor — UCLA Medical Center in Torrance.
Recent research indicates that introduction of DMPA as a Same Day injection policy is a safe and efficient way of providing women needed effective contraception within seven days of the office visit.1 Immediate administration of DMPA is associated with improved adherence to DMPA continuation and fewer pregnancies.2
To offer DMPA in the Same Day start manner, clinicians need to obtain a thorough history of unprotected intercourse since the last menstrual period to determine the need for pregnancy testing. Women who have had unprotected intercourse in that time frame should have a sensitive urine pregnancy test to determine their status. If patients have had unprotected intercourse in the last five days, they should be provided emergency contraception. If DMPA is given in the Same Day start manner, condoms must be used for the next seven days. Patients will need to repeat the pregnancy test two to three weeks after the injection if they have had any recent unprotected intercourse, says Nelson.
Impact on bone health?
Clinicians and patients continue to be mindful of DMPA's potential impact on bone health, following the 2004 "black box" warning added to DMPA labeling. The warning states that prolonged use of the drug may result in the loss of bone mineral density (BMD). The labeling now advises that DMPA should be used as a long-term birth control method (longer than two years) only if other birth control methods are inadequate. Women who continue to use the drug past the two-year mark should have their BMD evaluated.
The Association of Reproductive Health Professionals (ARHP) offers the following information for health care providers to help them discuss the revised labeling.3
- DMPA is a safe and effective contraceptive for adolescent females as well as adult women.
- Use of DMPA should not be restricted routinely based on skeletal health concerns, because there is no evidence of increased fracture risk from the reversible and transient decreased BMD evident in current DMPA users.
- The black box label does not mandate serial BMD testing or the provision of "add-back" estrogen supplementation.
- The current Food and Drug Administration (FDA) guidance does not prohibit use of DMPA for more than two years. Existing data do not suggest the need to place any time limit on DMPA use for adolescents or women in general.
For women who have additional risk factors for low BMD, such as cigarette smokers and women on chronic corticosteroids, clinicians can consider supplemental use of menopausal doses of estrogen along with ongoing DMPA use. Examples of menopausal doses of estrogen include conjugated equine oral estrogen 0.625 mg daily, micronized oral estradiol 1 mg daily, and transdermal estradiol 0.05 mg patches. All women should consume age-based, appropriate amounts of calcium and vitamin D, advises the ARHP.3 (ARHP offers a handout on the revised DMPA labeling at www.arhp.org.)
- Nelson AL, Katz T. Initiation and continuation rates seen in 2-year experience with Same Day injections of DMPA. Contraception 2007; 75:84-87.
- Rickert VI, Tiezzi L, Lipshutz J, et al. Depo Now: Preventing unintended pregnancies among adolescents and young adults. J Adolesc Health 2007; 40:22-28.
- Association of Reproductive Health Professionals. What You Need To Know. Labeling Changes for Depot Medroxy-progesterone Acetate. Accessed at: www.arhp.org.