A young female patient says she’s interested in using the contraceptive injectable Depo-Provera (depot medroxyprogesterone acetate or DMPA, marketed in the United States by Pharmacia Corp., Peapack, NJ). Do you inform her of the potential for diminished bone mass that has been linked with use of this method?
More than half (55%) of participants in the 2002 Contraceptive Technology Update Contraception Survey said they only inform patients of this possible side effect, a slight increase from the 52.9% figure recorded in 2001. About 27% said they used other strategies, such as discussing calcium supplementation, compared with 31.2% in 2001. About 5% indicated they inform patients of the potential risk, and either prescribe estrogen replacement therapy or oral contraceptives (OCs) to supple-ment low estrogen levels in DMPA users. About 12% said they take no precautions in this area, similar to the 10.6% 2001 figure.
Just-published research, however, may influence your practice. The prospective study, which enrolled women from a Washington state health maintenance organization, compared hip and spine bone density measurements taken in 182 reproductive-age women ages 18-39 receiving DMPA injections to those of 258 comparable women not receiving the drug. Researchers made bone density measurements at the start of the study and repeated them every six months for up to three years.1
Use of DMPA is strongly associated with bone density loss, echoing earlier reports,2,3 the study findings indicate. However, researchers note bone loss associated with DMPA use appears to be largely reversible once the injections are stopped.
When it comes to use of DMPA in adolescent women, long-term impact on bone mineralization is not known. Researchers who examined DMPA use among the women in the Washington state health maintenance organization have begun studying a group of adolescent users to determine the effect of the injection’s use in this age group.
Such information is of great interest to family planning providers. About 95% of respondents to the 2002 CTU survey say they would provide DMPA to teens, slightly less than 2001’s 97% response.
Since the Food and Drug Administration approved the method in 1992, DMPA use has grown among adolescent users. While about half of teens report use of OCs, and a third say they use condoms, about 10% record use of DMPA.4
Many teens try DMPA and stop after a few shots due to weight gain, says Kerry Raghib, CNM, MSN, a certified nurse-midwife at Trinity Medical Center, Medical Arts Clinic in Minot, ND. According to A Pocket Guide to Managing Contraception, providers can use a "teachable moment" to help patients examine options to combat weight gain:
- Eat less. Small, frequent meals help some to lose weight.
- Exercise more.
- Find patterns of eating and exercise you enjoy.
- Call Overeaters Anonymous, a free source of support.
- Drink 10 glasses of water daily.5
Many 2002 CTU survey participants say they advise the importance of calcium supplementation and weight-bearing exercise for good bone health. Women ages 19-50 should get at least 1,000 mg of calcium daily, and teens ages 14-18 should get 1,300 mg, according to Building Strong Bones: It Takes a Lifetime, a new patient education brochure from the Washington, DC-based Association of Reproductive Health Professionals (ARHP). (Review the brochure on ARHP’s web site at www.arhp.org/bonehealth.)
1. Scholes D, LaCroix AZ, Ichikawa LE, et al. Injectable hormone contraception and bone density: Results from a prospective study. Epidemiology 2002; 13:581-587.
2. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991; 303:13-16.
3. Cundy T, Cornish J, Evans MC, et al. Recovery of bone density in women who stop using medroxyprogesterone acetate. BMJ 1994; 308:247-248.
4. Abma JC, Chandra A, Mosher WD, et al. Fertility, family planning, and women’s health: New data from the 1995 National Survey of Family Growth. Vital Health Stat 1997; Series 23, Number 19.
5. Hatcher RA, Nelson AL, Zieman M, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2001.
To order a free copy of the brochure Building Strong Bones: It Takes a Lifetime, contact: Association of Reproductive Health Professionals (ARHP). Tele-phone: (202) 466-3825. E-mail: firstname.lastname@example.org. Providers may order up to 25 brochures free of charge; orders above that number are 10 cents each for ARHP members, 15 cents each for nonmembers, plus shipping charges of $3 for 25, up to a maximum of $10.