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For many family planning providers, adolescents represent a significant portion of their patient population. The 1999 Contraceptive Technology Update Contraception Survey explored two issues associated with adolescent reproductive health care: use of Depo-Provera (depot medroxyprogesterone acetate, or DMPA), a progestin-only contraceptive injectable, and treatment of dysmenorrhea.
Since DMPA, manufactured by Pharmacia and Upjohn of Bridgewater, NJ, obtained federal Food and Drug Administration approval in 1992, it has gained acceptance among contraceptive users, particularly among adolescents. It is estimated that 15% of teens ages 15 to 17 use DMPA.1 "It is very, very popular with our teens," says Amador Ramirez, MD, medical director of the Barren River District Health Department in Bowling Green, KY. "We have over 250 patients on Depo right now."
While the effects of DMPA on bone growth and mineralization in adolescents are not yet fully understood, survey respondents say they are willing to prescribe the injectable for young teens. Ninety-six percent of 1999 respondents are in favor of such a practice, up slightly from 93% in 1998. (See chart, p. 107, bottom left column.)
"Depo is very popular among teens in our area, not so much with the college age, because they can’t get it over the summer without a second exam at home," notes Susan Skotleski-Krum, MSN, CRNP, nursing instructor at Lycoming College in Williamsport, PA, who sees patients at the college health center and at local family planning agencies. "College students also are plan -ning to get married out of school, and they worry about when their period will come back, so they tend to stick with the pill. But Depo has been great for teens."
Calcium, exercise urged
Half of adult bone mass is acquired during adolescence, with the most rapid gains in bone mineralization between ages 11 and 14.2 Questions about the use of DMPA center around research indicating that users of DMPA may develop decreased bone density.3 A subsequent study of some of the original DMPA users who discontinued the method found that bone density tended to increase after the method was stopped.4
Until research further clarifies the issue, the majority of survey respondents say they will inform patients of this possible side effect. A total of 53% of readers now inform patients, compared with 63% who said they would do so in 1998. Twenty-seven percent said they take another type of precaution, compared with 19% in 1998, and 17% indicated they do nothing, up slightly from 15% in 1998. (See chart, p. 107, top left column.)
Providers use a variety of approaches. About 37% recommend calcium supplementation, and 26% call for increased calcium and weight-bearing exercise. Other responses include combining calcium supplementation and vitamin D and providing education on smoking cessation.
Patricia Carrick, FNP-C, clinic coordinator at Beaverhead Family Planning Clinic in Dillon, MT, says she informs patients about the potential side effect and prescribes 1,000 mg to 1,500 mg calcium, as well as vitamin D. "We also discuss the importance of exercise and diets," Carrick notes. "It is still a poor substitute for good old estrogen, and I am concerned."
What is your initial approach when a 17-year-old presents with severe menstrual cramps but says she is not sexually active and does not plan to be within the next year?
Almost half (48%) of respondents to the 1999 survey say they would prescribe both OCs and a prostaglandin inhibitor. About 35% said they would use a combination approach in 1998. In 1999, about one-quarter would begin with an OC alone, while 23% would use a prostaglandin inhibitor. (See chart, above.)
The use of both OCs and a prostaglandin inhibitor represents a complementary strategy for targeting the underlying problem of primary dysmenorrhea, according to Contraceptive Tech nology.5 OCs tend to decrease menstrual cramps and pain, including symptoms that have been resistant to therapy with prostaglandin inhibit ors alone.
1. Kaiser Family Foundation. Fact Sheet: Contraceptive Use. Menlo Park, CA: Kaiser Family Foundation; June 1997.
2. Nelson AL. Hormonal influences on young bones: When should we worry? Presented at Contraceptive Technol ogy Conference, Washington, DC, and San Francisco, March 1998.
3. Cundy T, Evans M, Roberts H, et al. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991; 303:13-16.
4. Cundy T, Cornish J, Evans MC, et al. Recovery of bone density in women who stop using medroxyprogesterone acetate. BMJ 1994; 308:247-248.
5. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th ed. New York City: Ardent Media; 1998.