DMPA: Survey offers snapshot of shot use

Rewind to November 2004: the Food and Drug Administration (FDA) announces the addition of a "black box" warning to the labeling for the injectable contraceptive depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer, New York City and MedroxyPROGESTERone Injection, Teva Pharmaceuticals USA, North Wales, PA). The warning highlights that prolonged use may result in the loss of bone mineral density (BMD). What has been the impact on use of the contraceptive shot?

More clinicians are not in favor of prescribing DMPA for young teens, according to results of the 2005 Contraceptive Technology Update Contraception Survey. About 86% say they are in favor of the practice; about 94% approved of such use in 2000.

"Depo popularity has gone down due to the bone density issue and the potential weight gain and the irregular bleeding," reports Lynn Fair, RNC, WHNP, a nurse practitioner at the Columbia/ Boone Health Department in Columbia, MO. She attributes the drop in use due to word of mouth.

The revised label states that bone loss in women who use Depo-Provera is greater with increased duration of use and may not be completely reversible. The injectable contraceptive should be used as a long-term birth control method (longer than two years) only if other birth control methods are inadequate, the label advises. Women who continue to use Depo-Provera past the two-year mark should have their BMD evaluated, according to the labeling.

New research has emerged in 2005 regarding the BMD question. One study’s findings indicate that lower bone density appears to recover in adolescent females once they stop using the contraceptive injection.1 Data from a long-term cohort study comparing BMD in adult DMPA users and nonusers suggest that while bone mineral density declines in current DMPA users, it is followed by recovery after discontinuation.2

In light of questions regarding the impact of contraceptive use on bone health, the World Health Organization has issued a statement on the subject. Its recommendations regarding DMPA state:

  • there should be no restriction on the use of DMPA, including no restriction on duration of use, among women ages 18-45 who are otherwise eligible to use the method;
  • among adolescents (menarche to younger than 18 years old) and women older than age 45, the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk. Since data are insufficient to determine if this is the case with long-term use among these age groups, the overall risks and benefits for continuing use of the method should be reconsidered over time with the individual user.3

Most (60%) participants in the 2005 CTU survey say they only inform women that DMPA may diminish bone mass. About 30% say they take other precautions as well, such as advising dual-energy, X-ray absorptiometry (DEXA) scans to check bone density. About 7% report they provide women with a low-estrogen estrogen replacement therapy drug or a low-dose combined oral contraceptive along with the contraceptive shot.

DMPA has proven to be a popular form of contraception. Among females who received services in Title X-funded clinics during 2003, 16% relied on the contraceptive injection as their primary method of birth control.4

It will be interesting to see if decreased bone density also could be influenced by the fact that many teens using DMPA are part of the "Mountain Dew" generation, says Jackie Bodden, RN-C, APNP, program director and nurse practitioner at the Reproductive Health Care Center in Platteville, WI. Many teens have been drinking soft drinks instead of milk since grade school, she observes.

Clinicians at the Platteville center stress adequate calcium intake for teens, since most adolescents already are not getting the recommended daily amount of calcium, says Bodden. Counseling also stresses daily exercise such as walking to stimulate long bones, she notes.

"Switching off Depo-Provera after two years when this has been their method of choice has only resulted in dissatisfaction and unintended pregnancy," states Bodden.

References

  1. Scholes D, LaCroix AZ, Ichikawa LE, et al. Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception. Arch Pediatr Adolesc Med 2005; 159:139-144.
  2. Kaunitz AM, Kipersztok S. Evaluation of bone mineral density recovery following discontinuation of DMPA-IM contraception. Presented at the American College of Obstetricians and Gynecologists Annual Clinical Meeting. San Francisco; May 2005.
  3. World Health Organization. Statement on Hormonal Contraception and Bone Health. Geneva: July 2005. Accessed at: www.who.int/reproductivehealth/family_planning/bone_ health.html.
  4. Golden AL. OPA Program Instruction Series, OPA 05-01: Updated safety information for Depo-Provera Contraceptive Injection (medroxyprogesterone acetate injectable suspension). Letter. Feb. 10, 2005. Accessed at: opa.osophs.dhhs.gov/titlex/pis/opa05-01.pdf.