DMPA: Check snapshot of current clinical use

The next patient in your exam room is a 16-year-old young woman who says she needs effective contraception. She has tried oral contraceptives (OCs), but she says she has trouble remembering to take a daily pill. What options can you offer her?

The contraceptive injection depot medroxyprogesterone acetate (DMPA, marketed as Depo Provera, Pfizer, New York City) continues as a top choice for birth control, particularly among adolescents. About 90% of respondents to Contraceptive Technology Update’s 2004 Contraceptive Survey say they would prescribe the injectable for young teens, holding steady from 2003’s level.

The use of DMPA is second only to OCs at Winnebago County Health Department, a public health facility in Rockford, IL, says Gayle Krevel, RN, MS, CLC, supervisor of women’s health.

"Many teens like Depo," states JoElle Thomas, WHCNP, nurse practitioner at Custer Family Planning, a not-for-profit family planning agency in Bismarck, ND. "It is convenient."

What about bone health?

Bone health is an important issue for adolescents: half of a woman’s bone mass is gained during puberty and the first several years after menarche.1

Women who use DMPA may experience bone loss. A recent study indicates that women using the injectable for two years recorded an approximate 6% decline in bone mineral density of roughly 6%, compared with a loss of 2.6% among women on oral contraceptives.2 While earlier research suggests that such loss is reversible after the method is stopped,3 providers may want to include recommendations on calcium replacement and exercise to promote bone health.

About half (52%) of CTU 2004 survey respondents say they inform patients that DMPA may diminish bone mass; 33% use other methods, such as counseling on calcium supplementation and importance of weight-bearing exercise, in emphasizing a bone-healthy message.

"I have many clients on Depo," says Donna Gray, CNM, NP, director of family planning at Wyoming County Public Health Department Men’s and Women’s Health Clinic, a public health facility in Warsaw, NY. "We tell them all to increase their calcium intake."

Weight gain is the primary reason patients stop DMPA, says Tina Mladenka, MSN, OGNP, a Pocatello, ID-based community health nurse practitioner. "DMPA is popular with some of our patients, including teens, but others who have tried it hate it," Mladenka states. "Many of my patients are overweight or obese, and these women seem to have more weight gain problems than the thinner women."

Counseling on the possibility of weight gain is an important part in helping women stay the course with DMPA, according to A Pocket Guide to Managing Contraception. Women may experience an average weight gain of 5.4 pounds in the first year.4 Be sure to weigh women at each visit to monitor potential weight gain, and use the following tips in a "teachable moment" to help patients manage their weight, advise authors of A Pocket Guide to Managing Contraception:

  • Eat less; small, frequent meals helps some to lose weight.
  • Eat a balanced diet with lots of fruits and vegetables and minimal fats, chips, cookies, pasta, and other carbohydrates.
  • Exercise more.
  • Find patterns of eating and exercising that you enjoy! You won’t do them for long unless you enjoy the process.
  • Drink eight to 10 glasses of water daily.
  • Check the web site for Overeaters Anonymous, a free resource: www.overeatersanonymous.org.

References

1. DMPA and bone density loss: an update. Contraception Report 1999; 10(5). Accessed at: www.contraceptiononline.org/contrareport/article01.cfm?art=86.

2. Berenson AB, Breitkopf CR, Grady JJ, et al. Effects of hormonal contraception on bone mineral density after 24 months of use. Obstet Gynecol 2004; 103(5 Pt 1):899-906.

3. Scholes D, LaCroix AZ, Ichikawa LE, et al. Injectable hormone contraception and bone density: Results from a prospective study. Epidemiology 2002; 13:581-587.

4. Hatcher RA, Zieman M, Cwiak C, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2004.