Review articleThe use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health
Introduction
The contraceptive use of depot-medroxyprogesterone acetate (DMPA, Depo-Provera®) and its potential impact on skeletal health have generated controversy among clinicians who care for women and policy makers [1]. To address these issues, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, on the use of the DMPA contraceptive injections and its potential impact on skeletal health. Physicians delegated by the Federation of General Practitioners of Quebec, the Association of Obstetricians and Gynaecologists of Quebec, the Association of Rheumatologists of Quebec, the Association of Orthopaedic Surgeons of Quebec, the Association of physiatrists of Quebec, the Association of Endocrinologists of Quebec and the Society of Obstetricians and Gynaecologists of Canada were invited to discuss the state of knowledge on the topic with the persons in charge of this sector at the INSPQ. Dr. Andrew M. Kaunitz of the University of Florida College of Medicine-Jacksonville in the United States was also invited to present a synthesis of the results of the most recent research.
Participants reviewed the scientific literature using the study classification method according to the level of proof [2] described in Appendix A, where possible. In the light of this analysis and after reviewing guidelines produced by professional organizations and societies on the impact of DMPA on bone mineral density (BMD), participants reached a consensus position. The present publication reviews the incidence of unintended pregnancy and osteoporosis in Quebec and Canada, characteristics of DMPA, its use, indications, mode of action and metabolic effects. Impact of DMPA, pregnancy, breastfeeding and other risk factors on BMD and fracture risk are presented. Summaries of guidelines of several professional organizations and the consensus position of the Quebec group end this document.
Section snippets
Description and effectiveness
DMPA is an injectable progestin-only product, used as a contraceptive by millions of women in over 90 countries around the world [3] since 1967. It was approved for contraception in the United States in 1992 [4] and in Canada in 1997 [5]. It is considered to be a highly effective contraceptive with a theoretical efficacy of 99.7% (perfect use) and a use efficacy of 97% (use by the general population) [6].
Incidence of unplanned pregnancies
According to the Canadian Contraception Study in 2006 [7], 27% of French-speaking Canadian
Definition
Osteoporosis is defined as a “progressive systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue responsible for a consequent increase in bone fragility and susceptibility to fracture” [29]. Prior to the occurrence of a fracture, osteoporosis can be diagnosed by measuring the BMD. The BMD corresponds to the quantity of calcium in grams per square centimeter measured by dual-photon absorptiometry using X rays. This measurement compared to
Pregnancy and breastfeeding
During pregnancy and lactation, certain physiological changes are associated with reductions in BMD. On one hand, calcium is transferred from the mother to the child for mineralization of the fetus and the incorporation of calcium in maternal milk [43], [44], [45]. On the other hand, post-partum amenorrhea is characterized by hypoestrogenism related to the inhibiting effect of prolactin on the pituitary–gonadal axis and the granulosa cells of the ovary [43], [44], [46].
Evaluating BMD during
Revision of guidelines of learned societies and consensus position
As previously mentioned, in November 2004 and June 2005, respectively, the US Food and Drug Administration [98] and Health Canada [99] issued warnings to advise health professionals and the population that the use of DMPA for contraception could cause a significant loss of BMD, that this loss increased with the length of use and could be incompletely reversible, that long-term use (>2 years according to the FDA) should be reserved for women for whom other contraceptive methods were inadequate
Acknowledgments
The authors wish to thank Dr. Réal Morin (INSPQ) for the management of the scientific meeting, Dr. Andrew M. Kaunitz for coming from the United States and sharing his expertise, Mrs. Eva Ouedraogo (INSPQ) for taking valuable notes during the meeting, Mr. Robert Jacob (INSPQ) for participating as a scientific advisor, Mrs. Ludmila Moulaoui and Souad Ouchelli (INSPQ) for preparing the documentation related to the meeting, Mr. Rafy Dikranian from the regional bank of interpreters of the Health and
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MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies
2020, Reproductive BiologyCitation Excerpt :The controversy surrounding MPA use is mainly related to the administration of the injectable DMPA formulation in contraception, which is different (dosage and various excipients) from the oral formulation used in the present study. This controversy is linked to a plethora of debatable user side effects such as increased weight-gain and risk for hypertension [49], mood changes and depression [50,51], decreases in bone mineral density [52] and more recently potential increased susceptibility to HIV infection [53,54]. However, DMPA is very effective in preventing conception with no pregnancies reported in 16,023 cycles using a new subcutaneous formulation [55].
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2016, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :The greatest loss occurs during the first 1 to 2 years of use, and then BMD levels appear to stabilize.147–149 It is important to note that the BMD loss experienced by both adult and adolescent DMPA users has never been shown to be below 1 standard deviation of normal level (osteoporosis is defined as a BMD reduction of 2.5 standard deviations below normal level), even after 5 years of use.150 This reduction also is in the same range as BMD reduction observed during pregnancy or breastfeeding (a decrease of 4% to 5%), which recovers from baseline once pregnancy is over or breastfeeding is discontinued.150,151
Body weight and body composition of depot medroxyprogesterone acetate users
2014, ContraceptionCitation Excerpt :The concern about weight gain associated with progestin-only contraceptives (POCs) can lead some women to discontinue these methods [2]. One of the most commonly used POCs worldwide is depot medroxyprogesterone acetate (DMPA) [5], a highly effective and safe long-acting reversible contraceptive [6,7]. Nevertheless, in previous studies, its use has been associated with an increase in weight [5,6,8,9], which has led some women to discontinue the method [10,11].