Elsevier

Contraception

Volume 79, Issue 3, March 2009, Pages 167-177
Contraception

Review article
The use of depot-medroxyprogesterone acetate in contraception and its potential impact on skeletal health

Proceedings of the Quebec Consensus Meeting on DMPA and Skeletal Health held in Montreal, Quebec, Canada, on February 15, 2008.
https://doi.org/10.1016/j.contraception.2008.10.016Get rights and content

Abstract

Background

In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology.

Study Design

Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations.

Results

The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA.

Conclusion

Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

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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