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| |  Bone Loss Associated With Depot Shot No Different Than Loss Caused by Pregnancy, Breastfeeding Washington, DC -- September 4, 2008 -- Concerns about the effects of depot medroxyprogesterone acetate (DMPA) on bone mineral density (BMD) should not prevent clinicians from prescribing this method of contraception nor should its use be limited to 2 years, according to a new Committee Opinion released by The American College of Obstetricians and Gynecologists (ACOG). Though DMPA has a known link to BMD loss, studies show that most of the loss is temporary and is similar to the BMD loss caused by pregnancy and breastfeeding. "Women should be thoroughly counseled about the risks and benefits of DMPA so they can make an informed decision about whether it's right for them," said Denise Jamieson, MD, ACOG's Committee on Gynecologic Practice. "Many women would choose the theoretical risk of future fracture over the very real risk of an unintended pregnancy." In 2004, the US Food and Drug Administration (FDA) issued a black box warning discouraging the use of DMPA for more than 2 consecutive years. The warning states that prolonged use may result in significant loss of BMD and the longer the drug is used, the less likely the loss will be reversed after discontinuation. Additionally, one DMPA manufacturer has recommended bone scans for women after 2 years of use. Bone loss does occur, especially within the first 2 years of DMPA use, but evidence suggests that within 1 to 2 years after discontinuation, BMD in most adolescents and women rebounds to near baseline levels. The FDA's warning is based on intermediate effects on BMD, which may or may not be relevant to increased risk of fracture. Studies show that former adult DMPA users have BMD rates similar to women who have never used the drug. Bone loss in reproductive-aged women is not exclusive to DMPA users. Adult women show similar rates of temporary bone loss during pregnancy (2%-8%) and breastfeeding (3%-5%), when compared with BMD loss sustained by DMPA users (3%-5%). Adolescents using DMPA lose BMD at a time when their BMD would typically increase, which can be a cause of concern. However, while low BMD is linked to an increased risk of fracture in older women, no studies have linked DMPA-related BMD loss with increased rates of fracture in younger women with a low-fracture risk. Daily exercise and age-appropriate calcium and Vitamin-D intake should be encouraged in DMPA users, especially in teens, who often do not get enough calcium. Although studies have shown that low-dose estrogen supplementation slows bone DMPA bone loss, ACOG does not currently recommend it. Clinicians should counsel women on the side effects of DMPA, such as breakthrough bleeding, to curb the high discontinuation rate for this contraceptive method. ACOG recommends that other effective, long-term methods of contraception that have no effect on bone density, such as contraceptive implants and intrauterine devices, should also be considered as first-line methods for adolescents. SOURCE: American College of Obstetricians and Gynecologists
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