Snapshot: Use of DMPA stays steady
It has been two years since a "black box" warning was added to the labeling for the contraceptive injection depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer; New York City; Medroxyprogesterone Acetate Injection, Teva Pharmaceuticals USA, North Wales, PA) The warning states that prolonged use of the drug may result in the loss of bone mineral density (BMD). Has the added warning affected clinicians' practice?
According to results of the 2006 Contraceptive Technology Update Contraception Survey, participants continue to prescribe the drug, especially for younger women. About 86% say they are in favor of prescribing the drug for young teens, similar to 2005 survey results.
The revised labeling advises that DMPA should be used as a long-term birth control method (longer than two years) only if other birth control methods are inadequate. Women who continue to use the drug past the two-year mark should have their BMD evaluated.
Clinicians at the Women's Clinic at the Univer-sity of Florida Student Health Care Center in Gainesville discuss the two-year interval of use, says Phylis Craig, ARNP, clinic supervisor. Clinicians will continue patients on DMPA past the two-year period with education and counseling on the method, she states. DMPA has continued to be very popular among patients ages 18-22, second only to oral contraceptives, says Craig. The injectable drug represents a friendly method for all women, but especially young women, she notes.
DMPA provides a contraceptive option for older women who smoke, says Cathy Smith, ARNP, a family nurse practitioner at Skagit County Health Department in Mount Vernon, WA. Clinicians at her facility lean toward such progestin-only methods for these women, she notes.
Use of DMPA has played an important role in the recently observed declining rates of unintended pregnancy and induced abortion in U.S. teens,1 says Andrew Kaunitz, MD, professor and assistant chairman of the Department of Obstetrics and Gynecology at the University of Florida Health Science Center in Jacksonville. Against this backdrop, it is good news that the labeling change apparently has not curtailed use of the injectable contraceptive, he notes. "In my practice, we field questions from teens and parents regarding bone health issues and DMPA; otherwise, our practice pattern has not changed in terms of ongoing initiation and continuation of injectable birth control," states Kaunitz.
Societies weigh in
What do professional societies say about DMPA, particularly when it comes to use of the drug in adolescents?
The Society for Adolescent Medicine recently released a position paper on the subject.2 Its main recommendation states that clinicians continue to prescribe DMPA, with counseling about the risks and benefits, in most of the adolescent population desiring to use the contraceptive method.2 Clinicians should inform patients about the potential for bone loss, as well as be aware of the individual risk profile for osteopenia on DMPA. Low body weight, particularly a body mass index of <16, has been associated with higher risk of osteopenia in adolescents.1 Other conditions, such as anorexia nervosa, cystic fibrosis, and hyperthyroidism, also have been associated with adverse effects on bone density.1 If an adolescent does not fit the risk profile for osteopenia, she may be expected to use DMPA without risk for the condition. It is up to clinicians, along with their patients, to consider use of dual-energy X-ray absorptiometry (DXA) testing if there are concerns about particular risk factors for osteopenia. However, bone densitometry is not routinely indicated at initiation or follow-up of healthy adolescents who choose DMPA, the guidance states.1
When DMPA's revised labeling was issued, many facilities interpreted the language as a two-year limit on use of the drug; however, current research offers no clear rationale for such practice, the guidance states.1 "We know that as with lactation, DMPA is associated with BMD declines during use, and with recovery following use," says Kaunitz. "In terms of teens and DMPA, it is nice to know that BMD recovers quickly in teens, with complete recovery to baseline BMD by one year after the last injection." Teens who do choose DMPA should be counseled on daily exercise as well as a daily intake of 1,300 mg calcium carbonate plus 400 IU vitamin D, the society guidance advises.1
The American College of Obstetricians and Gynecologists (ACOG) offers the following key points for clinicians when it comes to DMPA use:
- Based on current evidence on DMPA use and skeletal health, concerns regarding BMD should not restrict initiation or continuation of DMPA use in adults or teens.
- Since the clinical implications of dual-energy X-ray absorptiometry testing in premenopausal women are not well established, DXA assessment is not recommended for DMPA users.
- The safety of bisphosphonates in reproductive-age women is not established; therefore, such medications should not be prescribed to current or former DMPA users.
- Encourage adequate calcium intake for DMPA users, as well as for all women, regardless of contraceptive use.3
References
1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90-96.
2. Cromer BA, Scholes D, Berenson A, et al. Depot medroxy-progesterone acetate and bone mineral density in adolescents — the Black Box Warning: A Position Paper of the Society for Adolescent Medicine. J Adolesc Health 2006; 39:296-301.
3. American College of Obstetricians and Gynecologists. DMPA use and skeletal health. ACOG Today 2005; November/ December:9.
It has been two years since a "black box" warning was added to the labeling for the contraceptive injection depot medroxyprogesterone acetate.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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