ASK THE EXPERTS
Frequent urination and Depo-Provera
Question: If a patient on Depo-Provera (DMPA) has frequent urination, could it be a warning sign of a more significant problem? What are the necessary steps in further treatment?
— Barb Manion, a provider at a Wisconsin family planning clinic
Andrew Kaunitz, MD, professor and assistant chair of the department of OB/GYN at the University of Florida Health Sciences Center in Jacksonville, FL:
Women using long-acting contraceptives, and sometimes their clinicians, often attribute unrelated health problems to the contraceptive. Frequent urination in a woman using DMPA is not likely related to her DMPA use. The "usual" causes of frequent urination, including urinary tract infections and diabetes, should be considered.
Anita Nelson, MD, medical director of the Women’s Health Care Clinic, Harbor-University of California at Los Angeles Medical Center in Torrance, CA:
What you have described could be a sign of a urinary tract infection or diabetes. In fact, you could make some points here that methods of longer duration, such as the IUD, DMPA, and Norplant are very vulnerable to charges such as these. Anything a woman uses over time, including the pill, is often associated with changes. It is important to be alert to subtle changes, but a urinary tract infection or diabetes is not associated with DMPA.
Susan Wysocki, RNC, BSN, NP, president of the National Association of Nurse Practitioners in Reproductive Health in Washington, DC:
This is the second time I have heard this question. But I have never seen it referenced. I wonder if a possible cause could be hypoestrogenicity? My questions would be: Is her exam normal? Does the patient’s vagina shows signs of decreased rugae? If she is having some vaginal atrophy, the tissue around her urethra could also be atrophic and therefore cause some urinary symptoms.
Question: When do you do a FSH (follicle-stimulating hormone) to confirm menopause in a perimenopausal woman using DMPA? Does she have to be off the DMPA first, and if so, how long? Or will the FSH rise regardless?
— Margie DeLong, CRNP, Barb Korosi, CRNP, Jackie Amalong, CRNP, Family Planning Association of Northeast Ohio in Painesville
Kaunitz: Regarding making the transition from DMPA to HRT, first of all, I am not aware that any data addresses this topic. Accordingly, my recommendations reflect clinical judgment.
Women who use DMPA in their late 40s/early 50s do not experience menopause in the conventional sense i.e., because they may already be amenorrheic, they will not experience the new onset of amenorrhea. Because DMPA suppresses hot flashes, these will not likely occur. Checking FSH levels is not necessarily helpful in this setting, for two reasons. First, menopausal [elevated] FSH levels may be suppressed [lowered] by DMPA. Second, in perimenopausal women, a single elevated FSH does not predict menopause; levels fluctuate markedly in this setting.
Here’s the approach I use when women in their 40s or beyond have been using DMPA and are doing well on it. Women who are perimeno pausal are often relatively hypoestrogenic. In addition, women who use DMPA are also relatively hypoestrogenic. Accordingly, I continue the DMPA and liberally supplement such women with estrogen (e.g. oral conjugated estrogen 1.25 mg daily, 1.25 of estropipate, estradiol 1 mg, or esterified estrogen 1.25 mg.) You also can employ lower doses of estrogen. Alternatively, you can use transdermal estrogen supplementation.
Given the expense and poor predictive value of measuring FSH levels in this setting, I would instead arbitrarily continue the DMPA with supplemental estrogen until the patient is in her mid-50s. At that point, if desired, you can change the patient to conventional hormonal replacement therapy. The risk of ovulation/pregnancy is low in a woman in her mid-50s.
However, if this issue is of concern, to ensure "seamless" contraception in such a woman, I would encourage her to use barrier contraception for the first three to six months after discontinuing DMPA. If the woman did not appear to be heaving regular cycles off hormones [or on HRT], this would tend to confirm that menopause had indeed "arrived" and that the woman need not continue any contraception.
Nelson: This is not a conventional answer, but you may want to consider these ideas: It is really not clinically necessary to perfectly time the diagnosis of menopause in DMPA users. Cross-sectional studies show that long-term users of DMPA may have lower bone mineral density than controls. This bone mineralization loss apparently is reversed over time once a premenopausal woman stops using DMPA.
However, if a woman plans to use DMPA all the way up to menopause, it may be prudent to add physiologic estrogen replacement to the DMPA as the woman approaches the last few of her reproductive years to increase BMD. In this situation, with the woman using DMPA and estrogen, she can be continued on this treatment for a few years beyond the average age of menopause to ensure she does not need contraception. At that time, the DMPA can be transitioned to more conventional menopausal hormonal replacement.
Sharon Schnare, FNP, CNM, a Seattle-based family planning clinician and consultant: If a perimenopausal woman has symptoms of menopause on DMPA, then I would draw an FSH level. If the FSH is 30 or greater, I would consider her menopausal.
DMPA apparently blunts FSH to some degree. If I thought I needed a more accurate FSH, I could wait 12 weeks after her last DMPA shot, draw the FSH at that time.
I am not aware of any studies following FSH in older reproductive-age women on DMPA, so I do not know how long DMPA can blunt FSH after the last injection. It would also be reasonable to stop her DMPA injections at age 50 to 52 and start hormone replacement therapy at that time.
Wysocki: I would think a woman would have to be off DMPA or at the end of the 12 weeks at the very least, but there is also a refractory period of up to 11 to 18 months for return ovulation. If it was going to return, I certainly would not want her to go off contraception altogether. Perhaps you could transition her to oral contraceptives, if estrogen is not a problem, or mini-pills, if irregular bleeding isn’t a problem, then go from there.
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