Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls

doi:10.1016/j.jadohealth.2004.07.005

Journal of Adolescent Health

Volume 35, Issue 6, December 2004, Pages 434-441

https://doi.org/10.1016/j.jadohealth.2004.07.005 Get rights and content

Purpose

To conduct a longitudinal comparison of bone mineral density (BMD) in 370 adolescent girls, aged 12–18, who self-selected depot medroxyprogesterone acetate (DMPA) or an oral contraceptive (OC) containing 20μg ethinyl estradiol/100μg levonorgestrel with that in girls who received no hormonal treatment (control group).

Methods

Lumbar spine and femoral neck BMD measurements were obtained by dual energy x-ray absorptiometry at baseline and 12 months. Data were analyzed with repeated measures analysis of covariance methods.

Results

Over 12 months, lumbar spine BMD decreased in the DMPA group (n = 29), with a mean percent change of −1.4% (95% confidence interval [CI] −2.73, −0.10), and increased by a mean of 3.8% (95% CI 3.11, 4.57) in the control group [n = 107 (p < .001)]. The increase in mean percent change in lumbar spine BMD in the OC group (n = 79), 2.3% (95% CI 1.49, 3.18), was significantly smaller than in the control group (p = .03). Over 12 months, the mean percent change in femoral neck BMD was −2.2% (95% CI −3.95, −0.39) in the DMPA group, but increased 2.3% (95% CI 1.29, 3.27) in the control group (p < .001). The increase in mean percent change at the femoral neck in the OC group, 0.3% (95% CI −0.87, 1.41), was significantly lower than in the control group (p = .03).

Conclusions

Our study contributes to an increasing body of knowledge indicating a negative impact of DMPA on bone health in young women. Additional findings suggest a potential adverse effect of an OC containing 20 μg ethinyl estradiol/100 μg levonorgestrel on bone health in adolescents.

Section snippets

Materials and methods

This study was designed as a 24-month, prospective examination of BMD and hormonal contraception in adolescents. This report presents results from a 12-month interim analysis. Postmenarcheal girls, ranging from 12–18 years of age, were recruited from four general adolescent health clinics located in a large, urban, metropolitan setting. Specifically, adolescent girls requesting contraception, and selecting either DMPA or OC, were eligible for enrollment. Concurrently, girls attending the same

Results

At baseline, the study population included 370 adolescent girls who self-selected either DMPA (n = 53) or OC (n = 165) as their contraceptive method, or who were abstinent or using a nonhormonal form of contraception (n = 152). Descriptive baseline data are presented in Table 1. The control group was significantly younger in chronologic age and gynecologic age than the other two treatment groups. The OC group had significantly higher body weight and body mass index than the other two groups. No

Discussion

The major question generated from the findings in this study is whether two currently prescribed methods of contraception, DMPA and an OC containing 20 μg ethinyl estradiol/100 μg levonorgestrel, exert a deleterious effect on the skeleton in the adolescent girl. The preponderance of research examining the relationship of hormonal contraception to bone health has been conducted in adult pre-menopausal women of widely varying ages. The implied assumption from these studies is that the results can

References (29)

B.A. Cromer et al.
Prospective comparison of bone density in adolescent girls receiving depot medroxyprogesterone acetate (Depo-Provera), levonorgestrel (Norplant), or oral contraceptives
J Pediatr
(1996)
C. Nappi et al.
Effects of a low-dose and ultra-low-dose combine oral contraceptive use on bone turnover and BMD in young fertile womenA prospective randomized study
Contraception
(2003)
D. Scholes et al.
The association between depot medroxyprogesterone acetate contraception and bone mineral density in adolescent women
Contraception
(2004)
E. Lara-Torre et al.
Bone mineral density in adolescent females using depot medroxyprogesterone acetate
J Pediatr Adolesc Gynecol
(2004)
N.H. Busen et al.
Bone mineral density in a cohort of adolescent women using depot medroxyprogesterone acetate for one to two years
J Adolesc Health
(2003)
A.B. Berenson et al.
A prospective, controlled study of the effects of hormonal contraception on bone mineral density
Obstet Gynecol
(2001)
W. Kuohung et al.
Low-dose oral contraceptives and bone mineral densityan evidence-based analysis
Contraception
(2000)
V. Mais et al.
Bone metabolism in young women taking a monophasic pill containing 20 μg ethinyl estradiol
Contraception
(1993)
F. Polatti et al.
Bone mass and long-term monophasic oral contraceptive treatment in young women
Contraception
(1995)
T. Lloyd et al.
Oral contraceptive use by teenage women does not affect peak bone massA longitudinal study
Fertil Steril
(2000)

S.D. Reed et al.

Longitudinal changes in bone mineral density in relation to oral contraceptive use

Contraception

(2003)

J.A. Pasco et al.

Oral contraceptives and bone mineral densityA population-based study

Am J Obstet Gynecol

(2000)

J.P. Sabatier et al.

Evolution of lumbar bone mineral content during adolescence and adulthoodA longitudinal study in 395 healthy females 10–24 years of age and 206 premenopausal women

Osteoporos Int

(1999)

J.E. Compston

Sex steriods and bone

Physiol Rev

(2001)

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N° 313 - Suppression menstruelle en présence de circonstances particulières
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Parmi ses avantages additionnels, on trouve une absence relative d'interactions médicamenteuses et l'atténuation des convulsions28 et des crises liées aux drépanocytes29. La baisse des taux d'œstrogènes attribuable à l'utilisation d'AMPR pendant l'adolescence est associée à une perte osseuse de 3,1 % au niveau de la colonne lombaire et de 6,1 % au niveau de la hanche19, 30. Heureusement, certaines études laissent entendre que la perte de DMO est transitoire et sa récupération a été démontrée chez des patientes adultes et adolescentes à la suite de l'abandon des injections30–33.
Offrir, aux fournisseurs de soins de santé, un document de consensus canadien comptant des recommandations pour ce qui est de la suppression menstruelle chez les patientes qui font face à des obstacles physiques et/ou cognitifs ou chez les patientes qui font l'objet d'un traitement contre le cancer et pour lesquelles les règles pourraient exercer un effet délétère sur la santé.
Le présent document analyse les options disponibles aux fins de la suppression menstruelle, les indications, les contre-indications et les effets indésirables (tant immédiats qu'à long terme) propres à cette dernière, et les explorations et le monitorage nécessaires tout au long de la suppression.
Les cliniciens seront mieux renseignés au sujet des options et des indications propres à la suppression menstruelle chez les patientes qui présentent des déficiences cognitives et/ou physiques et chez les patientes qui font l'objet d'une chimiothérapie, d'une radiothérapie ou d'autres traitements contre le cancer.
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La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1).
La rédaction (à l'intention des fournisseurs de soins de santé) de lignes directrices traitant particulièrement de la suppression menstruelle au sein des populations exposées à des risques s'avère nécessaire.
- 1
  La suppression menstruelle et l'aménorrhée thérapeutique devraient être considérées comme étant des options sûres et viables pour les femmes qui doivent ou qui souhaitent obtenir une atténuation ou l'élimination de leurs règles (II-2A).
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  Des agents hormonaux combinés ou ne contenant que de la progestérone peuvent être utilisés de façon prolongée ou continue aux fins de l'obtention d'une suppression menstruelle (I-A).
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No. 313-Menstrual Suppression in Special Circumstances
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To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health.
This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression.
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- 1
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  Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia (II-2A).

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Original articlesDepot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls

Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

J Pediatr

Contraception

Contraception

J Pediatr Adolesc Gynecol

J Adolesc Health

Obstet Gynecol

Contraception

Contraception

Contraception

Fertil Steril

Contraception

Am J Obstet Gynecol

Evolution of lumbar bone mineral content during adolescence and adulthoodA longitudinal study in 395 healthy females 10–24 years of age and 206 premenopausal women

Osteoporos Int

Sex steriods and bone

Physiol Rev

Original articles
Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls