Original studies
Bone mineral density in adolescent females using depot medroxyprogesterone acetate

https://doi.org/10.1016/j.jpag.2003.11.017Get rights and content

Abstract

Study objective

To examine bone mineral density (BMD) on a semi-annual basis among control subjects and adolescent females receiving depot medroxyprogesterone acetate (DMPA) injection or oral contraceptives.

Design

Non-randomized prospective study.

Setting

Teenage pregnancy prevention intervention clinic.

Participants

Adolescent females who were new users of DMPA injection (N = 58, age12–21) or the oral contraceptive pill (N = 71, age 11–19) and normal menstruating girls (N = 19, age 15–18).

Interventions

Baseline and 6-monthly measures of lumbar vertebral BMD using dual-energy X-ray absorptiometry over a 2-year period.

Main outcome measures

comparison of percent change on BMD over time between DMPA users, pill users, and normal menstruating girls.

Results

There was no difference on group characteristics at baseline except for the ethnicity between the controls and the DMPA grouup. There was a statistically significant decrease in BMD between DMPA users and controls at 6 months (−3.02% change, P = 0.014) 12 months (−3.38% change, P = 0.001) 18 months (−4.81% change, P<0.001) and 24 months (−6.81% change, P = 0.010). There was no statistical difference between pill users and controls.

Conclusion

There is a relationship between DMPA use and a decrease in BMD compared to normal menstruating controls that seems to persist up to 24 months.

Introduction

Bone mineral density (BMD) in females accrues steadily throughout childhood, then rises exponentially during puberty, especially during the ages of 11 through 14, and plateaus with sexual maturity by age 19.1 Up to 90% of the total adult bone content is acquired at the end of the teenage years.2 Therefore, critical changes in bone mass occurring during adolescence may have a profound effect given the peak bone accumulation at this stage of life. Depot medroxyprogesterone acetate (DMPA) is a popular contraceptive method among adolescents because of its effectiveness and dosing schedule. Multiple reports in adults have shown a definitive decrease in bone mineral density in those who use DMPA, with a suggested recovery after discontinuation.3., 4., 5. Evidence in the adolescent population is limited to one report by Cromer et al, who noted decrease in BMD of 3.1% at 2 years in a small number of adolescent patients (n = 8) compared to pill users, levonorgestrel insert users, and normal menstruating controls.6

The objective of this study was to prospectively examine BMD on a semi-annual basis among control subjects and adolescent females receiving DMPA injection or oral contraceptives.

Section snippets

Materials and methods

Approval was received from the Institutional Review Board at the University of Louisville School of Medicine, and signed informed consent was obtained from the patient and from her legal guardian when appropriate. Adolescent females between the ages of 11 and 21 years who presented to our teenage pregnancy prevention intervention clinic who were new users of DMPA injection or the combination oral contraceptive pill were prospectively evaluated. Controls were recruited from those patients that

Results

Data from 148 consecutively recruited patients were included at baseline in the study for analysis. The overall population characteristics at baseline are illustrated on Table 1 and show no difference in mean age, age distribution, BMD, body mass index, smoking or exercise between groups. A greater percentage of African American girls were noted in the DMPA group compared to controls. Patients' group distribution at different followup intervals is presented on Table 2.

Table 3 and Fig. 1

Discussion

Although most studies in adults agree that DMPA negatively affects BMD, Bohamondes et al showed no difference in 50 premenopausal women who used DMPA and those who didn't with a mean age of 31 years old.7 Scholes et al also showed that although patients using DMPA had a decrease on BMD at all ages (18–39 years old). After discontinuation of the drug, patients BMD values returned to normal and noted no difference with non-hormone users.8 This trend was also more marked for recovery in the

Conclusion

The results of our study reject the null hypothesis; in fact there seems to be a relationship between the use of DMPA and a decrease in BMD compared to normal menstruating controls that seems to persist up to 24 months. Further longitudinal longer-term studies may be required to evaluate the impact on adult BMD.

Acknowledgements

We thank Gil Haugh, MS, from the Outcomes Research Institute, University of Louisville, for his help with the statistical analysis. This paper was presented at the North American Society for Pediatric and Adolescent Gynecology 17th Annual Clinical Meeting in May 2003 as the first prize original research award. Funding was provided by the Alliant Community Trust Foundation.

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Synopsis: Depot medroxyprogesterone acetate administration in adolescent females appears to be associated with a decrease in bone mineral density that persists at 24 months of use.

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