Table 11

 Anorexic premenopausal women: no effect of oral contraceptives on bone mineral density

Study designReferenceNo of patientsOC exposureMeasurement of BMD/bone metabolismResults
OC, Oral contraceptive; BMD, bone mineral density; RCT, randomised controlled trial; AN, anorexia nervosa; EE, ethinyl oestradiol; CT, computed tomography; NS, non-significant; DXA, dual energy x ray absorptiometry; BSAP, bone specific alkaline phosphatase; NTx, N-telopeptides; rhIGF-I, recombinant human insulin-like growth factor I.
RCT (level 1b)Klibanski et al7448 women with AN (ages 16–42)0.625 mg Premarin/5 mg Provera (n = 16) v 35 μg EE (n = 6) v control (n = 26) for 18 monthsLumbar spine CTNo significant changes in BMD between oestrogen treated and control groups; 4% increase in BMD in oestrogen treated patients with initial ideal body weight of <70% v 20% decrease in BMD in control patients with initial ideal body weight of <70%
Gordon et al7551 women with AN (ages 14–28)20 μg EE +0.1 mg levonorgestrel v 50 mg dehydroepiandrosterone for 12 monthsLumbar spine, total body, total hip, femoral neck, trochanter DXA; serum osteocalcin, BSAP, urinary NTxNS increase in lumbar BMD in both groups; decrease in urinary NTx in both groups (suggesting decrease in resorption)
Grinspoon et al7660 women with AN35 μg EE+0.4 mg norethindrone (n = 15) v 30 μg/kg rhIGF-I (n = 14) v 30 μg/kg rhIGF-I+35 μg EE+0.4 mg norethindrone (n = 16) v control (placebo rhIGF-I, no OC) (n = 15) for 9 monthsLumbar spine, total body, distal radius, total hip, femoral neck DXAFactorial analysis: no effect of OC on BMD at any site; 4-group analysis: increase in AP lumbar BMD in combined rhIGF-I+OC group v baseline and v placebo; Overall: OCs may augment effects of rhIGF-I on BMD, but are not effective alone
Cohort (level 2b)Golden et al7750 women with AN (ages 13–21)Oestrogen treatment: OrthoTri-Cyclen (35 μg EE+0.18 mg norgestimate, days 1–7; 35 μg EE+0.215 mg norgestimate, days 8–14; 35 μg EE+0.25 mg norgestimate, days 15–21) (n = 10), Ortho-Cyclen (35 μg EE+0.25 mg norgestimate) (n = 6), Lo-Ovral (30 μg EE + 0.3 mg norgestrel) (n = 2), Lo-Estrin (30 μg EE + 1.5 mg norethindrone) (n = 2), Levlen (30 μg EE + 0.15 mg levonorgestrel) (n = 1), Alesse (20 μg EE + 0.1 mg levonorgestrel) (n = 1) (n = 22) v control (n = 28) for 36 monthsLumbar spine, left hip DXAInitial BMDs were decreased compared with the young adult reference mean; no significant changes in BMD from baseline in either oestrogen treated or control groups
Case series (level 4)Muñoz et al7838 women with AN (mean age 17.3 years)50 μg EE+0.5 mg norgestrel for 12 monthsLumbar spine DXANo change in BMD from baseline