DMPA has also been successfully used in the treatment of a variety of other gynecologic, menopausal, and oncologic conditions see Table 3. Clinicians should recognize that the use of DMPA for indications other than contraception or metastatic endometrial cancer constitutes off-label use. In fact, DMPA was found to have an even more profound protective effect against endometrial cancer than that attributed to oral contraceptives OC.
Use of DMPA appears to reduce plasma high-density lipoprotein levels, an observation of unknown clinical importance. Based on the absence of such changes, the American College of Obstetricians and Gynecologists suggest that DMPA is an appropriate contraceptive option for women in whom use of combination OC is considered unsafe Table 4.
Table 4. Clinical situations in which depot medroxyprogesterone acetate DMPA may be an appropriate contraceptive choice.
In view of the reassuring epidemiological safety data surrounding DMPA use and the unknown clinical implications of FMD changes in healthy young women, there is no justification for the suggestion that this highly effective injectable contraceptive might adversely impact cardiovascular health.
Clinicians should recognize that use of DMPA has not been linked with postmenopausal osteoporosis or fractures. Results of a meta-analysis of BMD among DMPA users and nonusers based on data from 10 cross-sectional and two longitudinal studies found that average BMD in current users was decreased but was within one standard deviation of the mean in nonusers. Few studies have addressed the impact of DMPA use during adolescence, a period during which it is important to achieve optimal bone mineral density.
A large cross-sectional study conducted in New Zealand, where DMPA has been routinely available as a contraceptive for several decades, 69 found that BMD among postmenopausal women who had initiated DMPA use at a median age of 41 years and continued use for a median duration of 3 years was not significantly different from that in never-users at any site.
These findings remind us that because the skeleton is a dynamic organ, long-term cross-sectional studies may not provide an accurate picture of long-term clinical effects of hormonal exposures.
An example would be a year-old, slender, white, cigarette-smoking DMPA user. Therefore, in long-term, ongoing DMPA users with multiple additional risk factors for low BMD, it would be reasonable to supplement the injections with menopausal doses of estrogen.
Table 5. Greater lumbar spine bone mineral density in depot medroxyprogesterone acetate DMPA users receiving conjugated estrogens versus placebo Based on data from Cundy T et al. J Clin Endocrinol Metab 78, Rates of OC failure and discontinuation can be exceedingly high among teenagers.
In contrast, DMPA can provide highly effective and acceptable contraception in adolescent populations. Women with psychiatric illness or who are mentally handicapped may also benefit from the convenience of injectable contraceptives. Some women choose DMPA for privacy reasons. No one other than their health care providers need know it is being used. Any method of hormonal contraception may be initiated immediately after induced or spontaneous termination of a first- or second-trimester pregnancy.
Women remain at increased risk for thromboembolism for several weeks after childbirth. Ovulation does not occur in nonbreastfeeding women before 25 days postpartum.
Use of combination OC can reduce the quantity and duration of lactation, although such use by well-nourished breastfeeding women does not appear to result in infant development problems. Progestin-only contraceptives do not impair lactation and, in fact, may increase the quality and duration of lactation. Thus, DMPA represents an appropriate choice for lactating women. When initiated immediately or at 6 weeks postpartum, DMPA has not been shown to decrease duration of lactation or infant weight gain.
Clinical experience at the University of Florida Health Science Center—Jacksonville with immediate postpartum initiation of DMPA in lactating women is extensive and reassuring with respect to infant and maternal outcomes.
An American College of Obstetricians and Gynecologists Practice Bulletin likewise supports the maternal and neonatal safety of immediate postpartum administration of DMPA, whether or not the mother is lactating. Use of long-acting progestin contraceptives may be appropriate when contraceptive doses of estrogen are contraindicated. Both pregnancy and combination OC use confer an increased risk for morbidity and mortality in women with the following conditions: 1 age older than 35 who smoke, have hypertension, or have diabetes; 2 coronary artery or other vascular disease; 3 increased risk for thromboembolism; 4 systemic lupus erythematosus SLE ; 87 5 overt hypertriglyceridemia; and 6 active liver disease.
Although combination OC use is contraindicated in patients with overt hypertriglyceridemia, progestin-only methods have not been shown to aggravate the condition.
Further, although active liver disease is a contraindication for combination OC use, a small clinical trial of oral MPA in adults with chronic liver disease suggested that DMPA may be a safe contraceptive choice for women with liver ailments. Package labeling lists some of the aforementioned conditions as contraindications to the use of injectable contraception. Although clinicians should familiarize themselves with the contraindications listed on package labeling for all medications they prescribe, progestin-only hormonal methods are appropriate contraceptive choices for many women with the aforementioned conditions.
A history of breast cancer is listed on package labeling as a contraindication to use of all hormonal birth control methods. Intrauterine devices represent an appropriate reversible contraceptive choice for breast cancer survivors. Anticonvulsants and antibiotics that induce hepatic enzymes see Table 3 can reduce the contraceptive efficacy of OC and levonorgestrel implants.
In addition to enhancing quality of life by allowing couples to choose whether and when they wish to bear children, effective contraception saves health care costs.
An analysis of 15 contraceptive methods found that over a 5-year period, DMPA and the copper-T IUD were the two most cost-effective reversible contraceptives.
After having a seizure disorder diagnosed, a year-old woman recently began therapy with carbamazepine. Two years previously, she had started use of combination OC and had been experiencing regular well-scheduled withdrawal bleeding. After beginning the anticonvulsant, however, breakthrough bleeding occurred. Recent cervical cytology was normal. Likewise, speculum examination revealed no evidence of vaginal or cervical pathology.
Drugs that induce the hepatic P enzyme system see Table 3 increase the metabolism of sex steroids, thus potentially reducing the effectiveness of OC.
Because no reduction in the contraceptive efficacy of mg of DMPA has been reported in women receiving concomitant drugs that induce hepatic enzymes, injectable contraceptives would be an appropriate choice in this case. DMPA also appears to have intrinsic anticonvulsant activity. Similar considerations apply to women using the enzyme-inducing antibiotic rifampin. A year-old has just delivered a healthy infant and will be discharged from the hospital the next day. She plans to breastfeed her infant.
Because combination OC can reduce breast milk volume, they are not an optimal method for lactating women. In addition, combination OC should not be initiated before 2—3 weeks postpartum because of their thrombogenic potential.
DMPA, as well as progestin-only mini pills, can be initiated immediately postpartum and do not suppress lactation. Although package labeling indicates that clinicians should wait until 6 weeks postpartum before initiating progestin-only methods in breastfeeding women, published data indicate that immediate postpartum initiation of long-acting progestin contraceptives and minipills does not compromise lactation or neonatal health.
A year-old woman recently became divorced from her husband, who underwent vasectomy. She smokes one pack of cigarettes daily and notes that her menses have become less predictable. At night she is sometimes kept awake by hot flashes. She has started to date a new partner. Perimenopausal symptoms and menopause occur on average 1 or more years earlier in women who smoke cigarettes.
Although combination OC would restore predictable menses and offer effective contraception for this woman, their use is contraindicated in women older than 35 years who smoke. DMPA would safely provide effective contraception for this woman. Concomitant estrogen supplementation e. This reduction of estrogen levels has been shown to reduce bone mass when used over the long term.
In adult women, this bone mass loss can be recovered when women stop using DMPA and their estrogen levels are restored.
However, concerns have been raised that DMPA in adolescent patients may have an adverse effect on bone growth because these patients have not attained maximal bone mass. This potential decrease in maximal bone mass may have a significant impact on bone fracture risk as these patients age.
Cromer and colleagues evaluated the use of monthly injections of estradiol cypionate in adolescents who receive DMPA and its potential benefit on bone mineral density. The trial was a double-blind, placebo-controlled, randomized study of adolescent females from 12 to 18 years of age who were seeking contraception. Exclusion criteria included the use of DMPA, pregnancy or abortion during the past six months, the use of oral contraception over the past three months, or a treatment or medical condition that may affect bone mineral density.
Before the randomization, participants were stratified by recruitment site, race, and number of years since menarche i. All of the participants received DMPA mg intramuscularly every 12 weeks with an intramuscular injection of 5 mg estradiol cypionate or placebo on a monthly basis. Participant information gathered included tobacco use, calcium intake, physical activity, and menstrual bleeding pattern. Height and weight were measured before the start of the study.
Bone mineral density was evaluated using a dual energy x-ray absorptiometry scan at baseline and at 12 and 24 months using standardized techniques. The main outcome measure was bone mineral density at the end of 24 months.
DMPA was approved by the U. Food and Drug Administration in DMPA blocks ovulation, the release of an egg from the ovaries. DMPA also thickens cervical mucus to block sperm. Each shot lasts for 13 weeks. After that, you must get a new shot to continue preventing pregnancy.
Your doctor will usually give the shot in your upper arm or buttocks, whichever you prefer. Otherwise, you need to use a backup birth control method for the first week. If 14 weeks or more have passed since your last shot, your doctor may perform a pregnancy test before giving you another shot.
The Depo-Provera shot is a highly effective birth control method. Most women taking the shot have progressively lighter periods. This is perfectly safe. Others may get longer, heavier periods. Some countries only permit women who already have 1 child to use Depo Provera. The studies were conducted over 7 and year periods, respectively, with extremely negative results including the death of 3 dogs due to "drug-induced diabetes," atrophication of adrenal glands, and malignant tumors.
There were similar results for the monkey study.
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