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Dr. Jim Shelton's Pearls "Pearl" for the week of July 19, 2005

Injectable Progestin-only Contraceptives and Bone Density

I understand that WHO recently convened a scientific review of injectable progestin contraceptives (such as DMPA [depo-medroxyprogesterone acetate]) and reduced bone density. Can you tell me the result?

Yes. Clearly, there is a legitimate concern because such progestin-only injectables do reduce bone density over time, in all likelihood because they largely suppress the ovaries' natural estrogen production (without replacement with another estrogen as combined oral contraceptives do). These effects are relatively modest and appear to be largely if not completely reversible. Still, there is specific concern about very young women who may not have achieved peak bone mass and older women nearing the menopause.

The WHO expert group examined the current evidence in depth, weighed the risks and benefits, and issued the following recommendation:

• There should be no restriction on the use of DMPA, including no restriction on duration of use, among women aged 18 to 45 who are otherwise eligible to use the method.

• Among adolescents (menarche to <18) and women over 45, the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk. Since data are insufficient to determine if this is the case with long-term use among these age groups, the overall risks and benefits for continuing use of the method should be reconsidered over time with the individual user.

• Recommendations regarding DMPA use also pertain to use of norethisterone enanthate (NET-EN).

Thus, the WHO position is fairly reassuring and in essence consistent with current WHO eligibility recommendations of a Category 1 for women 18 to 45 (Use in any circumstances) and Category 2 for women less than 18 and over 45 (Generally use). (Although for the latter group recommending some ongoing reconsideration with the client over time for long-term use.)

Reference: WHO statement on hormonal contraception and bone health. July 2005.

The "Pearls" offer answers to commonly asked questions about family planning. These "Pearls" are prepared by Dr. James D. Shelton, Senior Medical Scientist, Office of Population, United States Agency for International Development (USAID)

Disclaimer: The information provided on this web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development, the U.S. Government or The Johns Hopkins University.