[ Editorials | Departments and Series | Index ]

Contraception Corner

DMPA: Has it Been a Decade Already?

Anita Nelson, MD; Miriam Zieman, MD

Amid the excitement engendered by the four new birth control methods available this year, it would be easy to overlook the fact that the US Food and Drug Administration-approved Depo-Provera for contraception 10 years ago. But we need to take a moment and recognize that in the past decade the people of the United States have benefited greatly from this extremely effective, convenient, reversible method. Depot medroxyprogesterone acetate (DMPA, a progestin-only injectable administered every 3 months) has made very significant contributions to the goals of reducing unplanned pregnancy. One study calculated that the lion's share of the reduction in teen pregnancy in the United States in the 1990s was due to Depo-Provera and Norplant.¹

However, reviewing the past decade, we can see a curious pattern of use. In general practice, DMPA tends to be offered primarily to special niches of contracepting women: primarily to indigent women, adolescents, and mentally challenged women. One professional woman at a meeting recently volunteered that when she asked for DMPA at her postpartum visit, her doctor told her that she "didn't fit the profile." This practice is concerning, because clinical experience has taught that DMPA is a first-line contraceptive choice. From a narrow medical perspective, DMPA is one of the best contraceptives for women with many medical conditions. Women with seizure disorders are a prime example. Not only does progestin have mild anticonvulsant activity, there are no drug-drug interactions between DMPA and phenobarbital, phenytoin, or carbamazepine as might be expected with other low-dose progestin-only methods (eg, implants or mini-pills) or with estrogen-containing hormonal methods. Women on phenytoin or phenobarbital have alterations in vitamin K synthesis and, as a result, may suffer menorrhagia; DMPA reduces the woman's monthly blood loss. Similarly, women with sickle cell anemia also benefit from reduction of menstrual blood loss. In addition, one Egyptian study has demonstrated that women with sickle cell disease enjoyed a 70% reduction in the number of acute crises they suffered when they used DMPA.² And, of course, the DMPA-associated reduction in menses is important for women who must routinely cope with menorrhagia from adenomyosis or pain from primary or secondary dysmenorrhea. The toll that this latter problem inflicts is legend; dysmenorrhea is the leading cause of lost days of school and work in women aged 25 years and younger.

The question that must be asked is why DMPA is not being used for more women? The barriers tend to fall into three categories: provider concerns, patient concerns, and system issues. In the past year, several studies have provided important information that could change the way DMPA is integrated into the US contraceptive menu.

Clinician concerns about DMPA tend to focus on potential side effects of DMPA as well as access and continuation. Menstrual change concerns take center stage, either because of concerns that patients will not appreciate amenorrhea (see below) or will not tolerate break-through bleeding (BTB). Concerns about potential weight gain also discourage many from offering DMPA, as do concerns about osteoporosis. Interestingly, surveys show that the majority of reproductive aged women desire either infrequent or no menses.³ Discontinuation rates due to BTB and amenorrhea were significantly reduced by specific counseling in a landmark study by de Cetina.⁴ In a rural Mexican clinic of women who intrinsically equated amenorrhea with ill health, the investigators demonstrated that a formal program of structured counseling reduced discontinuation rates for BTB and amenorrhea from 43.4% in the traditional counseling group to 17.1% with structured counseling.

More than a dozen studies in the past 5 years have investigated the impact of DMPA on weight; the results are clearly mixed. Taneepanichskul et al found no difference in weight changes between long-term users of intrauterine devices vs DMPA.⁵ Although this design could be criticized for selection bias, it does provide encouraging reassurance that there are many women who do not gain any weight even with long-term DMPA use. Moore et al found no difference in weight gain with 1-year use of DMPA versus levonorgestrel implants or oral contraceptives.⁶ Risser reported that on average adolescent users of DMPA had greater weight gain than oral contraceptive users, but that virtually all of the difference in weight gain was seen in women whose baseline body mass indexes were elevated.⁷ Most studies that demonstrate significant weight gain show large variations, underscoring the very individual response each woman has to DMPA.^8,9 In the only randomized prospective study of weight gain with DMPA, Pelkman et al demonstrated that short-term DMPA users had no increase in weight or appetite and no decrease in their basal metabolic rates compared to placebo users.¹⁰ The impact of DMPA on the bone mineral density (BMD) of women aged 25 and older is now understood to be temporary; once DMPA is stopped, BMD is normalized in reproductive-aged users.¹¹ Orr-Walker showed that use of DMPA in the reproductive years does not affect BMD measurements of any site in post menopausal women.¹² The long-term impact of DMPA on adolescent bone is currently under study.

New insight into the questions patients may have about DMPA comes from a model contraceptive program in Canada. Since 1999, the Canadians have had access to a toll-free telephone information line. This line has been staffed by registered nurses and advance practice nurses with 8 to 12 years of clinical experience to provide general birth control information to inquiring women and to provide a wide range of support services to clinicians, including placing calls to women reminding them of their next appointments. In 2001, the information line logged 25,000 telephone contacts; the average call time was 5 minutes. Interestingly, analysis of these logs reveals that the questions women have about DMPA vary over time. While they are contemplating DMPA use, 34% of women had questions about potential bleeding changes, 22% had questions about weight changes, and 19% had questions about drug interactions. After women started using DMPA, the dominant issue was bleeding disturbances, with about 70% of the telephone calls about that topic. Initially, their questions were about spotting and bleeding and later about amenorrhea. Once women started using DMPA, questions about weight impacts dropped 5% to 31%. Questions about future fertility increased with duration of DMPA use; 12% of calls after 7 months of use were about this question. Virtually none of the calls after two injections were about drug interactions (4%), efficacy (3%), or BMD (<1%). Market research also indicates that it is important to deal with the issue of injections explicitly as many women are reluctant to raise this issue themselves. This information can be helpful to guide clinical patient counseling. Since patient visit time is limited and since we know that people in general will remember only three or four counseling points, it is important that the information provided during the office visit effectively addresses the patients' concerns.

The issues about access to DMPA are being addressed in many states as contraceptive equity acts are passed. The reality is that many physicians do not stock DMPA, so the patient must first go to her pharmacy and pick up the medication to take to her provider for the injection. Although this may be easier than programs that require women to go to their pharmacies every month to refill their pill prescriptions, other potential approaches to ease access may be available in the future, including from pharmacist-injections, workplace-nurse injections, and even self-injections.

As we enter the second decade of DMPA approval in the United States for contraception, it is clear that the potential for DMPA has only been partially realized and that the future may be even more promising.

REFERENCES

1. Brindis C. Building for the future: adolescent pregnancy prevention. J Am Med Womens Assoc. 1999;54(3):129-132.
2. de Abood M, de Castillo Z, Guerrero F, Espino M, Austin KL. Effect of Depo-Provera or microgynon on the painful crises of sickle cell anemia patients. Contraception. 1997;56(5):313-316.
3. den Tonkelaar I, Oddens BJ. Preferred frequency and characteristics of menstrual bleeding in relation to reproductive status, oral contraceptive use, and hormone replacement therapy use. Contraception. 1999;59(6):357-362.
4. Canto De Cetina TE, Canto P, Ordonez Luna M. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception. 2001;63(3):143-146.
5. Taneepanichskul S, Reinprayoon D, Jaisamrarn U. Effects of DMPA on weight and blood pressure in long-term acceptors. Contraception. 1999;59(5): 301-303.
6. Moore LL, Valuck R, McDougall C, Fink W. A comparative study of one-year weight gain among users of medroxyprogesterone acetate, levonorgestrel implants, and oral contraceptives. Contraception. 1995;52(4): 215-219.
7. Risser WL, Gefter LR, Barratt MS, Risser JM. Weight change in adolescents who used hormonal contraception. J Adolesc Health. 1999;24(6):433-436.
8. Templeman C, Boyd H, Hertweck SP. Depomedroxyprogesterone acetate use and weight gain among adolescents. J Pediatr Adolesc Gynecol. 2000;13(1): 45-46.
9. Espey E, Steinhart J, Ogburn T, Qualls C. Depo-provera associated with weight gain in Navajo women. Contraception. 2000;62(2):55-58.
10. Pelkman CL, Chow M, Heinbach RA, Rolls BJ. Short-term effects of a progestational contraceptive drug on food intake, resting energy expenditure, and body weight in young women. Am J Clin Nutr. 2001;73(1):19-26.
11. Tang OS, Tang G, Yip PS, Li B. Further evaluation on long-term depot-medroxyprogesterone acetate use and bone mineral density: a longitudinal cohort study. Contraception. 2000;62(4):161-164.
12. Orr-Walker BJ, Evans MC, Ames RW, Clearwater JM, Cundy T, Reid IR. The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women. Clin Endocrinol (Oxf). 1998;49(5):615-618.

back to top