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Depressive symptoms and Depo-Provera
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LITERATURE
HIGHLIGHTS
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Hormonal contraception is the DMPA as a contraceptive method most effective reversible method of were compared to trends in 50 birth control. In 1997, depo-medwomen choosing the IUD as a roxy progesterone acetate (DMPA) contraceptive. The women were was approved in Canada for use as a matched for age, sex, parity, contraceptive, introducing the income and weight at the initiaadvantages of high efficacy without tion of the study. the drawbacks of requiring daily The mean body weight at the attention. It is safe and 99 percent 120-month point in the DMPA effective in preventing pregnancy. group was 60.9 +/ -1.2 whereas the Guylaine Lefebvre, MD, FRCSC, Timing of the injections is impormean body weight at the same Site-Chief, Obstetrics and Gynaecology, tant in preventing ovulation. It time in the IUD group was 62.1 Ottawa Hospital, Civic Campus, should be given every 12 weeks, and +/-9.3 kg. There was no statistical Ottawa, Ontario difference between the two groups. there is evidence that the first injection should be given in the first week of the cycle. The The mean change in body weight in the DMPA and IUD convenience of receiving an injection once every three groups was 10.9 +/-1.2 and 11.2 +/-1.5 kg. There was no months is more attractive than other alternatives but statistical difference of mean change in body weight. studies have indicated a high discontinuation rate for the There were five cases of weight loss in the DMPA group drug. Some of the reasons for discontinuation are attriband four cases in the IUD group. uted to side effects or perceived risks associated with the Most previous studies were cross-sectional in design medication. Women may be discouraged from selecting and lacked comparison groups. The authors mention the this method as they are warned of potential weight gain inability to attribute weight change to the DMPA therand the possibility of decreased bone loss. In the last few apy without appropriate controls. This study although small in numbers does limit confounding variables. Longmonths, several studies have addressed those concerns with some insightful observations. term use of DMPA may not have any unfavourable effect on body weight. Comparative study of weight change between long-term DMPA and IUD Spinal bone density in women using acceptors. depot medroxyprogesterone contraTaneepanichskul S, Reinprayoon D, Prayoonsak K. ception. (Contraception 1998 Sept; 58:149-51).
Previous studies have reported conflicting results of weight changes in women choosing DMPA for contraception. Non-randomized studies have not taken into account possible confounding variables and the expected weight gain in the same population using other methods of contraception. This ten-year study was conducted in Thailand where DMPA has been used widely for several decades. Weight trends in 50 women who chose
JOURNAL SOGC
Cundy T, Cornish J, Roberts H, Elder H, Reid IR. (Obstet Gynecol 1998 Oct; 92:569-73).
Depo-medroxyprogesterone acetate prevents ovulation by suppressing gonadotrotrophin secretion. Women using DMPA are usually amenorrhoeic and have low plasma estradiol levels. Estrogen deficiency is associated with bone loss. This study reports the bone mineral density measurements in 200 women using DMPA as a contraceptive.
1103
OCTOBER 1999
,,, Women using DMPA for two years or longer were eligible for the study. Healthy women not using the drug were chosen as controls. One hundred and thirty-seven women were of European origin and 37 were of Polynesian origin. The median duration of DMPA was 12 years, with a range from two to 26 years. Lumbar spine bone density was significantly lower in the DMPA users than the controls in both ethnic groups (p less than .001). The mean z score in the DMPA users was -0.65 (95 % CI -0.80, -0.49). Thirtyseven percent of subjects had a z score of less than -1 and 8.5 percent less than-2.5. There was no relationship between z score and parity, current age, BMI, exercise score or daily calcium intake. Women starting DMPA before the age of 21 had lower z scores than women starting it after this age (-1.05 versus -0.59, p=.052). Two-way analysis of variance demonstrated that both long duration of use and early age at starting had significant effects on bone density. On average, the spinal bone density of women using DMPA was 0.65 standard deviations below the mean of the controls. The authors conclude that bone mineral density is reduced in DMPA users and that the change cannot be accounted for by cigarette smoking. There are no data to suggest that the incidence of fractures is increased in women currently using DMPA. More information is needed before we know if this deficit in bone density is maintained following discontinuation of the drug or if it increases fracture risk later in life.
comparison with women who chose progestin implants, sterilization or oral contraceptives. A depressive symptom score was computed for each study patient. The study included 2,007 women; 25 percent chose DMPA, 45 percent chose progestin implants, 16 percent chose oral contraceptives and 14 percent chose sterilization. Of the 495 women who chose DMPA, 393 (79 %) completed follow-up interviews 12 months after initiation of DMPA. Forty-four percent of women were still using DMPA. The baseline depressive symptom scores showed no difference statistically. Those women continuing to use the DMPA after one year of follow-up had lower depressive symptom scores at baseline than did the women who discontinued use by one year or who were lost to follow-up (p=0.09). There was no evidence in the continuing users or the discontinuers of an increase in depressive symptom scores over 12 months. The subgroup of women who were already experiencing the more depressive symptoms when they began to use DMPA did not experience a worsening of mood during the study period. The findings in this study do not support withholding DMPA because of concerns about possible mood changes. The authors recommend that women should be advised that positive or negative mood changes occur during the use ofDMPA as often as they do without its use.
Depressive symptoms and Depo-Provera.
Timing of onset of contraceptive effectiveness in Depo-Provera users. Effects on ovarian function.
Westhoff C, Truman C, Kalmuss D, Cushman L, Davidson A, Rulin M, Heartwell S. (Contraception 1998 Apr; 57:237-40).
Petta CA, Faundes A, Dunson TR, Ramos M, DeLucio M, Faundes D, Bahamondes L. (Fertil Steril 1998 Nov; 70:817-20).
In the US, the lifetime rate of major depression is 7.4 per 100 women and the annual rate for depressive episodes is three per 100 people. Depression or mood changes has been self-reported by one to five percent of DMPA users who were followed in large, observational studies. These previous studies are hampered by the lack of standardized measurements of mood and baseline measurements before initiation of the drug. This large, multicentre, prospective, cohort study evaluated the presence of depressive symptoms in women who had chosen DMPA as a contraceptive in
The principal mechanism of action of DMPA is inhibition of ovulation. It has been recommended that the initial injection of DMPA be administered within the first seven days of the menstrual cycle in order to prevent ovulation in that cycle. This is inconvenient for patient access and leads to a re-evaluation of the risks of ovulation if DMPA is given at other times during the cycle. Thirty women were enrolled in the study. Pelvic ultrasound was carried out to measure follicular size, and the level of serum was used to assess ovarian activity.
JOURNAL SOGC
Ez
1104
OCTOBER 1999
LITERATURE
HIGHLIGHTS
, , ,
Hormonal contraception is the DMPA as a contraceptive method most effective reversible method of were compared to trends in 50 birth control. In 1997, depo-medwomen choosing the IUD as a roxy progesterone acetate (DMPA) contraceptive. The women were was approved in Canada for use as a matched for age, sex, parity, contraceptive, introducing the income and weight at the initiaadvantages of high efficacy without tion of the study. the drawbacks of requiring daily The mean body weight at the attention. It is safe and 99 percent 120-month point in the DMPA effective in preventing pregnancy. group was 60.9 +/ -1.2 whereas the Guylaine Lefebvre, MD, FRCSC, Timing of the injections is impormean body weight at the same Site-Chief, Obstetrics and Gynaecology, tant in preventing ovulation. It time in the IUD group was 62.1 Ottawa Hospital, Civic Campus, should be given every 12 weeks, and +/-9.3 kg. There was no statistical Ottawa, Ontario difference between the two groups. there is evidence that the first injection should be given in the first week of the cycle. The The mean change in body weight in the DMPA and IUD convenience of receiving an injection once every three groups was 10.9 +/-1.2 and 11.2 +/-1.5 kg. There was no months is more attractive than other alternatives but statistical difference of mean change in body weight. studies have indicated a high discontinuation rate for the There were five cases of weight loss in the DMPA group drug. Some of the reasons for discontinuation are attriband four cases in the IUD group. uted to side effects or perceived risks associated with the Most previous studies were cross-sectional in design medication. Women may be discouraged from selecting and lacked comparison groups. The authors mention the this method as they are warned of potential weight gain inability to attribute weight change to the DMPA therand the possibility of decreased bone loss. In the last few apy without appropriate controls. This study although small in numbers does limit confounding variables. Longmonths, several studies have addressed those concerns with some insightful observations. term use of DMPA may not have any unfavourable effect on body weight. Comparative study of weight change between long-term DMPA and IUD Spinal bone density in women using acceptors. depot medroxyprogesterone contraTaneepanichskul S, Reinprayoon D, Prayoonsak K. ception. (Contraception 1998 Sept; 58:149-51).
Previous studies have reported conflicting results of weight changes in women choosing DMPA for contraception. Non-randomized studies have not taken into account possible confounding variables and the expected weight gain in the same population using other methods of contraception. This ten-year study was conducted in Thailand where DMPA has been used widely for several decades. Weight trends in 50 women who chose
JOURNAL SOGC
Cundy T, Cornish J, Roberts H, Elder H, Reid IR. (Obstet Gynecol 1998 Oct; 92:569-73).
Depo-medroxyprogesterone acetate prevents ovulation by suppressing gonadotrotrophin secretion. Women using DMPA are usually amenorrhoeic and have low plasma estradiol levels. Estrogen deficiency is associated with bone loss. This study reports the bone mineral density measurements in 200 women using DMPA as a contraceptive.
1103
OCTOBER 1999
,,, Women using DMPA for two years or longer were eligible for the study. Healthy women not using the drug were chosen as controls. One hundred and thirty-seven women were of European origin and 37 were of Polynesian origin. The median duration of DMPA was 12 years, with a range from two to 26 years. Lumbar spine bone density was significantly lower in the DMPA users than the controls in both ethnic groups (p less than .001). The mean z score in the DMPA users was -0.65 (95 % CI -0.80, -0.49). Thirtyseven percent of subjects had a z score of less than -1 and 8.5 percent less than-2.5. There was no relationship between z score and parity, current age, BMI, exercise score or daily calcium intake. Women starting DMPA before the age of 21 had lower z scores than women starting it after this age (-1.05 versus -0.59, p=.052). Two-way analysis of variance demonstrated that both long duration of use and early age at starting had significant effects on bone density. On average, the spinal bone density of women using DMPA was 0.65 standard deviations below the mean of the controls. The authors conclude that bone mineral density is reduced in DMPA users and that the change cannot be accounted for by cigarette smoking. There are no data to suggest that the incidence of fractures is increased in women currently using DMPA. More information is needed before we know if this deficit in bone density is maintained following discontinuation of the drug or if it increases fracture risk later in life.
comparison with women who chose progestin implants, sterilization or oral contraceptives. A depressive symptom score was computed for each study patient. The study included 2,007 women; 25 percent chose DMPA, 45 percent chose progestin implants, 16 percent chose oral contraceptives and 14 percent chose sterilization. Of the 495 women who chose DMPA, 393 (79 %) completed follow-up interviews 12 months after initiation of DMPA. Forty-four percent of women were still using DMPA. The baseline depressive symptom scores showed no difference statistically. Those women continuing to use the DMPA after one year of follow-up had lower depressive symptom scores at baseline than did the women who discontinued use by one year or who were lost to follow-up (p=0.09). There was no evidence in the continuing users or the discontinuers of an increase in depressive symptom scores over 12 months. The subgroup of women who were already experiencing the more depressive symptoms when they began to use DMPA did not experience a worsening of mood during the study period. The findings in this study do not support withholding DMPA because of concerns about possible mood changes. The authors recommend that women should be advised that positive or negative mood changes occur during the use ofDMPA as often as they do without its use.
Depressive symptoms and Depo-Provera.
Timing of onset of contraceptive effectiveness in Depo-Provera users. Effects on ovarian function.
Westhoff C, Truman C, Kalmuss D, Cushman L, Davidson A, Rulin M, Heartwell S. (Contraception 1998 Apr; 57:237-40).
Petta CA, Faundes A, Dunson TR, Ramos M, DeLucio M, Faundes D, Bahamondes L. (Fertil Steril 1998 Nov; 70:817-20).
In the US, the lifetime rate of major depression is 7.4 per 100 women and the annual rate for depressive episodes is three per 100 people. Depression or mood changes has been self-reported by one to five percent of DMPA users who were followed in large, observational studies. These previous studies are hampered by the lack of standardized measurements of mood and baseline measurements before initiation of the drug. This large, multicentre, prospective, cohort study evaluated the presence of depressive symptoms in women who had chosen DMPA as a contraceptive in
The principal mechanism of action of DMPA is inhibition of ovulation. It has been recommended that the initial injection of DMPA be administered within the first seven days of the menstrual cycle in order to prevent ovulation in that cycle. This is inconvenient for patient access and leads to a re-evaluation of the risks of ovulation if DMPA is given at other times during the cycle. Thirty women were enrolled in the study. Pelvic ultrasound was carried out to measure follicular size, and the level of serum was used to assess ovarian activity.
JOURNAL SOGC
Ez
1104
OCTOBER 1999