This is the current release of the guideline.

Unintended pregnancy

Counseling
Evaluation
Risk Assessment

Family Practice
Obstetrics and Gynecology

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians

To review the evidence and provide recommendations on the use of depot medroxyprogesterone acetate (DMPA)

Women of reproductive age

1. Counseling of patients on potential effects of depot medroxyprogesterone acetate (DMPA) on bone mineral density
2. Counseling of patients on overall risks and benefits of continuing DMPA use, including:
   • Calcium and vitamin D supplementation
   • Smoking cessation
   • Weight-bearing exercise
   • Decreased alcohol and caffeine consumption

• Bone mineral density
• Risk of fractures

Searches of Electronic Databases

Not stated

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.

II-3: Evidence from comparisons between times or places with or without the intervention. Dramatic results from uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on the Periodic Health Exam.

Systematic Review

Not stated

Expert Consensus

Not stated

Classification of Recommendations*

1. There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
2. There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
3. There is poor evidence regarding the inclusion or exclusion of the condition in a periodic health examination.
4. There is fair evidence to support the recommendation that the condition not be considered in a periodic health examination.
5. There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

*Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on the Periodic Health Exam.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

This update was prepared by the Ad Hoc Depot Medroxyprogesterone Acetate (DMPA) Committee of the Society of Obstetricians and Gynaecologists of Canada. This update was approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

The grades of recommendations (A-E) and levels of evidence (I, II-1, II-2, II-3, and III) are defined at the end of the "Major Recommendations" field.

Summary Statements

1. Depot medroxyprogesterone acetate (DMPA) use is associated with a decrease in bone mineral density (BMD). This decrease appears to be most rapid in the first two years of use. The loss of BMD appears to be largely reversible once DMPA is discontinued. (Level I)
2. DMPA is associated with a decrease in BMD in adolescents during a critical period of bone accretion. BMD decrease during adolescence may result in ultimately lower peak bone mass. (Level I)
3. Available data do not support the routine use of BMD testing in DMPA users. In selected patients with significant risk factors, BMD testing may be appropriate. BMD testing of DMPA users is best done in the context of a clinical study.
4. On the basis of current data, the advantages of using DMPA outweigh the concerns about its use by adolescent or perimenopausal women who have contraindications to, or difficulty using, other contraceptive methods. Research is needed to determine the long-term effects of DMPA use on BMD and future risk of fracture in adolescents and young adults.

Recommendations

1. Health care providers should inform patients of the potential effects of DMPA on BMD and counsel them on "bone health," including calcium and vitamin D supplementation, smoking cessation, weight-bearing exercise, and decreased alcohol and caffeine consumption. (Grade A)
2. Society of Obstetricians and Gynaecologists of Canada (SOGC) endorses the World health organization (WHO) recommendation that "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." (Grade A)
3. The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at intervals throughout the course of treatment. (Grade A)
4. SOGC does not recommend routine BMD testing in DMPA users. (Grade C)

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group.

II-3: Evidence from comparisons between times or places with or without the intervention. Dramatic results from uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Classification of Recommendations**

1. There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
2. There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
3. There is poor evidence regarding the inclusion or exclusion of the condition in a periodic health examination.
4. There is fair evidence to support the recommendation that the condition not be considered in a periodic health examination.
5. There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

*The quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on the Periodic Health Exam.

**Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on the Periodic Health Exam.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate use of depot medroxyprogesterone acetate (DMPA) for the prevention of pregnancy

• Frequently reported side effects with depot medroxyprogesterone acetate (DMPA) include menstrual cycle disturbances, headache, weight changes, and mood effects. Amenorrhea occurs in 55% to 60% of DMPA users at 12 months.
• DMPA use may result in a decrease in bone mineral density.
• Although this is a reversible method of contraception, return of fertility may be delayed for an average of up to nine months.

This guideline reflects emerging clinical and scientific advances as of the date issued and are subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

An implementation strategy was not provided.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2006 Apr

Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society

Society of Obstetricians and Gynaecologists of Canada

Ad Hoc DMPA Committee

Principal Author: Amanda Black, MD, FRCSC, Ottawa ON

Committee Members: Shelia Dunn, MD, CCFP (EM), Toronto ON; Edith Guilbert, MD, MSc, Quebec City QC; Francine Léger, MD, Montreal QC; Melissa Mirosh, MD, Kingston ON; Robert Reid, MD, FRCSC, Kingston ON

Special Contributors: Robert Josse, MD, FRCP, Toronto ON; André Lalonde, MD, FRCSC, Ottawa ON; Vyta Senikas, MD, FRCSC, Ottawa ON

Disclosure statements have been received from all members of the committee.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on April 29, 2009. The information was verified by the guideline developer on May 22, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.