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
- 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)
- 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)
- 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.
- 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
- 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)
- 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)
- The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at intervals throughout the course of treatment. (Grade A)
- 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**
- There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
- There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
- There is poor evidence regarding the inclusion or exclusion of the condition in a periodic health examination.
- There is fair evidence to support the recommendation that the condition not be considered in a periodic health examination.
- 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.
