DMPA and Bone Health: Settling a Fractious Issue

Summary and Comment |
March 14, 2013

DMPA and Bone Health: Settling a Fractious Issue

  1. Eleanor Bimla Schwarz, MD, MS

Large retrospective cohort study shows DMPA use did not raise fracture risk.

  1. Eleanor Bimla Schwarz, MD, MS

Concerns about the effects of depot medroxyprogesterone acetate (DMPA) on bone health resulted in a black box warning for injectable contraception, and have been hard to lay to rest. In a retrospective cohort study involving 18 years of data from the U.K. General Practice Research Database, investigators identified 312,395 women who used prescription contraception. During 1,722,356 woman-years of follow-up, 11,822 fractures were identified in DMPA users and nonusers.

Overall, absolute fracture rates remained below 1 per 100 woman-years in DMPA users. Analysis of a subcohort of 166,367 women with ≥6 months of baseline history showed that before they initiated contraception, women who chose DMPA had higher fracture risk than those who chose other forms of contraception. After initiation of DMPA use, fracture risk did not increase; furthermore, women in the full cohort who received a cumulative total of ≥8 DMPA injections had lower fracture risk than those who received fewer DMPA injections. Interestingly, analysis of fracture incidence by site showed that DMPA users were more likely than nonusers to sustain traumatic fractures, but not axial fractures.

Comment

These data suggest that those who are interested in promoting bone health might do well to focus more on violence prevention than on limiting contraceptive use. Given the abundant evidence that premenopausal bone mineral density is not an accurate marker of fracture risk or other clinically relevant outcomes, it's time for the FDA to remove the black box warning from depot medroxyprogesterone acetate.

Andrew M. Kaunitz, Editor-in-Chief of Journal Watch Women's Health, is an author on this study but had no role in the selection or editing of the summary.

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