Depo-medroxyprogesterone Acetate Use Research Articles

Hubungan Lama Penggunaan Kontrasepsi Hormonal Suntik DMPA dengan Kejadian Disfungsi Seksual, Literature Review

The biggest use of contraceptives in Indonesia is 3-month injectable contraceptives, 3- month contraceptives containing Depo Medroxyprogesterone acetate (DMPA) where long-term use of DMPA contraception results in sex hormone deficiency so that the acceptor experiences sexual dysfunction in aspects of sexual desire (libido) and intercourse pain. The purpose of this study was to analyze the relationship between the long use of DMPA injectable hormonal contraceptives with the incidence of sexual dysfunction in acceptors based on literature studies. The study used is a literature study with the type of Systematic Mapping Study. Articles are taken from databases in the form of Google Schoolar and Elsevier. The population obtained from the database was 23 articles, then screened using the PEOS framework and obtained as many as 5 articles consisting of four national articles and one international article. The results of the analysis of 5 articles found that the duration of DMPA use >2 years was 52.6% and 61.8% experienced sexual dysfunction. The results of the analysis test on the five articles showed that there was a 100% relationship between the duration of using DMPA injectable contraception and the incidence of sexual dysfunction. DMPA injection family planning acceptors should pay attention to the duration of use to reduce long-term risk, one of which is sexual dysfunction.

A ten year review of depot medroxyprogesterone acetate contraceptive use at Rivers State University Teaching Hospital, South Nigeria

Background: Depo Medroxyprogesterone Acetate (DMPA) also known as Depo provera is a long acting progestogen-only contraceptive injection used by women worldwide. It is given deep intramuscularly at interval of 3 months. It is easy to use, effective, safe, convenient and reversible. Objective was to determine the prevalence of DMPA contraceptive method and profile of its acceptors at the RSUTH.Methods: This was a retrospective study of 271 clients attending family planning clinic at the RSUTH from 1st January, 2008 - 31st December, 2017. Their records were retrieved from the clinic and reviewed. Data was extracted, coded and analyzed using the statistical package for social sciences (SPSS) IBM version 25.0 (Armonk, NY).Results: The prevalence rate of DMPA contraceptive among contraceptive acceptors at the RSUTH within the study period was 14.3 %. The modal age group was 30-34 years accounting for 103 (38.0%). Age range was 20-51 years. Two hundred and sixty eight (98.9%) had formal education. Majority of the clients had secondary level of education 209 (77.1 %). Of the 271 acceptors of DMPA, 175 (64.6%) were multipara. Most of the clients were married 259 (95.6%) and of Christian religion 265 (97.8%). Clinical personnel were the commonest source of information, accounting for 228 (84.1%).Conclusions: The prevalence of DMPA use over the study period was low. There is need for more counseling and enlightenment campaign to encourage our women to use this effective and safe method of contraception.

Effects of Long-Term Use of Depomedroxy Progesterone Acetate on Serum Lipids

Introduction: Long Acting Reversible Contraceptive (LARC) is one of the most popular method of family planning. The Aim of the study was to explore the effects of long-term use of Depomedroxyprogesterone acetate (DMPA) which is the most commonly used LARC, on serum lipid profile.
 Methods: This cross-sectional analytical study was carried out in the Department of Obstetrics and Gynaecology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, during the period December 2015 to September 2016. A total 70 married women at the age range of 20-35 years attending, the family planning clinic of BSMMU were included in this study. Out of them 35 subjects who had been using DMPA for ³ two years uninterruptedly were considered as cases and another 35 subjects who did not use any hormonal contraceptives were labeled as control. In both the groups, age and BMI were matched. All the study subjects in both groups were apparently healthy. Fasting blood samples were collected from each subject for the estimation of Total Cholesterol (TC), Triglyceride (TG), High-density Lipoprotein Cholesterol (HDLC) and Low-density Lipoprotein Cholesterol (LDLC). The data were collected in a pre-designed data sheet and analyzed with student T-test for the statistical significance.
 Results: Serum TC and LDLC level in group-I (cases) were significantly higher compared to group-II (control) and the difference was statistically significant (p<0.05). Serum High-density Lipoprotein Cholesterol (HDLC) level in group-I was lower than group-II which was also statistically significant (p=0.001). Serum Triglyceride level in group-I was higher than group- II, however the difference was not statistically significant (p=0.177).
 Conclusion: DMPA use for ³ two years increases serum TC and LDLC and decrease serum HDLC, which may increase the risk of atherosclerosis.
 Bangladesh J Obstet Gynaecol, 2019; Vol. 34(2): 106-111

Serum Vascular Endothelial Growth Factor (VEGF) in DMPA Acceptors: Influence on Bleeding Occurrence

Objective: To analyze the relationship between levels of serum vascular
 endothelial growth factor (VEGF) and bleeding occurrence in
 depo medroxyprogesterone acetate (DMPA) acceptors.
 
 Method: We employed a cross‐sectional study on 70 DMPA acceptors
 with DMPA use of 3 to 6 months who presented for midwifery
 service in Palembang. Blood samples were obtained in order
 to assess levels of serum VEGF using ELISA (enzyme‐linked immunoabsorbent
 assay) method. Laboratory assessments were carried
 out in PRODIA laboratory in Jakarta.
 
 Result: We recruited 70 subjects into our study. After 3 to 6 months
 of using DMPA, as much as 26 subjects (37.1%) reported complaints
 of bleeding and 44 subjects (62.9%) reported no bleeding. The mean
 level of serum VEGF in DMPA acceptors with bleeding was 355 K
 170 pg/ml, and 323 K 202 pg/ml in acceptors with no bleeding. We
 identified a significant association between duration of use and
 bleeding occurrence (p0.05).
 
 Conclusion: In our sample, we found an association between duration
 of DMPA use and presence of bleeding but VEGF levels was not
 found to be different in women experiencing abnormal uterine
 bleeding and those who did not.
 
 Keywords: bleeding, DMPA acceptor, serum VEGF

Use of injectable hormonal contraception and women's risk of herpes simplex virus type 2 acquisition: a prospective study of couples in Rakai, Uganda.

The injectable hormonal contraceptive depo-medroxyprogesterone acetate (DMPA) has been associated with increased risk of HIV acquisition, but findings are inconsistent. Whether DMPA increases the risk of other sexually transmitted viral infections is unknown. We assessed the association between DMPA use and incident herpes simplex virus type 2 (HSV2) infection in women. In this prospective study, we enrolled HIV-negative and HSV2-negative women aged 15-49 years whose HIV-negative male partners were concurrently enrolled in a randomised trial of male circumcision in Rakai, Uganda. We excluded women if either they or their male partners HIV seroconverted. The primary outcome was HSV2 seroconversion, assessed annually. The male circumcision trial was registered with ClinicalTrials.gov, number NCT00425984. Between Aug 11, 2003, and July 6, 2006, we enrolled 682 women in this study. We noted HSV2 seroconversions in 70 (10%) women. Incidence was 13·5 per 100 person-years in women consistently using DMPA (nine incident infections per 66·5 person-years), 4·3 per 100 person-years in pregnant women who were not using hormonal contraception (18 incident infections per 423·5 person-years), and 6·6 per 100 person-years in women who were neither pregnant nor using hormonal contraception (35 incident infections per 529·5 person-years). Women consistently using DMPA had an adjusted hazard ratio for HSV2 seroconversion of 2·26 (95% CI 1·09-4·69; p=0·029) compared with women who were neither pregnant nor using hormonal contraception. Of 132 women with HSV2-seropositive partners, seroconversion was 36·4 per 100 person-years in consistent DMPA users (four incident infections per 11 person-years) and 10·7 per 100 person-years in women who were neither pregnant nor using hormonal contraception (11 incident infections per 103 person-years; adjusted hazard ratio 6·23, 95% CI 1·49-26·3; p=0·012). Consistent DMPA use might increase risk of HSV2 seroconversion; however, study power was low. These findings should be assessed in larger populations with more frequent follow-up than in this study, and other contraceptive methods should also be assessed. Access to a wide range of highly effective contraceptive methods is needed for women, particularly in sub-Saharan Africa. Bill and Melinda Gates Foundation, Doris Duke Charitable Foundation, US National Institutes of Health, and Fogarty International Center.

Cervical Inflammation and Immunity Associated With Hormonal Contraception, Pregnancy, and HIV-1 Seroconversion

Hormonal contraception (HC), younger age, and pregnancy have been associated with increased HIV risk in some studies. We sought to elucidate the biological mechanisms for these associations. Case-control selection of specimens from a large, prospective, clinical study. We enrolled and followed 4531 HIV-negative women from Uganda and Zimbabwe using either the injectable depo-medroxyprogesterone acetate (DMPA), combined oral contraception, or no HC (NH). Innate immunity mediators were measured in cervical samples collected from women at their visit before HIV seroconversion (n = 199) and matched visits from women remaining HIV uninfected (n = 633). Generalized linear models were applied after Box-Cox power transformation. Higher RANTES and lower secretory leukocyte protease inhibitor (SLPI) levels were associated with HIV seroconversion. DMPA users had higher RANTES and lower BD-2 levels. Most inflammation-promoting and/or inflammation-inducible mediators were higher [interleukin (IL)-1β, IL-6, IL-8, MIP-3α, vascular endothelial growth factor, and SLPI], and the protective BD-2 and IL-1RA:IL-1β ratio were lower among combined oral contraception users. Pregnant women showed a similar cervical immunity status (higher IL-1β, IL-6, IL-8, vascular endothelial growth factor, SLPI, and IL-1RA; lower IL-1RA:IL-1β). Age <25 years was associated with lower SLPI, IL-8, MIP-3α but higher IL-1RA:IL-1β. Zimbabwean women (with higher HIV seroconversion rates) had overall higher pro-inflammatory and lower anti-inflammatory protein levels than Ugandan women. HC use, pregnancy, and young age alter cervical immunity in different ways known to increase risk of HIV, for example, through increased levels of pro-inflammatory cytokines or decreased levels of SLPI. Higher levels of RANTES may be one factor underlying a possible association between DMPA use and risk of HIV acquisition.

Effects of hormonal contraceptive use on HIV acquisition and transmission among HIV-discordant couples

The risk of HIV associated with hormonal contraceptives is controversial. We assessed hormonal contraceptive use and HIV incidence in HIV-discordant couples in Rakai, Uganda. HIV-discordant couples were retrospectively identified from a cohort between 1999 and 2009. Hormonal contraception included oral contraception, depomedroxyprogesterone acetate (DMPA), and implants (Norplant). Poisson regression estimated adjusted incidence rate ratios (adjIRRs) associated with hormonal contraceptive methods. A case-control subanalysis estimated odds ratios (ORs) of HIV associated with hormonal contraceptive, adjusted for viral load and age. We identified 190 male HIV-positive/female HIV-negative (M+F-) and 159 male HIV- negative/female HIV-positive (M-F+) couples not using antiretroviral therapy or condoms. Female HIV incidence was 5.8/100 person-years (py) among nonhormonal contraceptive users, 12.0/100 py among oral contraceptive users [adjIRR 2.65, 95% confidence interval (CI) 0.82-8.60], 4.5 among Norplant users (adjIRR: 0.89, 95% CI 0.11-7.10), and 7.5/100 py among DMPA users (adjIRR 1.42, 95% CI 0.60-3.36). Male HIV incidence was 7.4/100 py during nonhormonal contraceptive use, 16.5/100 py during female oral contraceptive use (adjIRR 2.52, 95% CI 0.49-12.95), and 4.9/100 py with DMPA use (adjIRR 0.57, 95% CI 0.19-1.70). The number of female seroconverters was three among oral contraceptive users, one among Norplant users, and seven among DMPA users. Male seroconverters were two during female oral contraceptive use, none with Norplant use, and three with DMPA use. In a nested case-control analysis after adjustment for HIV viral load, the adjOR associated with oral contraceptive use was 1.59 (95% CI 0.32-97.85) for M+F- and 2.11 (95% CI 0.18-25.26) for M-F+ couples. For DMPA use, the adjOR was 1.44 (95% CI 0.46-4.51) for M+F- and 1.40 (95% CI 0.30-6.49) for M-F+ couples. We did not observe significant risk of HIV acquisition or transmission with oral contraceptives or DMPA use in HIV discordant couples, but several point estimates were above 1.0 and statistical power was limited.

Hormonal contraception and the risk of HIV acquisition among women in South Africa

To evaluate the effect of hormonal contraception including combined oral contraceptives (COCs), and the injectable progestins depo-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (Net-En) on the risk of HIV acquisition among women in South Africa. We analyzed data from 5567 women aged 16-49 years participating in the Carraguard Phase 3 Efficacy Trial. Participants were interviewed about contraceptive use and sexual behaviors and underwent pelvic examinations and HIV testing quarterly. We used marginal structural Cox regression models to estimate the effect of hormonal contraception exposure on HIV acquisition risk among women overall and among young women (16-24 years) in particular. Two hundred and seventy participants became HIV-infected (3.7 per 100 woman-years); HIV incidence was 2.8, 4.6, 3.5 and 3.4 per 100 woman-years in the COC, DMPA, Net-En and nonhormonal contraceptive groups, respectively (P = 0.09). The adjusted hazard ratios (AHRs) were 0.84 [95% confidence interval (CI) 0.51-1.39], 1.28 (95% CI 0.92-1.78) and 0.92 (95% CI 0.64-1.32) among COC, DMPA and Net-En users, respectively, compared with the nonhormonal group controlling for covariates. Age modified the effect of hormonal contraception on HIV acquisition risk; among young women, the AHRs were 1.02 (95% CI 0.46-2.28) for COCs, 1.68 (95% CI 0.96-2.94) for DMPA and 1.36 (95% CI0.78-2.35) for Net-En users. In this study conducted among South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.

Combined Oral Contraceptive Use Increases HPV Persistence but Not New HPV Detection in a Cohort of Women From Thailand

Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear how COC use impacts risk of cervical carcinogenesis. We estimated the risk of new human papillomavirus (HPV) DNA detection and persistence among 1135 human immunodeficiency virus (HIV)-negative women aged 20-37 years from Thailand who were followed for 18 months at 6-month intervals. Type-specific HPV DNA, demographic information, hormonal contraceptive use, sexual behavior, genital tract coinfection, and Papanicolaou test results were assessed at baseline and each follow-up. Women who reported current COC use during follow-up were less likely to clear HPV infection compared with nonusers, independent of sexual behavior, and Papanicolaou test diagnosis (AHR: 0.67 [95% CI: .49-.93]). Similar associations were not observed among women reporting current use of depomedroxyprogesterone acetate (DMPA). Neither COC nor DMPA use was significantly associated with new HPV DNA detection. These data do not support the hypothesis that contraceptive use is associated with cervical cancer risk via increased risk of HPV acquisition. The increased risk of HPV persistence observed among current COC users suggests a possible influence of female sex hormones on host response to HPV infection.

Effects of Long-term Use of Depo-medroxyprogesterone Acetate on Lipid Metabolism in Nepalese Women

Various synthetic progestogens that are used as contraceptives have been reported to influence lipid and lipoprotein fractions differently. Depo-medroxyprogesterone acetate (DMPA), a synthetic progestogen, is used by Nepalese women as a contraceptive agent. Our study aims to determine the effects of long-term use of DMPA on lipid metabolism. We performed this study on 60 healthy Nepalese women who had been using DMPA for more than 2 yr and age- and weight-matched control subjects who were not using hormonal contraceptives. Fasting blood samples were collected from the subjects for the estimation of total cholesterol (TC) and triglyceride (TG) levels, and the levels of high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) were estimated using the Friedewald's equation. TC and LDL-C levels in DMPA users were significantly higher than those in non-users. Our study concluded that DMPA use induces lipid metabolism changes that can increase the risk of cardiovascular diseases.

Reproductive Hormones and Skeletal Health in Young Women

In young women, low estrogen levels complicate a wide variety of diseases, including premature ovarian failure, anorexia nervosa, athletic amenorrhea, prolactinoma, hypopituitarism, and chronic kidney disease. Hypoestrogenemia may also result from therapy with GnRH agonists, glucocorticosteroids, chemotherapy, and especially aromatase inhibitors. All of these situations are associated with bone loss, because estrogen chronically suppresses bone resorption. Several mechanisms are involved: 1) estrogen increases osteoclast apoptosis; 2) by suppressing interleukins and proinflammatory cytokine expression in bone marrow cells, estrogen decreases the number of osteoclasts; 3) by inhibiting the production of receptor activator of nuclear factor-κB ligand, estrogen reduces the number and activity of osteoclasts; and 4) by increasing stromal cell/osteoblast cell expression of TGFβ, estrogen inhibits osteoclast activity. Estrogen also has some positive effects on bone formation by acting as a mitogen to cells early in the osteoblast line, reducing apoptosis of osteoblasts, and increasing expression of TGFβ, bone morphogenetic proteins, and IGF-I (1). In these pathological conditions, the cause of the bone loss is frequently multifactorial. For example, women with anorexia nervosa also have low IGF levels. Nonspecific factors such as poor diet, reduced exercise, or chronic inflammation may further increase bone resorption. Low estrogen levels are also seen in healthy young women who are using depo-medroxyprogesterone acetate (DMPA) for contraception. Bone loss is a side effect of this medication (2). The bone mineral density (BMD) decreases at a more rapid rate during the first years of therapy and then continues to decrease at a slower rate (3). After 5 yr, the loss is about 6% (0.5 sd). The DMPA effects are worse in teenagers; combined results from four prospective studies found an average loss of spine BMD of 3.1% over 2 yr in DMPA users compared with a gain of 7.2% in untreated controls (4). A cross-sectional study in this issue by Walsh and colleagues (5) focused on the age of starting DMPA. One group aged 18–25 started DMPA before age 20, and another group aged 35–45 started after age 34. Each group had matched controls. Importantly, the average use was 37 months in both groups. This avoids the confounding between age and duration of use, which is encountered in other studies. The BMD was significantly lower than controls when DMPA was started in teenagers but not when it was started after age 34. Estrogen levels were lower in the DMPA users than the non-hormone users and were also lower in the younger women than in the older women. The authors concluded that estrogen levels mediated the effect of DMPA on bone markers because adding DMPA to a regression model reduced the correlation between markers and estrogen. These correlations were not very strong (r = −0.17 between N-telopeptide and estradiol-treated), so this is a tenuous conclusion, but it is bolstered by the findings from two other studies that adding estrogen to DMPA abolishes the negative effect on the skeleton (6,7). The age range of the older group of women is underrepresented in most of the previous studies of skeletal effects of DMPA. These results lead to several questions about basic bone biology. How are adolescent bones different from mature bones? How does DMPA use compare to the natural state of low estrogen seen in healthy lactating women? Is bone completely restored in these situations? There are also important clinical questions about potential risk of fractures and the skeletal risks from other forms of contraception.

Risk factors for repeat elective abortion

Repeat abortions account for 48% of all induced abortions in the United States. This study aims to identify correlates of repeat abortion in a US clinic. This cross-sectional study investigates a consecutive sample of 398 women who received elective abortion in an urban hospital. All participants answered demographic, reproductive, and other questions. Older women were more likely to have had a previous abortion than teenagers (odds ratio for women 20-29 years old, 2.9 [95% CI, 1.5-5.7]; odds ratio for women >or=30 years old, 6.7 [95% CI, 2.8-16.0]). Alcohol/drug abuse (odds ratio, 2.6; 95% CI, 1.3-5.3) also correlated with increased odds of previous abortion. Depo medroxyprogesterone acetate use approached a significant association (odds ratio, 3.2; 95% CI, 1.0-10.5). The associations between both alcohol/drug abuse and depo medroxyprogesterone acetate use and repeat abortion are new findings. Future studies are needed to identify modifiable risk factors for repeat abortion and to identify populations in which interventions, such as long-term contraception, may lower the risk.

Depo medroxyprogesterone acetate use in obese and morbidly obese women: incidence of ovulation

Depo medroxyprogesterone acetate use in obese and morbidly obese women: incidence of ovulation

Steroid hormones for contraception in women with sickle cell disease

Whether steroid contraceptives are appropriate for women with homozygous sickle cell (SS) disease remains unresolved. Historically, women with SS disease have experienced difficult pregnancies, characterized by high rates of maternal mortality and morbidity and poor infant outcomes. Unresolved questions about steroidal contraceptives in women with SS disease include whether using them may promote blood clots. To assess the safety of steroid hormones in this setting, we retrieved and analyzed all randomized controlled trials that examined steroid hormones for contraception in women with SS disease. We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, POPLINE and EMBASE (each from its inception to November, 2005) for randomized controlled trials of steroid hormone use for contraception in women with SS disease. We examined the reference list of each trial as well as that of review articles. We included any randomized controlled trial in any language that compared steroid hormones for contraception with another contraceptive or placebo. Frequency or intensity of sickle pain crises must have been reported as an outcome. We assessed for inclusion all titles and abstracts found. We evaluated the methodological quality of the trial found for potential biases by qualitatively assessing the study design, randomization method, allocation concealment, blinding, premature discontinuation rates, and loss to follow-up rates. We entered trial results in RevMan and reported Peto odds ratios with 95% confidence intervals for dichotomous outcomes, such as occurrence of sickle pain crises. Only one trial met the inclusion criteria. Twenty-five patients were randomized to three monthly depo-medroxyprogesterone acetate (DMPA) or intramuscular saline placebo injections in a crossover design. A six-month washout period was implemented before the crossover; however, pharmacological evidence indicates that levels of DMPA may be detected for more than 200 days after the injection. During DMPA use, women were less likely to experience painful sickle episodes (OR 0.23; 95% CI 0.05 to 1.02). No trial involved estrogen products. The limited available data suggest that DMPA is a safe contraceptive option for women in SS disease. In addition to providing effective contraception, DMPA may reduce sickle pain crises.

The Developmental Association of Relationship Quality, Hormonal Contraceptive Choice and Condom Non-Use among Adolescent Women

Purpose Consistent condom use is critical to efforts to prevent sexually transmitted infections among adolescents, but condom use may decline as relationships and contraceptive needs change. The purpose of this research is to assess changes in condom non-use longitudinally in the context of changes in relationship quality, coital frequency and hormonal contraceptive choice. Methods Participants were women (aged 14–17 years at enrollment) recruited from three urban adolescent medicine clinics. Data were collected at three-month intervals using a face-to-face structured interview. Participants were able to contribute up to 10 interviews, but on average contributed 4.2 interviews over the 27-month period. Independent variables assessed partner-specific relationship quality (five items; scale range 5–25; α = .92, e.g., this partner is a very important person to me); and, number of coital events with a specific partner. Additional items assessed experience with oral contraceptive pills (OCP) use and injected depo medroxy-progesterone acetate (DMPA). The outcome variable was number of coital events without condom use during the past three months. Analyses were conducted as a three-level hierarchical linear growth curve model using HLM 6. The Level 1 predictor was time, to test the hypothesis that condom non-use increases over time. Level 2 predictors assessed relationship quality and coital frequency across all partners to assess hypotheses that participants’ condom non-use increases over time as a function of relationship quality and coital frequency. Level 3 predictors assessed the participant-level influence of OCP or DMPA experience on time-related changes in condom non-use. Results A total of 176 women reported 279 sex partners and contributed 478 visits. Both average coital frequency and average condom non-use linearly increased during the 27-month follow-up. At any given follow-up, about 35% reported recent OCP use, and 65% reported DMPA use. HLM analyses showed that condom non-use increased as a function of time (β = .12; p = .03, Level 1 analysis). Increased condom non-use over time was primarily a function of increased coital frequency (β = .01; p = .00), although higher levels of relationship quality were associated with increased condom non-use at enrollment (β = .44; p = .00, Level 2 analysis). The temporal rise in condom non-use significantly increased among DMPA users (β = .06; p = .00) but not OCP users (Level 3 analysis) (β = −.04; p = .06). Conclusions Developmentally, relationship characteristics and coital frequency appear to have increasing weight in decisions about condom use. Hormonal contraceptive methods are not equivalently associated with the overall temporal decline in condom use. Future research associated with dual contraceptive/condom use should address differential factors associated condom use in combination with different hormonal methods.

Bone Mineral Density Assessment in Premenopausal Women

In the absence of fragility fractures, low bone mineral density may reflect attainment of a lower peak bone mass in comparison with the young adult mean value. It is necessary to distinguish between low peak bone mass and a systemic disorder resulting in low bone mineral density and skeletal fragility. Low peak bone mass in the absence of fragility fracture or progressive bone loss may not require pharmacological intervention. However, systemic disorders contributing to bone loss do require diagnosis and intervention. Common causes of low bone density in premenopausal women include ovulatory disturbances and low body weight. Other diseases, conditions or medications may also contribute to bone loss and these should be identified and treated if present. Fracture risk is reduced by lifestyle changes and pharmacological intervention in those with glucocorticoid-induced bone loss. Discontinuing depo medroxyprogesterone acetate use has been associated with improvements in bone mineral density. Bone mineral density alone is insufficient for the diagnosis of osteoporosis in premenopausal women in the absence of fragility fractures. Bone mineral density testing should only be performed in premenopausal women in the presence of approved indications.

Long-Acting Injectable Progestin Contraception and Risk of Type 2 Diabetes in Latino Women With Prior Gestational Diabetes Mellitus

To investigate the impact of a long-acting injectable progestin, depo-medroxyprogesterone acetate (DMPA), compared with combination oral contraceptives (COCs) on the risk of diabetes in Latino women with prior gestational diabetes mellitus (GDM). An observational cohort study of 526 Hispanic women with prior GDM who were not diabetic in their postpartum visit during January 1987 to October 1997 and who elected DMPA (n = 96) or COCs (n = 430) as initial contraception were followed for a maximum of 9.2 years with a median follow-up of approximately 12 months. Oral glucose tolerance tests were performed and choice of contraception method was recorded at each visit as part of routine clinical care. Annual diabetes incidence rates were 19% in the DMPA group and 12% in the COC group, with an unadjusted hazard ratio (HR) of 1.58 (95% CI 1.00-2.50; P = 0.05) for DMPA compared with COCs. Adjustment for baseline imbalances reduced the HR to 1.18 (0.67-2.28; P = 0.57). Additional adjustment for weight gain during follow-up, which was on average 1.8 kg higher in the DMPA group (P < 0.0001), reduced the HR to 1.07. DMPA interacted with baseline serum triglyceride levels and, separately, with breast-feeding to increase the diabetes risk. DMPA use was associated with an increased risk of diabetes that appeared to be explained by three factors: 1) use in women with increased baseline diabetes risk, 2) weight gain during use, and 3) use with high baseline triglycerides and/or during breast-feeding.

Vaginal Yeast Colonization in Nonpregnant Women: A Longitudinal Study

We sought to investigate the prevalence and risk factors for vaginal yeast colonization over a 1-year period. We conducted a longitudinal cohort study of 1,248 asymptomatic young women by collecting demographic and behavioral data at baseline, 4, 8, and 12 months. Seventy percent of women were colonized by vaginal yeast at one or more visits, but only 4% were colonized at all 4 visits. Using an adjusted generalized estimating equation model, factors associated with vaginal yeast colonization were marijuana use in the previous 4 months, depomedroxyprogesterone acetate use in the past 4 months, sexual intercourse in the previous 5 days, and concurrent colonization with lactobacilli and group B streptococcus. Symptoms of pruritus and vulvovaginal burning were associated with yeast colonization, but antifungal use was not. Recent sexual intercourse and use of injection contraceptives are risk factors for yeast colonization. Rates of antifungal use did not show an association with yeast colonization. The reporting of antifungal use by women lacking yeast colonization suggests that self-diagnosis is inaccurate. II-2.

The impact of lifestyle factors on stress fractures in female Army recruits.

Estimates are that stress fractures during basic training (BT) occur in as many as 14% of US female military recruits. Injuries of this type lead to morbidity ranging from minor pain to serious lifetime disability. Since women are assuming an increasing role in the military, this high risk of stress fracture is of concern. The purpose of this prospective study was to determine factors that predict stress fracture during BT in US Army female recruits. The analysis was part of an investigation using quantitative ultrasound (QUS) to determine risk of stress fracture during BT. Prior to the start of BT, we obtained QUS measurements and asked each subject to complete a risk factor questionnaire. We completed assessments for 3758 recruits who then proceeded to 8 weeks of BT, during which time any diagnosed stress fractures were reported to us by Army clinicians. Stress fractures were confirmed with radiographs. The incidence of stress fracture was 8.5% per 8 weeks. Factors associated with stress fracture include: QUS, age, race, alcohol and tobacco use, weight-bearing exercise, lowest adult weight, corticosteroid use, and, in white women only, use of depo-medroxyprogesterone acetate (DMPA). Women who fractured were older than women who remained fracture-free, and black women were less likely to sustain a fracture than whites and other races. Compared with their non-stress-fracture counterparts, recruits who developed stress fractures were more likely to report current or past smoking, alcoholic drinking of > 10 drinks/week, corticosteroid use and lower adult weight. A history of regular exercise was protective against stress fracture, and a longer history of exercise further decreased the relative risk of fracture. Although current weight was not associated with stress fracture, lowest adult weight was inversely related to the risk of fracture. We conclude that prevention of stress fractures in female military recruits should include a thorough assessment of lifestyle factors such as exercise patterns, alcohol and tobacco habits, and corticosteroid and DMPA use. Assessment of risk factors may be helpful in pinpointing female recruits who should have further evaluation of their bone health or additional preparation, such as gradual increases in physical activity, prior to being exposed to the rigor of BT.

Depomedroxyprogesterone-induced Hypoestrogenism and Changes in Vaginal Flora and Epithelium

Objective: To identify the effects of depomedroxyprogesterone acetate (DMPA) on vaginal microbial flora and epithelium. Methods: Women who desired DMPA for contraception were evaluated before and at 3 and 6 months after initiation of 150-mg DMPA injections every 3 months. At each visit we assessed genital symptoms vaginal signs vaginal microflora and histopathology by vaginal biopsies. Results: Among 38 women observed for 6 months there was significant reduction in mean serum estradiol level (99.9 +or- 9.3 pg/mL to 26.6 +or- 1.6 pg/mL P < .001). The number of subjects with any Lactobacillus did not change but the number with hydrogen peroxide (H2O2)-positive Lactobacillus decreased from 20% before to 12% after 6 months of DMPA (P = .005). The log concentration in colony-forming units per milliliter of vaginal fluid of H2O2-positive Lactobacillus decreased in a linear manner from 4.0 +or- 0.6 at baseline to 2.5 +or- 0.6 after 6 months of DMPA use (P = .006). The mean number of cell layers in the epithelium was reduced slightly from 28.1 +or- 0.7 to 25.9 +or- 0.9 (P = .05) epithelial thickness decreased from 1.02 +or- 0.04 mm to 0.89 +or- 0.05 mm (P = .005) and the glycogen-positive thickness decreased from 0.81 +or- 0.04 mm at baseline to 0.66 +or- 0.05 after 6 months of DMPA use (P = .005). Conclusion: Depomedroxyprogesterone acetate produced a systemic hypoestrogenic state associated with decreased H2O2-positive Lactobacillus colonization and slight thinning of the glycogen vaginal epithelial layer. Such changes possibly compromise the vaginal barrier to infection.