OsteoEd

Practice Cases

Depot Medroxyprogesterone Acetate (Depo-Provera, DMPA) Effects on Bone Mineral Density

Kim O'Connor, MD Literature reviewed August 23, 2007. Updated November 23, 2008

An 18 year old female is seeing you for her preventive health visit. She has been taking Depo Provera® (DMPA) for the past three years. She read something in a women's magazine about Depo Provera affecting bone density. She wants to know if this is something that she should be concerned about and if she should stop the medication.

  • PMHx:
    • Remarkable for irregular menses.
    • Weight 108 lbs. BMI 16
  • FHx: No h/o osteoporosis
  • Soc Hx:
    • Occasionally smokes 2-4 cigarettes on the weekends
    • She is a ballet dancer
  • Medications:
    • Depo Provera: 150 mg IM every three months
    • Occasional multivitamin

Click an answer under each question.

  1. What happens to bone mineral density (BMD) in adolescents on DMPA?

    • Option A BMD decreases in the hip and spine by 4% per year
    • Option B BMD is unchanged, but during this age one expects to see an increase in BMD
    • Option C BMD decreases in the spine only by 1-2 % per year
    • Option D BMD decreases in both the spine and hip but rate losses are variable between studies

  2. She wants to know if her risk of fracture is higher if she continues to take the DMPA? What do you tell her?

    • Option A Fracture risk in adolescents decreases with longer duration of use
    • Option B Fracture risk is unknown
    • Option C Fracture risk is increased in postmenopausal women who used DMPA during adolescence
    • Option D Fracture risk in adolescents increases with longer duration of use

  3. What is the mechanism of bone loss?

    • Option A DMPA directly inhibits osteoblasts
    • Option B DMPA causes estrogen deficiency
    • Option C DMPA directly activates osteoclasts

  4. She wants to know if other progestogen-only forms of birth control have a similar effect on bone density as DMPA?

    • Option A Yes, they are all associated with a decrease in bone density compared to nonusers
    • Option B No, none of them have been shown to cause a decrease on bone density
    • Option C It is variable depending on the type of progestin used

  5. Does adding estrogen help to minimize bone loss?

  6. Is there anything she can be doing to prevent additional bone loss?

    • Option A Encourage non-weight bearing exercise several times per week
    • Option B Recommend calcium supplementation if her diet is low in calcium rich foods
    • Option C Recommend a low protein diet

  7. What will happen to her bone density once she stops the DMPA?

    • Option A When she becomes postmenopausal, her bone mineral density will be significantly lower than nonusers of DMPA
    • Option B Her bone mineral density will increase more rapidly than nonusers of DMPA
    • Option C Her bone mineral density will continue to decline at rates faster than in the nonusers of DMPA
    • Option D There will no change in her bone density

  8. Her mom told her to ask you to order a bone density (DEXA) scan. Which other elements in her history may make this a reasonable request?

    • Option A Her Body Mass Index is 16
    • Option B She takes ballet classes three days per week
    • Option C Prior to her use of DMPA, she had irregular menstrual periods

  9. She does not think that she can be compliant with other birth control options. She does not want an IUD or any type of implant. She wants to know if you feel that the DMPA should be discontinued. You tell her:

    • Option A She should stop it because of the FDA Black Box Warning that it should not be used longer than 2 years
    • Option B This seems to be the best birth control method for her and the risks of pregnancy outweigh the risks of continuing DMPA
Key Points
Last edited July 03, 2009