Bone Health Management for Long-Term DMPA Users
Counsel your patient on calcium and vitamin D supplementation, regular weight-bearing exercise, and avoidance of smoking and alcohol to maintain skeletal health while continuing depot medroxyprogesterone acetate (DMPA) injections. 1
Core Recommendations for Bone Health
While continuing DMPA after 9 years of use, implement the following evidence-based interventions:
Lifestyle and Supplementation
- Ensure adequate calcium and vitamin D intake through diet or supplementation at age-appropriate doses 1, 2
- Recommend regular weight-bearing exercise to help maintain bone mineral density 1
- Strongly advise smoking cessation if applicable, as tobacco use compounds bone loss risk 1
- Counsel on alcohol avoidance or minimization, as chronic alcohol use increases osteoporosis risk 1
Understanding the Bone Density Changes
Your patient should understand these key facts about DMPA and bone health:
- Bone mineral density (BMD) loss is greatest in the first 2 years of DMPA use, with smaller declines in subsequent years 2
- After 5 years of use, mean BMD decreases of approximately 5-6% at the spine and hip have been documented 2
- BMD loss is largely reversible after DMPA discontinuation, with partial recovery occurring during the 2-year post-therapy period 1, 2, 3
- No high-quality data demonstrate that DMPA increases fracture risk in adolescents or adults later in life 3
Bone Density Screening Considerations
Routine DEXA scanning is not recommended for women using DMPA, even with long-term use 1. However:
- Consider BMD evaluation if your patient has additional osteoporosis risk factors such as metabolic bone disease, chronic corticosteroid use, anorexia nervosa, or strong family history of osteoporosis 2
- If BMD assessment is performed and shows significant loss, this information should inform ongoing risk-benefit discussions about continuing DMPA 2
Important Clinical Context
The FDA black box warning about bone loss should not automatically preclude continued DMPA use beyond 2 years 3. The decision to continue should weigh:
- Current evidence suggests BMD recovery occurs after discontinuation, making the long-term clinical significance uncertain 1, 3
- The health risks of unintended pregnancy must be balanced against theoretical bone health concerns, particularly since your patient wishes to continue this method 3
- DMPA remains appropriate for long-term use when other methods are inadequate or unacceptable to the patient 2, 3
Common Pitfalls to Avoid
- Do not discontinue DMPA solely based on duration of use without considering the patient's contraceptive needs and preferences 3
- Do not order routine DEXA scans in otherwise healthy women using DMPA, as there is no evidence supporting this practice 1
- Do not fail to counsel on modifiable risk factors (calcium, vitamin D, exercise, smoking, alcohol) which are the primary interventions available 1, 2