Hormonal contraception in women with medical conditions

One population-based prospective cohort study followed 457 nongravid women aged 18 to 39 years. These women had bone density measured every 6 months for 3 years using dual-energy x-ray absorptiometry. Although bone density decreased among DMPA users at the spine and total hip compared with nonusers, there was no difference in bone density 30 months after discontinuation of birth control injections.²⁷

In a study of 170 adolescent women 14 to 18 years of age, 80 were DMPA users and 90 were nonusers. Bone density was measured every 6 months for 24 or 36 months, and declined significantly at the hip and spine in DMPA users. Sixty-one women discontinued DMPA during the course of the study. After discontinuation, bone density increased at all anatomical sites, recovering completely over the course of 1 year.²⁸

Although the US Food and Drug Administration issued a black box warning in the fall of 2004 that use of DMPA should be reconsidered after 2 years, particularly in teens, the studies I just mentioned suggest there should be no routine restrictions on the use of DMPA in terms of skeletal health, and that DMPA use by itself is not an indication for bone density measurement.

6. Patch and ring

Assume contraindications are the same as for OCs

OBG Management: What about newer forms of combination contraceptives such as the patch and ring?

KAUNITZ: The new practice bulletin contains information on the patch, the ring, and the levonorgestrel-releasing IUD, which were not available when the earlier bulletin was prepared. In that version we talked about combination pills only.

Even so, we continue to have much more data on the Pill than the ring or patch. For that reason, until more data become available, the patch and the ring should be assumed to have the same contraindications as combination OCs. We have very little data—if any—on the use of newer combination contraceptives in high-risk women or those with medical problems.