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Ask Dr. Sue
DEPO-PROVERA
Dear Dr. Sue,
My 15 year old daughter wants to start birth control. We’ve been discussing her options, and both agree that
the four times a year shot would be best for her, since
remembering to take something every single day would be
difficult. I’ve hear that people often stop having
periods when they’re on this shot, though, and wonder if
that isn’t dangerous.
Dear Mom,
I’d like to congratulate you and your daughter both for
having the kind of relationship that allows her to come
to you about these important issues.
Depo-Provera is the injectable contraceptive that you’re
thinking of. It is given once every three months, and
does require a visit to the doctor’s office or health
department. It is very important that those visits take
place when your doctor advises, so a certain degree of
organizational skills is necessary, but it is easier for
many people than remembering to take a pill every night,
or to change a patch every week.
Depo-Provera does usually cause periods to stop after it
has been used for a few months. The lack of periods in
and of itself is not a problem. Periods stop, though,
because this hormone causes the body to produce less
estrogen. It is well known that a decrease in estrogen
production can lead to decreased bone density. Whether
this is a real problem is still under investigation.
Why is bone density important? Decreased bone density
means decreased bone strength. Osteoporosis is the
condition in which bone density is dangerously low. About 10 million Americans have this disease, and it is
responsible for more than 1.5 million fractures every
year. Fractures in women with osteoporosis cause great
disability: according to one source, six months after
such a fracture, only 15% of patients can walk across a
room without help.
Previous research suggested that after Depo-Provera was
stopped, any loss in bone density that had occurred went
away. This suggested that it did not increase the
overall risk of osteoporosis. This loss of bone may be a
greater concern in adolescents and teens, though,
because they are actually losing bone density at a time
when they should be making a great deal of bone. The
question that remains unanswered is whether they can
truly catch up all the way, considering that half of a
woman’s bone mass is supposed to be laid down during
puberty and the first few years after periods begin. When young women with eating disorders are studied, it
looks as though bone density catch-up is not complete;
the same may be true for young women on Depo Provera.
It is well known, however, that early pregnancy takes a
significant toll on young bones, not to mention its
effects on a young woman’s life and future. Therefore it
is important to weigh the possible risks of Depo Provera
against the benefit, which is its reliability as a
contraceptive agent.
There are other risk factors for osteoporosis, as well. These include a family history of the disease, poor
nutrition (especially inadequate calcium and vitamin D
intake), low body weight, eating disorders, physical
inactivity, certain medications (including steroids,
heparin, and some anti-seizure medications), age,
smoking, excessive caffeine intake, alcohol abuse and
chronic medical conditions like bone disease, an
overactive thyroid and kidney failure. Women of
Caucasian and Asian background are at greater risk than
those of Hispanic or African American ethnicity. Of
course, only some of these risk factors are
controllable.
Some physicians believe that Depo-Provera should be
avoided in girls under age 15 or within 3 years of the
onset of periods, since that is the time of greatest
bone development. Others believe that if there are no
other risk factors available, Depo-Provera is still
worth considering in this age group, especially if the
teen is unlikely to be on it for longer than two years
(the average length of time for a teen girl to stay on
Depo-Provera is just one year.) The package insert now
includes the following statement: “It is unknown if use
of Depo-Provera Contraceptive Injection during
adolescence or early adulthood, a critical period of
bone accretion, will reduce peak bone mass and increase
the risk of osteoporotic fracture later in life. Depo-Provera Contraceptive Injection should be used as a
long-term birth control method (e.g. longer than two
years) only if other birth control methods are
inadequate.” If a teen girl does stay on Depo-Provera
for 3 or more years, she should probably have a bone
density study done.
Discuss the risks and benefits of Depo-Provera with your
daughter’s pediatrician. If it is mutually decided that
it is still the best contraceptive choice for her, there
are some things she can do to encourage the growth of
strong, healthy bones. She should get the recommended
amount of calcium (1200 mg for adolescent girls). A
glass of milk contains about 300 mg of calcium, one-half
cup of tofu has 430 mg, yogurt 340 to 490 mg per 8 oz.
cup, and cheese between 160 and 200 mg per 1 oz. serving. If your daughter is unable or unwilling to get adequate
amounts of calcium from dietary sources, she should take
supplements. Most multiple vitamins contain between 150
and 200 mg of calcium. Multiple vitamins also contain
Vitamin D, which is necessary for bone production (as
well as other nutrients that your daughter’s diet may be
deficient in.) In addition to a multivitamin, she may
need a calcium tablet (500 mg of calcium), a chewable
antacid (400 mg), or a Viactiv chocolate or caramel
flavored chewable (500 mg).
Physical activity is another essential ingredient of
bone production. She should participate in
weight-bearing activities such as walking, running,
stair-climbing, jumping rope, or a sport such as
racquetball, field hockey, basketball, soccer, weightlifting, or dancing. At least 30 minutes of moderate
physical activity on most (preferably all) days of the
week is necessary.
She should also avoid those risk factors that are under
her control, including cigarette smoking and alcohol
consumption.
 
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