Have women aged over 40 on Depo-Provera had

Have women aged over 40 on Depo-Provera had a documented discussion on ‘bone health’ in the last two years? Dr Nicola Mullin MRCOG MFFP Consultant in Sexual and Reproductive Health, Chester, UK ESC 2006

Depo Provera • • 150 mg medroxyprogesterone acetate Administered every 12 weeks by im injection Prevents ovulation Suitable for women who are oestrogen intolerant or unable to take a daily pill ESC 2006

Who uses Depo-Provera? • 9% women attending Family Planning clinics in England (83, 200 women) source: Office of National Statistics, KT 31 returns, 2004 • 6. 5% of all contraceptive prescriptions in England (includes family doctors who do 80% of contraceptive work in UK) source: Department of Health, prescription cost analysis, 2004 ESC 2006

Contraceptive methods chosen by women attending Family Planning Clinics, England, 2003 -04 Primary method All methods All Under 16 -19 20 -24 25 -34 35+ ages 16 1000’s 899. 8 74. 2 223. 2 214. 9 230. 5 157 Injectable 83. 2 9% 2. 7 4% 19. 2 9% Source: Office of National Statistics, KT 31 returns, 2004 ESC 2006 24. 2 11% 23. 8 10% 13. 3 8%

Depo-Provera and bone • Reduction in bone mineral density (BMD) • Effects greatest at 2 -3 years of use • In adult women, BMD appears to recover when DMPA stopped • Some data suggest that rate of recovery is dependant on duration of use Cundy T et al, BMJ 1991; 303: 13 -16, Scholes D et al, Epidemiology 2002; 13: 581 -7 Cundy T et al, Am J Obs Gynae, 2003; 186: 978 -983 ESC 2006

Committee on Safety of Medicines • UK guidance to all doctors and nurses: • ‘In women of all ages careful evaluation of the risk and benefits of treatment should be carried out in those who wish to continue to use DMPA for more than two years. • In women with significant lifestyle and/or medical risk factors for osteoporosis other methods should be considered. ’ November 2004 ESC 2006

Faculty of Family Planning & Reproductive Health Care • Contraceptive use in Women over 40 Publıshed January 2005 • Women should be informed of the association between DMPA and bone density • Women with additional risks for low BMD should be discouraged from using DMPA ESC 2006

Why do an audit? • To ascertain that all older women are fully informed about the risks and benefits of DMPA and are aware of other methods of contraception • Contraception is free to everyone in UK. (not condoms) ESC 2006

Audit standard • 100% of women aged 40 & over using DMPA have had a documented discussion about bone health in the last two years. • Clinical staff were issued with the new guidance in 2004 • No formal training was given ESC 2006

Method • One city centre clinic selected (1200 attendances per year) • 3 months of client visits reviewed • 192 women in total using DMPA • 17 women aged 40+ (8. 85%) ESC 2006

Results n=14 • Mean age 43, range 40 -49 years • Mean duration of use 4. 5 years range 0 -10 years • 7 smokers • 3 case notes were not found ESC 2006 -

Results • 10/14 (71%) had evidence of discussion about bone health in last 2 years • Wide variation in quality of documentation – from ‘BMD or osteoporosis’ to full list of all risk factors for osteoporosis ESC 2006

Results • Only 2 had alcohol consumption recorded • 6/14 had other methods of contraception discussed ESC 2006

Results • Four women had obvious relative contraindications to DMPA or osteoporosis risks – Graves disease & oral steroid use for 2 years – Epileptic – Osteopaenic on bone scan in 2004, on Calcium – Alcoholic ESC 2006

Conclusion • Many clients (71%) had some disccuiosn regarding bone health • But there was no consistent content or documentation • Some staff do not seem to know all the risk factors for low bone density ESC 2006

Recommendations • Staff training is planned to raise awareness of Depo. Provera use & bone density in older women • Stıcky label ın case notes • Staff are regularly reminded to offer a full range of methods to all clients (as appropriate) ESC 2006

Acknowledgements • Dr Lucy Mather, Senior House Officer • Community Contraception and Sexual Health Clinic staff, Cheshıre West Prımary Care Trust. ESC 2006