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• W2006397557 abstract "In the United States, some 9% of adolescent girls become pregnant each year: 5% give birth, 3% have induced abortions, and 1% have miscarriages or stillbirths—rates much higher than in other developed countries [[1]Darroch J.E. Adolescent pregnancy trends and demographics.Curr Womens Health Rep. 2001; 1: 102-110PubMed Google Scholar]. Fortunately, the incidence of teen pregnancy in the United States has been declining [[2]Guttmacher Institute. Facts on American Teens’ Sexual and Reproductive Health [cited 2006 Sep]. Available from: http://www.guttmacher.org/pubs/fb_ATSRH.html.Google Scholar]. It is encouraging that less sexual activity accounts for some of this decrease. However, the lion’s share of the ebbing incidence of pregnancy among U.S. teens has been attributed to growing use of long-acting hormonal contraceptives, particularly depot medroxyprogesterone acetate (Depo-Provera, DMPA; Pfizer, New York, NY) [[3]Centers for Disease Control and PreventionAchievements in public health, 1990–1999: family planning.MMWR. 1999; 48: 1073-1080Google Scholar]. The 2002 National Survey of Family Growth found that as of 2002, 21% of sexually experienced teens had used DMPA, a proportion that increased from 10% in 1995 [[4]Centers for Disease Control and Prevention. Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2002—A Fact Sheet for Series 23, Number 24 [cited 2005 Jun]. Available from: http://www.cdc.gov/nchs/data/series/sr_23/sr23_024FactSheet.pdf.Google Scholar].Successful use of oral contraceptives (OC) mandates consistent daily pill ingestion, something many adults and more teens find challenging [[5]Dardano K.L. Burkman R.T. Contraceptive compliance.Obstet Gynecol Clin North Am. 2000; 27: 933-941Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. This explains why annual failure rates among typical users overall approximate 8% [[6]Trussell J. Contraceptive failure in the United States.Contraception. 2004; 70: 89-96Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar]. In teens, OC failure rates are higher, with some reports observing annual pregnancy rates in excess of 25% [7Templeton C.L. Cook V. Goldsmith L.J. et al.Postpartum contraceptive use among adolescent mothers.Obstet Gynecol. 2000; 95: 770-776Crossref PubMed Scopus (66) Google Scholar, 8O’Dell C.M. Forke C.M. Polaneczky M.M. et al.Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.Obstet Gynecol. 1998; 91: 609-614Crossref PubMed Scopus (58) Google Scholar] and one report noting that 20% of teen OC users had conceived within 6 months [[9]Dinerman L.M. Wilson M.D. Duggan A.K. Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods.Arch Pediatr Adolesc Med. 1995; 149: 967-972Crossref PubMed Scopus (35) Google Scholar]. When the adolescent medicine specialist Stevens-Simon and her colleagues in Denver assessed a cohort of 272 racially diverse teen mothers, they observed repeat pregnancy rates in the first 6 months postpartum of 0%, 4%, 14%, and 23%, respectively, for teens choosing Norplant, DMPA, OC, and no method in the puerperium [[10]Stevens-Simon C. Kelly L. Kulick R. A village would be nice but … it takes a long-acting contraceptive to prevent repeat adolescent pregnancies.Am J Prev Med. 2001; 21: 60-65Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar]. In their publication entitled “A Village Would Be Nice But … It takes a Long-Acting Contraceptive to Prevent Repeat Adolescent Pregnancies,” they concluded that frequent school visits, contact with supportive healthcare and social service providers, and return to school were not associated with prevention of repeat pregnancy. In contrast, selection of long-acting hormonal contraceptives (implants or injections) was associated with pregnancy prevention in this high risk cohort of teens [[10]Stevens-Simon C. Kelly L. Kulick R. A village would be nice but … it takes a long-acting contraceptive to prevent repeat adolescent pregnancies.Am J Prev Med. 2001; 21: 60-65Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar]. Many other reports confirm the extremely high contraceptive efficacy of injections [11Smith R.D. Cromer B.A. Hayes J.R. Brown R.T. Medroxyprogesterone acetate (Depo-Provera) use in adolescents: uterine bleeding and blood pressure patterns, patient satisfaction, and continuation rates.Adolesc Pediatr Gynecol. 1995; 8: 24-28Abstract Full Text PDF Scopus (37) Google Scholar, 12Matson S.C. Henderson K.A. McGrath G.J. Physical findings and symptoms of depot medroxyprogesterone acetate use in adolescent females.J Pediatr Adolesc Gynecol. 1997; 10: 18-23Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 13Chotnopparatpattara P. Taneepanichskul S. Use of depot medroxyprogesterone acetate in Thai adolescents.Contraception. 2000; 62: 137-140Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 14Bonny A.E. Ziegler J. Harvey R. et al.Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no normal contraceptive method.Arch Pediatr Adolesc Med. 2006; 160: 40-45Crossref PubMed Scopus (106) Google Scholar] and implants [9Dinerman L.M. Wilson M.D. Duggan A.K. Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods.Arch Pediatr Adolesc Med. 1995; 149: 967-972Crossref PubMed Scopus (35) Google Scholar, 15Polaneczky M. Slap G. Forke C. et al.The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers.N Engl J Med. 1994; 331: 1201-1206Crossref PubMed Scopus (151) Google Scholar]. Because of problems associated with difficult removals and other concerns, the six-capsule implantable contraceptive Norplant is no longer marketed in the United States [[16]Boonstra H. Duran V. Northington Gamble V. et al.The “boom and bust phenomenon”: the hopes, dreams and broken promises of the contraceptive revolution.Contraception. 2000; 61: 9-25Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar]. Fortunately, in 2006 a single rod progestin-releasing contraceptive implant (Implanon; Organon, Roseland, NJ) received Food and Drug Administration (FDA) approval for up to 3 years of use. Insertion and removal of this highly effective single rod implant is easier and quicker than with Norplant [[17]Funk S. Miller M.M. Mishell Jr, D.R. et al.Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel.Contraception. 2005; 71: 319-326Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar]. Sales of Implanon will be restricted to clinicians who have been trained during manufacturer-sponsored instructional sessions. Due to their high efficacy, long-acting hormonal contraceptives are more cost-effective than OC and barrier contraceptives when used over multiple years [[18]Chiou C.F. Trussell J. Reyes E. et al.Economic analysis of contraceptives for women.Contraception. 2003; 68: 3-10Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar]. However, because the costs related to purchase and insertion of implants are substantial, insurance will play an important role in determining access to implantable contraception.Long-acting hormonal contraceptives cause menstrual changes in all users. After initiating DMPA, users experience unpredictable spotting or light bleeding. By 1 year of use (four injections), some 70% of users will be amenorrheic [[19]Westhoff C.L. Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety.Contraception. 2003; 68: 75-87Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. In contrast, the unpredictable spotting and/or light bleeding that accompanies use of Implanon persists as long as women use this contraceptive [[17]Funk S. Miller M.M. Mishell Jr, D.R. et al.Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel.Contraception. 2005; 71: 319-326Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar]. Candid proactive counseling regarding these bleeding changes results in greater DMPA and implant continuation [20Canto De Cetina T.E. Canto P. Luna M.O. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate.Contraception. 2001; 63: 143-146Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 21Lei Z.W. Wu S.C. Garceau R.J. et al.Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception.Contraception. 1993; 53: 357-361Abstract Full Text PDF Scopus (107) Google Scholar, 22Alvarez-Sanchez F. Brache V. Faundes A. The clinical performance of NORPLANT implants over time: a comparison of two cohorts.Stud Fam Plann. 1988; 19: 118-121Crossref PubMed Scopus (28) Google Scholar].During use of DMPA injections, ovarian estradiol production declines, leading to decreases in bone mineral density (BMD) [[23]Curtis K.M. Martins S.L. Progestogen-only contraception and bone mineral density: a systemic review.Contraception. 2006; 73: 470-487Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar]. In 2004, concerns regarding declines in BMD in current DMPA users led the FDA to issue a Black Box warning regarding skeletal health and injectable contraception [[24]Kaunitz A.M. Depo-Provera’s black box: time to reconsider (Editorial)?.Contraception. 2005; 72: 165-167Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar], which has made some clinicians, patients, and parents reluctant to initiate or continue DMPA birth control. Fortunately, BMD completely recovers after teens [[25]Scholes D. LaCroix A.Z. Ichikawa L.E. et al.Change in bone density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception.Arch Pediatr Adolesc Med. 2005; 159: 139-144Crossref PubMed Scopus (185) Google Scholar] and adults [[26]Scholes D. LaCroix A.Z. Ichikawa L.E. et al.Injectable hormone contraception and bone density: results from a prospective study.Epidemiology. 2002; 13: 581-587Crossref PubMed Scopus (147) Google Scholar] discontinue injections. Large cross-sectional studies [27Pettiti D.B. Piaggo G. Mehta S. et al.Steroid hormone contraception and bone mineral density: a cross-sectional study in an international population: the WHO Study of Hormonal Contraception and Bone Health.Obstet Gynecol. 2000; 95: 736-744Crossref PubMed Scopus (144) Google Scholar, 28Orr-Walker B.J. Evans M.C. Ames R.W. et al.The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women.Clin Endocrinol (Oxf). 1998; 49: 615-618Crossref PubMed Scopus (96) Google Scholar] have also documented complete return of BMD in former users of DMPA, and use of DMPA has not been linked to later occurrence of osteoporosis or fractures [[19]Westhoff C.L. Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety.Contraception. 2003; 68: 75-87Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. Accordingly, the Society for Adolescent Medicine issued a position paper recommending continued prescription of DMPA for most adolescents [[29]Cromer B.A. Scholes D. Berenson A. et al.Depot medroxyprogesterone acetate and bone mineral density in adolescents—the black box warning: a position paper of the Society for Adolescent Medicine.J Adolesc Health. 2006; 39: 296-301Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar]. Likewise, the American College of Obstetricians and Gynecologists (ACOG) has stated “… the advantages of DMPA likely outweigh the theoretical safety concerns regarding bone mineral density and fractures” in teens [[30]American College of Obstetricians and GynecologistsACOG Practice Bulletin Number 73: use of hormonal contraception in women with coexisting medical conditions.Obstet Gynecol. 2006; 107: 1453-1472Crossref PubMed Scopus (283) Google Scholar]. The World Health Organization’s guidance regarding DMPA in teens [[31]World Health Organization. WHO Statement on Hormonal Contraception and Bone Health [cited 2005 Jul]. Available from: http://www.who.int/reproductive-health/family_planning/docs/hormonal_contraception_bone_health.pdf.Google Scholar] is similar to that of ACOG. In my practice, skeletal health concerns have not restricted initiation or continuation of DMPA in adolescent or adult patients.Facilitating initiation of injections is also an important factor in increasing contraceptive use among teen patients. Package labeling for DMPA specifies that the initial injection should occur within 5 days of the onset of menses, a narrow window that forces most patients to return for their first injection. Westhoff, an innovative obstetrician-gynecologist researcher, and her team of investigators at Columbia University in New York City have thought outside the box in their approach to improving initiating of hormonal contraception. This group has coined the term “Quick Start,” which refers to immediate in-office initiation of OC tablets in contraceptive patients with negative pregnancy tests, regardless of at what point they are in their menstrual cycle [[32]Westhoff C. Kerns J. Morroni C. et al.Quick Start: a novel oral contraceptive initiation method.Contraception. 2002; 79: 322-329Google Scholar]. This immediate initiation approach has also been used with the vaginal contraceptive ring [[33]Schafer J.E. Osborne L.M. Davis A.R. Westhoff C. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive.Contraception. 2006; 73: 488-492Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar]. In a report in this issue of the Journal of Adolescent Health, Westhoff’s group, led by Columbia colleague Rickert, details their “Depo Now” algorithm, which allows patients with negative pregnancy tests to receive their first DMPA injection at the current office visit rather than return on their next menses for their injection [[34]Rickert V.I. Tiezzi L. Lipshutz J. et al.Depo Now: preventing unintended pregnancies among adolescent and young adults.J Adolesc Health. 2007; 40: 22-28Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Young women 14 to 26 years of age who wanted to start DMPA injections were randomized to Depo Now (n = 101) or a “bridge” method of birth control (OC, patch or ring according to patient choice [n = 223]). All patients were asked to return in 3 weeks for a repeat urine pregnancy test and (for those randomized to a bridge contraceptive) to receive their initial DMPA injection. DMPA continuation rates at 9 months were incrementally, but not statistically significantly higher in the Depo Now group (29.7% vs. 21.1%). More impressive was that the participants randomized to Depo Now were far less likely to conceive during the study period. The pregnancy rate in women randomized to the bridge birth control method was almost four times higher than in those randomized to Depo Now, underscoring the advantages of facilitating immediate initial injections in young women choosing to start injectable contraception.Along with expediting initial injections, flexible approaches to follow-up injections increase our patients’ contraceptive success. Package labeling specifies that DMPA intramuscular injection patients return each 3 months for repeat injections. Some practices forbid follow-up injections occurring earlier than 12 or later than 14 weeks after the previous injection. In the real world of patient care, many women return for repeat injections outside of this window. For instance, if a DMPA user returns for a reinjection at 9, 10, or 11 weeks after her prior injection, immediate reinjection is appropriate. Likewise, reinjection after a negative urine pregnancy test is also appropriate for DMPA users who present more than 14 weeks after their last injection. DMPA is available as an intramuscular (150 mg) injection administered in the gluteal or deltoid muscles and a subcutaneous (104 mg) injection administered in the abdomen or anterior thigh. The schedule of initiation and repeat injections and the high contraceptive efficacy and menstrual changes associated with use are similar for the intramuscular and subcutaneous formulations [[35]Jain J. Jakimiuk A.J. Bode F.R. et al.Contraceptive efficacy and safety of DMPA-SC.Contraception. 2004; 70: 269-275Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar].Long-acting hormonal contraceptives represent the most important tool in our ongoing endeavor to prevent teen pregnancy. Clinicians who provide their adolescent patients ready access to injectable and implantable contraception, and facilitate initiation and ongoing use of these methods, will be taking an important step toward improving the health and well-being of their teenage patients, their families, and our society. In the United States, some 9% of adolescent girls become pregnant each year: 5% give birth, 3% have induced abortions, and 1% have miscarriages or stillbirths—rates much higher than in other developed countries [[1]Darroch J.E. Adolescent pregnancy trends and demographics.Curr Womens Health Rep. 2001; 1: 102-110PubMed Google Scholar]. Fortunately, the incidence of teen pregnancy in the United States has been declining [[2]Guttmacher Institute. Facts on American Teens’ Sexual and Reproductive Health [cited 2006 Sep]. Available from: http://www.guttmacher.org/pubs/fb_ATSRH.html.Google Scholar]. It is encouraging that less sexual activity accounts for some of this decrease. However, the lion’s share of the ebbing incidence of pregnancy among U.S. teens has been attributed to growing use of long-acting hormonal contraceptives, particularly depot medroxyprogesterone acetate (Depo-Provera, DMPA; Pfizer, New York, NY) [[3]Centers for Disease Control and PreventionAchievements in public health, 1990–1999: family planning.MMWR. 1999; 48: 1073-1080Google Scholar]. The 2002 National Survey of Family Growth found that as of 2002, 21% of sexually experienced teens had used DMPA, a proportion that increased from 10% in 1995 [[4]Centers for Disease Control and Prevention. Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2002—A Fact Sheet for Series 23, Number 24 [cited 2005 Jun]. Available from: http://www.cdc.gov/nchs/data/series/sr_23/sr23_024FactSheet.pdf.Google Scholar]. Successful use of oral contraceptives (OC) mandates consistent daily pill ingestion, something many adults and more teens find challenging [[5]Dardano K.L. Burkman R.T. Contraceptive compliance.Obstet Gynecol Clin North Am. 2000; 27: 933-941Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. This explains why annual failure rates among typical users overall approximate 8% [[6]Trussell J. Contraceptive failure in the United States.Contraception. 2004; 70: 89-96Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar]. In teens, OC failure rates are higher, with some reports observing annual pregnancy rates in excess of 25% [7Templeton C.L. Cook V. Goldsmith L.J. et al.Postpartum contraceptive use among adolescent mothers.Obstet Gynecol. 2000; 95: 770-776Crossref PubMed Scopus (66) Google Scholar, 8O’Dell C.M. Forke C.M. Polaneczky M.M. et al.Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.Obstet Gynecol. 1998; 91: 609-614Crossref PubMed Scopus (58) Google Scholar] and one report noting that 20% of teen OC users had conceived within 6 months [[9]Dinerman L.M. Wilson M.D. Duggan A.K. Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods.Arch Pediatr Adolesc Med. 1995; 149: 967-972Crossref PubMed Scopus (35) Google Scholar]. When the adolescent medicine specialist Stevens-Simon and her colleagues in Denver assessed a cohort of 272 racially diverse teen mothers, they observed repeat pregnancy rates in the first 6 months postpartum of 0%, 4%, 14%, and 23%, respectively, for teens choosing Norplant, DMPA, OC, and no method in the puerperium [[10]Stevens-Simon C. Kelly L. Kulick R. A village would be nice but … it takes a long-acting contraceptive to prevent repeat adolescent pregnancies.Am J Prev Med. 2001; 21: 60-65Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar]. In their publication entitled “A Village Would Be Nice But … It takes a Long-Acting Contraceptive to Prevent Repeat Adolescent Pregnancies,” they concluded that frequent school visits, contact with supportive healthcare and social service providers, and return to school were not associated with prevention of repeat pregnancy. In contrast, selection of long-acting hormonal contraceptives (implants or injections) was associated with pregnancy prevention in this high risk cohort of teens [[10]Stevens-Simon C. Kelly L. Kulick R. A village would be nice but … it takes a long-acting contraceptive to prevent repeat adolescent pregnancies.Am J Prev Med. 2001; 21: 60-65Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar]. Many other reports confirm the extremely high contraceptive efficacy of injections [11Smith R.D. Cromer B.A. Hayes J.R. Brown R.T. Medroxyprogesterone acetate (Depo-Provera) use in adolescents: uterine bleeding and blood pressure patterns, patient satisfaction, and continuation rates.Adolesc Pediatr Gynecol. 1995; 8: 24-28Abstract Full Text PDF Scopus (37) Google Scholar, 12Matson S.C. Henderson K.A. McGrath G.J. Physical findings and symptoms of depot medroxyprogesterone acetate use in adolescent females.J Pediatr Adolesc Gynecol. 1997; 10: 18-23Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 13Chotnopparatpattara P. Taneepanichskul S. Use of depot medroxyprogesterone acetate in Thai adolescents.Contraception. 2000; 62: 137-140Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 14Bonny A.E. Ziegler J. Harvey R. et al.Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no normal contraceptive method.Arch Pediatr Adolesc Med. 2006; 160: 40-45Crossref PubMed Scopus (106) Google Scholar] and implants [9Dinerman L.M. Wilson M.D. Duggan A.K. Joffe A. Outcomes of adolescents using levonorgestrel implants vs oral contraceptives or other contraceptive methods.Arch Pediatr Adolesc Med. 1995; 149: 967-972Crossref PubMed Scopus (35) Google Scholar, 15Polaneczky M. Slap G. Forke C. et al.The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers.N Engl J Med. 1994; 331: 1201-1206Crossref PubMed Scopus (151) Google Scholar]. Because of problems associated with difficult removals and other concerns, the six-capsule implantable contraceptive Norplant is no longer marketed in the United States [[16]Boonstra H. Duran V. Northington Gamble V. et al.The “boom and bust phenomenon”: the hopes, dreams and broken promises of the contraceptive revolution.Contraception. 2000; 61: 9-25Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar]. Fortunately, in 2006 a single rod progestin-releasing contraceptive implant (Implanon; Organon, Roseland, NJ) received Food and Drug Administration (FDA) approval for up to 3 years of use. Insertion and removal of this highly effective single rod implant is easier and quicker than with Norplant [[17]Funk S. Miller M.M. Mishell Jr, D.R. et al.Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel.Contraception. 2005; 71: 319-326Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar]. Sales of Implanon will be restricted to clinicians who have been trained during manufacturer-sponsored instructional sessions. Due to their high efficacy, long-acting hormonal contraceptives are more cost-effective than OC and barrier contraceptives when used over multiple years [[18]Chiou C.F. Trussell J. Reyes E. et al.Economic analysis of contraceptives for women.Contraception. 2003; 68: 3-10Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar]. However, because the costs related to purchase and insertion of implants are substantial, insurance will play an important role in determining access to implantable contraception. Long-acting hormonal contraceptives cause menstrual changes in all users. After initiating DMPA, users experience unpredictable spotting or light bleeding. By 1 year of use (four injections), some 70% of users will be amenorrheic [[19]Westhoff C.L. Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety.Contraception. 2003; 68: 75-87Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. In contrast, the unpredictable spotting and/or light bleeding that accompanies use of Implanon persists as long as women use this contraceptive [[17]Funk S. Miller M.M. Mishell Jr, D.R. et al.Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel.Contraception. 2005; 71: 319-326Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar]. Candid proactive counseling regarding these bleeding changes results in greater DMPA and implant continuation [20Canto De Cetina T.E. Canto P. Luna M.O. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate.Contraception. 2001; 63: 143-146Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 21Lei Z.W. Wu S.C. Garceau R.J. et al.Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception.Contraception. 1993; 53: 357-361Abstract Full Text PDF Scopus (107) Google Scholar, 22Alvarez-Sanchez F. Brache V. Faundes A. The clinical performance of NORPLANT implants over time: a comparison of two cohorts.Stud Fam Plann. 1988; 19: 118-121Crossref PubMed Scopus (28) Google Scholar]. During use of DMPA injections, ovarian estradiol production declines, leading to decreases in bone mineral density (BMD) [[23]Curtis K.M. Martins S.L. Progestogen-only contraception and bone mineral density: a systemic review.Contraception. 2006; 73: 470-487Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar]. In 2004, concerns regarding declines in BMD in current DMPA users led the FDA to issue a Black Box warning regarding skeletal health and injectable contraception [[24]Kaunitz A.M. Depo-Provera’s black box: time to reconsider (Editorial)?.Contraception. 2005; 72: 165-167Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar], which has made some clinicians, patients, and parents reluctant to initiate or continue DMPA birth control. Fortunately, BMD completely recovers after teens [[25]Scholes D. LaCroix A.Z. Ichikawa L.E. et al.Change in bone density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception.Arch Pediatr Adolesc Med. 2005; 159: 139-144Crossref PubMed Scopus (185) Google Scholar] and adults [[26]Scholes D. LaCroix A.Z. Ichikawa L.E. et al.Injectable hormone contraception and bone density: results from a prospective study.Epidemiology. 2002; 13: 581-587Crossref PubMed Scopus (147) Google Scholar] discontinue injections. Large cross-sectional studies [27Pettiti D.B. Piaggo G. Mehta S. et al.Steroid hormone contraception and bone mineral density: a cross-sectional study in an international population: the WHO Study of Hormonal Contraception and Bone Health.Obstet Gynecol. 2000; 95: 736-744Crossref PubMed Scopus (144) Google Scholar, 28Orr-Walker B.J. Evans M.C. Ames R.W. et al.The effect of past use of the injectable contraceptive depot medroxyprogesterone acetate on bone mineral density in normal post-menopausal women.Clin Endocrinol (Oxf). 1998; 49: 615-618Crossref PubMed Scopus (96) Google Scholar] have also documented complete return of BMD in former users of DMPA, and use of DMPA has not been linked to later occurrence of osteoporosis or fractures [[19]Westhoff C.L. Depot-medroxyprogesterone acetate injection (Depo-Provera): a highly effective contraceptive option with proven long-term safety.Contraception. 2003; 68: 75-87Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar]. Accordingly, the Society for Adolescent Medicine issued a position paper recommending continued prescription of DMPA for most adolescents [[29]Cromer B.A. Scholes D. Berenson A. et al.Depot medroxyprogesterone acetate and bone mineral density in adolescents—the black box warning: a position paper of the Society for Adolescent Medicine.J Adolesc Health. 2006; 39: 296-301Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar]. Likewise, the American College of Obstetricians and Gynecologists (ACOG) has stated “… the advantages of DMPA likely outweigh the theoretical safety concerns regarding bone mineral density and fractures” in teens [[30]American College of Obstetricians and GynecologistsACOG Practice Bulletin Number 73: use of hormonal contraception in women with coexisting medical conditions.Obstet Gynecol. 2006; 107: 1453-1472Crossref PubMed Scopus (283) Google Scholar]. The World Health Organization’s guidance regarding DMPA in teens [[31]World Health Organization. WHO Statement on Hormonal Contraception and Bone Health [cited 2005 Jul]. Available from: http://www.who.int/reproductive-health/family_planning/docs/hormonal_contraception_bone_health.pdf.Google Scholar] is similar to that of ACOG. In my practice, skeletal health concerns have not restricted initiation or continuation of DMPA in adolescent or adult patients. Facilitating initiation of injections is also an important factor in increasing contraceptive use among teen patients. Package labeling for DMPA specifies that the initial injection should occur within 5 days of the onset of menses, a narrow window that forces most patients to return for their first injection. Westhoff, an innovative obstetrician-gynecologist researcher, and her team of investigators at Columbia University in New York City have thought outside the box in their approach to improving initiating of hormonal contraception. This group has coined the term “Quick Start,” which refers to immediate in-office initiation of OC tablets in contraceptive patients with negative pregnancy tests, regardless of at what point they are in their menstrual cycle [[32]Westhoff C. Kerns J. Morroni C. et al.Quick Start: a novel oral contraceptive initiation method.Contraception. 2002; 79: 322-329Google Scholar]. This immediate initiation approach has also been used with the vaginal contraceptive ring [[33]Schafer J.E. Osborne L.M. Davis A.R. Westhoff C. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive.Contraception. 2006; 73: 488-492Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar]. In a report in this issue of the Journal of Adolescent Health, Westhoff’s group, led by Columbia colleague Rickert, details their “Depo Now” algorithm, which allows patients with negative pregnancy tests to receive their first DMPA injection at the current office visit rather than return on their next menses for their injection [[34]Rickert V.I. Tiezzi L. Lipshutz J. et al.Depo Now: preventing unintended pregnancies among adolescent and young adults.J Adolesc Health. 2007; 40: 22-28Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Young women 14 to 26 years of age who wanted to start DMPA injections were randomized to Depo Now (n = 101) or a “bridge” method of birth control (OC, patch or ring according to patient choice [n = 223]). All patients were asked to return in 3 weeks for a repeat urine pregnancy test and (for those randomized to a bridge contraceptive) to receive their initial DMPA injection. DMPA continuation rates at 9 months were incrementally, but not statistically significantly higher in the Depo Now group (29.7% vs. 21.1%). More impressive was that the participants randomized to Depo Now were far less likely to conceive during the study period. The pregnancy rate in women randomized to the bridge birth control method was almost four times higher than in those randomized to Depo Now, underscoring the advantages of facilitating immediate initial injections in young women choosing to start injectable contraception. Along with expediting initial injections, flexible approaches to follow-up injections increase our patients’ contraceptive success. Package labeling specifies that DMPA intramuscular injection patients return each 3 months for repeat injections. Some practices forbid follow-up injections occurring earlier than 12 or later than 14 weeks after the previous injection. In the real world of patient care, many women return for repeat injections outside of this window. For instance, if a DMPA user returns for a reinjection at 9, 10, or 11 weeks after her prior injection, immediate reinjection is appropriate. Likewise, reinjection after a negative urine pregnancy test is also appropriate for DMPA users who present more than 14 weeks after their last injection. DMPA is available as an intramuscular (150 mg) injection administered in the gluteal or deltoid muscles and a subcutaneous (104 mg) injection administered in the abdomen or anterior thigh. The schedule of initiation and repeat injections and the high contraceptive efficacy and menstrual changes associated with use are similar for the intramuscular and subcutaneous formulations [[35]Jain J. Jakimiuk A.J. Bode F.R. et al.Contraceptive efficacy and safety of DMPA-SC.Contraception. 2004; 70: 269-275Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar]. Long-acting hormonal contraceptives represent the most important tool in our ongoing endeavor to prevent teen pregnancy. Clinicians who provide their adolescent patients ready access to injectable and implantable contraception, and facilitate initiation and ongoing use of these methods, will be taking an important step toward improving the health and well-being of their teenage patients, their families, and our society." @default.
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