Members Enquiry Service
The Clinical Effectiveness Unit (CEU) provides an evidence-based enquiry service for FSRH members. The CEU will conduct a literature review and summarise the available evidence in relation to a particular medical condition and/or contraceptive method.
Recent Questions and Answers that have been submitted to the CEU can be seen below. Please note, the full answer includes references to more information and guidance.
To gain access to the enquiries service, please log in to ‘My FSRH’ and click on ‘My Clinical Enquiries’ to search for questions or submit your own question. This service is available to current FSRH members. If you are an FSRH member and have not yet created your ‘My FSRH’ account, please click the ‘Register’ button on the top right of this website and follow the steps to gain access to your account.
Example Question One
I would be grateful for advice regarding the management of a 22yr old lady who has achondroplasia. She has had her implant removed and would like to consider using Depo-Provea. I wanted to check if using Depo-Provea would be a safe option for this lady or if there would be any difference in the risk/benefit profile of its use especially related to weight gain and bone mass density. She is currently using POP. She has no other medical history of note and does not take any medication.
Achondroplasia (ACH) is a bone growth disorder that causes the most common form of dwarfism. It is caused by a gene mutation that impairs the body’s ability to turn cartilage into bone. Common health complications for individuals with ACH include apnoea, obesity and recurrent ear infections. Individuals with this condition may also develop kyphosis, spinal stenosis and hydrocephaly.(1-3)
The CEU reviewed the professional literature and found no evidence relating to progestogen and/or contraceptive use by women with ACH relating specifically to osteoporosis and weight gain.
The CEU found some evidence of ACH being linked to low bone mineral density (BMD). An observational study including 18 individuals with ACH (9 female and 9 male, average age 19.8 ±7.5 years) determined that those with the condition have below average BMD. Another cross-sectional study found that 5 out of 11 individuals with ACH (mean age 40.3 ±8 years) had low BMD. Both studies are limited by small numbers, lack of controls and observational nature. It is not known if this low BMD translates into an increased lifetime fracture risk.
Weight gain is a common side effect of DMPA use. There is no evidence to guide on whether individuals with ACH are more or less likely to gain weight while using DMPA than the general population.
The Progestogen-Only Injectable Contraception guideline states that, “[t]he FSRH supports guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA) which advises that...for women with significant lifestyle and/or medical risk factors for osteoporosis other methods of contraception should be considered.” The CEU recommends that alternative contraceptive methods be discussed with women with ACH due to the potential bone-related complications and DMPA only considered if no other method was suitable or acceptable.
Example Question Two
I have a 50 year old lady with a BMI of 34 who had gastric sleeve surgery 6 months ago and has lost 5 stone in weight since the op. She has been using depo injection for the last 20 years and declines all other methods. She is not menopausal (no symptoms and FSH levels checked by GP) and is aware of the bone effects of depo. Although not ideal, is depo still safe to use in this patient?
Sleeve gastrectomy (SG) is an operation which removes 75-80% of the stomach. This procedure reduces stomach volume and removes cells which control hunger hormones.(1-3) Compared with other forms of bariatric surgery, this is a relatively new procedure and therefore there is less evidence relating to the outcomes of SG than other weight loss surgeries.
The current evidence regarding bone outcomes following bariatric surgery is mixed.(5-9) The CEU conducted a review of the literature regarding SG specifically and found three studies looking at its effect on bone composition. Two small, prospective cohort studies (n=8, n=29) of women who underwent SG found significant decreases in BMD in the six months or year following surgery. Conversely, one small, retrospective cohort study of 39 women who underwent SG found an increase in BMD, with a direct correlation between vitamin D levels and positive BMD changes.
The updated guideline Contraception for Women Over 40 is due to be published in the next month. It will advise clinicians that, due to bone health concerns, women 50 or older using depot medroxyprogesterone (DMPA) should be counselled on alternative methods of contraception as there are safer methods that are equally effective at this age.
The evidence regarding severity and consequences of bone loss in women undergoing SG in their later reproductive years is lacking, and there are no studies that look at women who have undergone SG using DMPA. Considering the unknown but potentially negative effect of SG on BMD and given that long-term use of DMPA is already a risk factor for osteoporosis, clinicians should advise women aged 50 or older who have had SG to use contraceptive methods other than DMPA.
Example Question Three
What contraception can a woman with Loeys-Dietz syndrome use to delay her period for holidays? She had an aortic dissection during pregnancy that required surgery.
Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder characterised by enlargement of the aorta and associated complications, e.g. tortuosity, aneurysm, and dissection.[1,2] Individuals may also experience skeletal problems (including osteoporosis and cervical spine instability), osteoarthritis, hernias, gastrointestinal problems and spenic or bowel rupture.(1-3) Women with LDS are at an increased risk of uterine perforation and aortic dissection during pregnancy.[1,4]
LDS was only identified in 2005, meaning there is incredibly limited information regarding this condition. A literature search revealed no evidence discussing exogenous hormone or contraception use in women with LDS. A search of the most closely related condition, Marfan Syndrome, also found no evidence relating to contraception.
The limited available evidence states that individuals with LDS may have widespread and/or aggressive vascular disease, but relating to underlying connective tissue disease rather than thromboembolism.
The CEU contacted Johns Hopkins’ Institute of Genetic Medicine for an expert opinion. They advise against intrauterine contraception due to a recurrent history of excessive uterine bleeding, uterine fragility and uterine rupture in LDS. The majority of women treated at the Institute use oral contraception without complication. Low bone mineral density and the potential complication of osteoporosis associated with LDS [1,4] would suggest that progestogen-only injectables are not appropriate. The CEU would therefore recommend discussing progestogen-only pills or the progestogen-only implant for ongoing contraception. Expert opinion would support use of combined hormonal contraception but the CEU cannot find any scientific evidence to endorse this. Oral medroxy-progesterone acetate to delay menstruation for social indications would not be contraindicated.
Please note: The advice given by the CEU should be considered as guidance only and is meant to be used alongside clinical judgement to guide clinical practice or policy. Questions that are a matter of clinical judgment and not evidence should be directed to local sexual and reproductive health leads.