Have women aged over 40 on Depo-Provera had a documented discussion on bone health in the last two years

1. ESC 2006 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

2. ESC 2006 Depo Provera 150 mg medroxyprogesterone acetate Administered every12 weeks by im injection Prevents ovulation Suitable for women who are oestrogen intolerant or unable to take a daily pill

3. ESC 2006 Who uses Depo-Provera? 9% women attending Family Planning clinics in England (83,200 women) source: Office of National Statistics, KT31 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 50% discontinue in one year GPs do nearly 80% of all contraception consultations per year Depo use was 3-4% FP population in 199350% discontinue in one year GPs do nearly 80% of all contraception consultations per year Depo use was 3-4% FP population in 1993

4. ESC 2006 Contraceptive methods chosen by women attending Family Planning Clinics, England, 2003-04 Depo is primary methods of first contacts in 8%Depo is primary methods of first contacts in 8%

5. ESC 2006 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 Limited data suggest that at menopause the bone density of previous users may be no different form that of women who have never used DMPA Research continues � currently no evidence to say whether Depo at any age is associated with increased risk of O and fractures in later life.Limited data suggest that at menopause the bone density of previous users may be no different form that of women who have never used DMPA Research continues � currently no evidence to say whether Depo at any age is associated with increased risk of O and fractures in later life.

6. 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.� Why was two years chosen?Why was two years chosen?

7. ESC 2006 Faculty of Family Planning & Reproductive Health Care Contraceptive use in Women over 40 Published 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 DMPA is allowed up to age 50 but many experts start to change women from depo by age 45DMPA is allowed up to age 50 but many experts start to change women from depo by age 45

8. 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) Audits of young people have been done in last 2 years and presented to scientific meetings across UKAudits of young people have been done in last 2 years and presented to scientific meetings across UK

9. 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 Variation in documentation was noticedVariation in documentation was noticed

10. 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%)

11. 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 2 new patients2 new patients

12. 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 Diet exercise alcohol calcium intake FH osteoporosis history of steroid use etcDiet exercise alcohol calcium intake FH osteoporosis history of steroid use etc

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

14. 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

15. 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

16. ESC 2006 Recommendations Staff training is planned to raise awareness of Depo-Provera use & bone density in older women Sticky label in case notes Staff are regularly reminded to offer a full range of methods to all clients (as appropriate) Reaudit later this yearReaudit later this year

17. ESC 2006 Acknowledgements Dr Lucy Mather, Senior House Officer Community Contraception and Sexual Health Clinic staff, Cheshire West Primary Care Trust.