Margaret Stager

Bone mineral density in adolescent females using injectable or oral contraceptives: a 24-month prospective study

OBJECTIVE To determine whether bone mineral density (BMD) is lower in hormonal-contraceptive users than in an untreated comparison group. DESIGN Observational, prospective cohort; 24-month duration. SETTING Adolescent clinics in a metropolitan Midwestern setting. PATIENT(S) Four hundred thirty-three postmenarcheal girls, 12-18 years of age, who were on depot medroxyprogesterone acetate (DMPA; n = 58), were on oral contraceptives (OCs; n = 187), or were untreated (n = 188). INTERVENTION(S) Depot medroxyprogesterone acetate and OCs containing 100 microg of levonorgestrel and 20 microg of ethinyl E(2). MAIN OUTCOME MEASURE(S) Measurements of BMD at spine and femoral neck were obtained by using dual x-ray absorptiometry at baseline and 6-month intervals. RESULT(S) Over 24 months, mean percentage change in spine BMD was as follows: DMPA, -1.5%; OC, +4.2%; and untreated, +6.3%. Mean percentage change in femoral neck BMD was as follows: DMPA, -5.2%; OC, +3.0%; and untreated, +3.8%. Statistical significance was found between the DMPA group and the other two groups. In the DMPA group, mean percentage change in spine BMD over the first 12 months was -1.4%; the rate of change slowed to -0.1% over the second 12 months. No bone density loss reached the level of osteopenia. CONCLUSION(S) Adolescent girls receiving DMPA had significant loss in BMD, compared with bone gain in the OC and untreated group. However, the clinical significance of this finding is mitigated by slowed loss after the 1st year of DMPA use and general maintenance of bone density values within the normal range in the DMPA group.

Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections

BACKGROUND Depot medroxyprogesterone acetate (DMPA) is a highly effective progestin-only contraceptive that is widely used by adolescents. We investigated bone mineral density (BMD) changes in female adolescents during and following use of this method. STUDY DESIGN A multicenter, prospective, non-randomized observational study in 98 healthy female adolescents aged 12-18 years who initiated DMPA intramuscular injections for contraception and provided BMD data for up to 240 weeks while receiving DMPA and for up to 300 weeks after DMPA cessation. BMD at the lumbar spine (LS), total hip (TH) and femoral neck (FN) was assessed by dual-energy X-ray absorptiometry. A mixed model analysis of variance was used to examine BMD changes. RESULTS At the time of their final DMPA injection, participants had mean BMD declines from baseline of 2.7% (LS), 4.1% (TH) and 3.9% (FN) (p<.001 at all three sites). Within 60 weeks of discontinuation of DMPA, mean LS BMD had returned to baseline levels, and 240 weeks after DMPA discontinuation, the mean LS BMD was 4.7% above baseline. Mean TH and FN BMD values recovered to baseline values more slowly: 240 weeks and 180 weeks, respectively, after the last DMPA injection. CONCLUSIONS BMD loss in female adolescents receiving DMPA for contraception is substantially or fully reversible in most girls following discontinuation of DMPA, with faster recovery at the LS than at the hip.

Direct Messaging to Parents/Guardians to Improve Adolescent Immunizations

PURPOSE To study the impact on adolescent immunization rates of direct messages to parents/guardians. METHODS Electronic health record rules identified adolescents needing an immunization. Parents/guardians of adolescents were messaged via a single vendor using automated text, prerecorded voice, and/or postcard. RESULTS Parents/guardians of 3,393 patients, ages 11-18 years, with one or more primary care visits in the prior 2 years, identified as needing (average of 2.04 years) a vaccination (meningococcal conjugate, human papillomavirus, or tetanus, diphtheria, and pertussis vaccines) were messaged (mean age, 14 years; 50% male; 38% African-American; 23% white; 19% Hispanic; and 79% public health insurance). A total of 7,094 messages were sent: 3,334 automated voice (47%), 2,631 texts (37%), and 1,129 postcards (16%). After the first message, 865 adolescents (25.5%) received at least one vaccine. Within 24 weeks of messaging 1,324 vaccines (745 human papillomavirus; 403 meningococcal conjugate; and 176 tetanus, diphtheria, and pertussis vaccines) occurred in 959 visits (83.8% physician visits and 16.2% nurse visits). Average visits generated

Research articles published in the Journal of Adolescent Health: a two-decade comparison.

204 gross reimbursement for

Biopsychosocial variables associated with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate in adolescents: adolescents who lost 5% or more from baseline vs. those who lost less than 5%

1.77 in messaging expenses per vaccine given. No differences in immunization completion rates occurred by age, gender, race/ethnicity, or insurance type. At 24 weeks, one message was more effective than two or three messages (35.6%, 19.4%, and 24.1% effectiveness, respectively; p < .0001). Texts and postcards correlated with more vaccination visits (38.8% and 40.1%, respectively) than phone calls (31.5%; p = .04). More vaccines due led to increasing message effectiveness. CONCLUSIONS Automated texts, voice messages, and postcards had a significant positive effect on vaccination rates in adolescents needing vaccination and required minimal financial expenditure.

The Relationship of Pre-pubertal BMI Status to Post-pubertal BMI Status: An 8 Year Cohort Study

PURPOSE To examine changes in subject contents and study designs of research articles published in the Journal of Adolescent Health since its inception. METHODS A retrospective review of all research articles was conducted from selected years, ranging from 1980 through 1998. The study sample was composed of the following: original articles, case reports, brief scientific reports, international articles, fellowship forum, and health briefs. RESULTS A total of 582 articles were evaluated. The total percentage of medical topics in research articles published in the Journal decreased from 61% in 1980-1981 to 38% in 1997-1998 (p <.01). This finding was in contrast to topics related to psychosocial issues, which increased from 23% to 50% (p <.01) over the same period. This change was largely accounted for by studies focusing on high-risk behavior. Retrospective designs, including case reports/series and chart reviews, decreased from 25% of all research articles in 1980-1981 to 9% in 1997-1998 (p <.01). The percentage of observational studies, i.e., those using cross-sectional and longitudinal designs, increased from 62% to 79% over the same period (p <.01). No changes were observed in the percentage of experimental designs, never exceeding >5% of total study designs. Finally, over the 20 years, professional background and academic departments of first authors of research broadened, with increasing contributions from nonphysicians and from non-pediatric disciplines such as psychology, public health, and nutrition. CONCLUSION A shift in subject content of research articles from medical to psychosocial topics was observed over the past 2 decades. A shift in research designs from retrospective to cross-sectional and longitudinal was observed over the same period. The pool of authors has diversified.

Depot medroxyprogesterone acetate, oral contraceptives and bone mineral density in a cohort of adolescent girls

BACKGROUND It is unclear why some adolescents experience substantial bone mineral density (BMD) loss, while others experience a minimal decrease during depot medroxyprogesterone acetate (DMPA) use. We examined biopsychosocial factors in adolescents who experienced ≥5% BMD loss from baseline compared with adolescents who experienced <5% BMD loss during DMPA use. STUDY DESIGN A multicenter, prospective, nonrandomized study of 181 female adolescents who initiated DMPA for contraception was conducted. BMD (by dual-energy X-ray absorptiometry) and serum estradiol were measured at initiation and every 6 months for 240 weeks of DMPA use. RESULTS Half of participants experienced BMD loss of ≥5% from baseline at the hip, and a quarter experienced BMD loss of ≥5% at the lumbar spine (BMD substantial losers, SL). Hip and lumbar spine BMD-SL received a significantly greater number of DMPA injections than non-SL (p<.001). Decreased estradiol levels did not statistically differ between BMD loss subgroups. Hip BMD-SL had significantly lower baseline body mass index (BMI) than non-SL (p=.002), and there was an inverse relationship between weight gain and degree of BMD loss. Mean calcium intake was significantly lower (p<.05) in hip BMD-SL, and reported alcohol use was significantly higher (p<.05) in lumbar spine BMD-SL compared with non-SL. CONCLUSIONS BMD loss of ≥5% was more common at the hip than at the lumbar spine among adolescents using DMPA. Decreased serum estradiol levels did not correlate with magnitude of BMD loss. Lower BMI and calcium intake and greater alcohol use were associated with greater BMD loss in adolescents using DMPA.

Double-blinded randomized controlled trial of estrogen supplementation in adolescent girls who receive depot medroxyprogesterone acetate for contraception.

Objective: To investigate body mass index (BMI) percentile trends in a longitudinal cohort through puberty and to identify factors associated with post-pubertal overweight/obese BMI percentile status. Methods: A retrospective cohort study of 760 children over eight years in a large academic healthcare system. Each child had one pre-puberty visit during 1999-2000 while aged 6-11 and one post-puberty visit during 2006-2007. Demographic and BMI data was collected on all subjects. For pre-pubertal overweight/obese subjects (BMI ≥ 85th percentile), additional data was reviewed. Results: Overall, rates of overweight/obesity increased from 39% to 46% from pre to post puberty, respectively. Neither race/ethnicity nor gender was associated with increased post-pubertal BMI percentile. Twenty percent of children with normal pre-puberty BMI percentile progressed to being overweight/obese. A high normal pre-pubertal BMI (72nd-84th percentile) was predictive of post-pubertal overweight/obese status. Having a post-puberty overweight/ obese BMI percentile was 20.4 times more likely if the pre-puberty BMI was ≥ 85th percentile. Pre-puberty overweight/ obese subjects were less likely to be obese post-puberty if they met with a nutritionist/dietician. Few overweight/obese subjects had a provider-documented diagnosis of overweight/obese pre-puberty and weight related co-morbidities doubled through puberty, but neither influenced post-pubertal BMI percentile status. Conclusions: A pre-pubertal BMI at high normal (72nd-84th percentile), or a BMI ≥ 85th percentile, but not race/ ethnicity or gender, are risk factors for an overweight/obese BMI status post-puberty. Most children do not out grow their overweight/obese status through puberty, signifying the need for improved, earlier identification of and intervention for the pre-pubertal overweight/obese children and those near overweight (BMI ≥ 72nd percentile).