1.
Anticoncepción hormonal y
salud ósea
ANDRES RICAURTE S. MD
PONTIFICIA UNIVERSIDAD JAVERIANA

2.
Mujeres adultas

3.
Perimenopausicas

4.
Tiempo de uso / postmenopausia

5.
 To summarize the prospective studies, one “good” study [94] and one
“fair” study [80] found that adolescents and young women who used COCs
with 20 μg EE did not gain as much BMD as nonusers. Another “fair”
study [79] and one “poor” study [89] investigated other formulations and
found no significant differences, but BMD was generally lower in COC
users compared with controls. The differences may have not reached
significance because of insufficient statistical power and the short duration
of the studies.

6.
 In summary, the highest quality evidence from prospective studies
(“good”) indicates that COCs do not significantly affect BMD among
premenopausal women [91], [92] and [96]. In contrast, two “fair” cohort
studies [77] and [101] reported that BMD was significantly lower in COC
users than nonusers, and one “poor” cohort study [95] reported a
significant positive effect for COCs. Very limited evidence does not support
an effect of a combined injectable contraceptive (Mesigyna) on BMD, but
use of the NuvaRing may result in lower BMD compared with nonusers.

7.
 In summary, evidence from six “fair” and two “poor” prospective studies
suggests that COCs have no deleterious effect on BMD in perimenopausal
women and that low-dose formulations may prevent menopausal bone
loss. The majority of cross-sectional studies indicate that having ever used
COCs is not associated with differences (from women who have never used
COCs) in BMD at any anatomical site.

8.
 A fair number of studies have examined the association between COC use
and the clinical endpoint of interest — fracture. However, the inconsistency
of study findings makes it difficult to interpret the body of evidence as a
whole. In addition, data are lacking for older age groups, in which
osteoporotic fractures are most common. Because COCs were first licensed
just four decades ago, the effects of their long-term use on risk of
osteoporotic fracture are only now becoming evident. Furthermore, none
of the studies identified for this review estimated relative risks for low-
dose formulations, and thus, it is difficult to generalize to today's COC
users. Most women currently using low-dose pills are of younger ages
when osteoporotic fractures are rare.

9.
 The body of evidence relating to COC use and BMD is best evaluated by age
group. Limited evidence suggests that adolescents and young (<23 years)
women who use COCs have lower BMD than controls. One possible
explanation is that the formulations studied (low-dose and very low dose) are
insufficient to support optimal bone acquisition during adolescence. More
studies of young COC users are needed to determine if this is the case. It
remains unclear whether COCs prevent young women from attaining their
peak bone mass, and whether failure to reach peak bone mass is related to
increased risk of osteoporosis later in life. We found that adult women who use
COCs generally have BMD similar to nonusers. It may be that healthy
premenopausal women have sufficient amounts of endogenous estrogen to
maintain bone mass, and thus, using COCs confers no extra benefit. The exact
mechanisms are unclear, however. Evidence suggests that COC use during the
perimenopausal or postmenopausal periods has a bone-sparing effect.

10.
 There is very little evidence for how other combined hormonal methods
affect BMD. Two studies suggest no effect from using Mesigyna but a
negative effect for the NuvaRing in premenopausal adult women. More
evidence is needed to reach a reliable conclusion.
 In many cases, the studies we reviewed were difficult to interpret and
compare. Studies varied in design, age of participants, setting, anatomical
site of measurement and the techniques for measurement (e.g., DEXA). In
addition, we encountered variation in length of follow-up, adjustment
variables, COC formulation and the duration of use.

11.
 Finally, BMD is an imperfect indicator of true fracture risk, even in
postmenopausal populations. In premenopausal women, the significance
of low BMD and how it relates to future risk of fracture is poorly
understood. Correspondingly, how changes in BMD because of COC use
before menopause will affect clinical outcomes in the postmenopausal
period remains unclear.

12.
 Current adult and adolescent users of depot medroxyprogesterone acetate (DMPA) have lower mean bone mineral density (BMD) compared with
nonusers of hormonal contraception; however, generally no more than 1 standard deviation difference. Initial BMD loss in DMPA users stabilizes over
time and long-term users may only lose negligible BMD on a yearly basis.
 Progestogen-only implants do not appear to affect BMD and there is limited information on other progestogen-only contraceptives.
 Evidence shows that BMD recovers after discontinuation of DMPA in premenopausal and adolescent women.
 The effect of combined oral contraceptives (COCs) on BMD is variable, with no effect reported in premenopausal women; however, growing evidence
suggests that low-dose COCs may be detrimental to BMD in adolescents and young women. Evidence points to small losses in BMD in users of low-
dose and ultra-low-dose COCs. In adolescents, low-dose COC users have been shown to gain less BMD than nonhormonal user controls.
 There are limited data on newer methods of contraception such as the contraceptive patch, vaginal ring, combined injectable
 There is inconclusive evidence on fracture risk and COCs, and almost no evidence on facture outcome and DMPA.
 Current adult and adolescent users of depot medroxyprogesterone acetate (DMPA) have lower mean bone mineral density (BMD) compared with
nonusers of hormonal contraception; however, generally no more than 1 standard deviation difference. Initial BMD loss in DMPA users stabilizes over
time and long-term users may only lose negligible BMD on a yearly basis.
 Progestogen-only implants do not appear to affect BMD and there is limited information on other progestogen-only contraceptives.
 Evidence shows that BMD recovers after discontinuation of DMPA in premenopausal and adolescent women.
 The effect of combined oral contraceptives (COCs) on BMD is variable, with no effect reported in premenopausal women; however, growing evidence
suggests that low-dose COCs may be detrimental to BMD in adolescents and young women. Evidence points to small losses in BMD in users of low-
dose and ultra-low-dose COCs. In adolescents, low-dose COC users have been shown to gain less BMD than nonhormonal user controls.
 There are limited data on newer methods of contraception such as the contraceptive patch, vaginal ring, combined injectable
 There is inconclusive evidence on fracture risk and COCs, and almost no evidence on facture outcome and DMPA.