2/12/05njm

Q. Should I prescribe Depo Provera as a long term agent for more than 2
years?

A. There is concern about bone loss if used \> 2 yrs. Here are some
alternative strategies

Yes, here are some benchmark Advisories about bone loss in Depo Provera
use \> 2 consecutive years.

Pfizer issued letters to providers in the US advising that all women
should only use Depo

Provera for \> 2 years if other birth control methods are inadequate.

The U.S. FDA 'Black Box' warning states that women who use the drug may
experience significant loss of BMD; the loss increases with duration of
use and may not be

completely reversible. The effect of adolescent or early adulthood use
of Depo-Provera, on peak

bone mass and future risk of osteoporotic fracture, is unknown

The United Kingdom Committee on Safety of Medications has issued a
letter to advice

prescribers:

-That Depo-Provera may only be used as first-line contraception in
adolescents when other methods are considered unacceptable or unsuitable

-That women who wish to use Depo-Provera for \> 2 years should undergo a
re-evaluation of the risks and benefits

-That other forms of contraception should be considered in women with
risk factors for osteoporosis (see risk factors below)

#### [OB/GYN CCC Editorial comment:]{.underline}

The FDA Black Box warning was based on one controlled clinical trial in
adults and one ongoing open label, non-randomized clinical trial in
adolescent females. The loss increases with duration of use and may not
be completely reversible. There is evidence, in both adults and
adolescents, that the decrease in BMD is at least partially reversible
after Depo Provera CI is discontinued and ovarian estrogen production
increases. Long term studies on BMD loss in adolescents are not
available at this time, but are ongoing.

Please note the FDA does not have data to address whether calcium or
Vitamin D may lessen BMD loss in women using Depo Provera CI. All
patients should have adequate calcium or Vitamin D intake. There is also
randomized clinical data that estrogen supplementation is protective in
adolescent girls. (see below)

Another approach, if long term Depo Provera CI is deemed essential, is
to measure BMD. In adolescents, interpretation of BMD results should
take into account patient age and skeletal maturity. Also see other
citations below

**[Bottomline]{.underline}:**

Until further data is available, use of Depo Provera CI for longer than
2 years should be limited, while adequate intake of calcium and Vitamin
D should be encouraged. If other forms of birth control are inadequate,
then BMD should be measured and should take into account patient age and
skeletal maturity. Estrogen supplementation can also be considered.

**Management:**

**First approach:**

If patient has been using Depo-Provera for \> 2 years, then use another
birth control method. There are many other methods of long term birth
control. If the patient had chosen Depo Provera to avoid frequent intake
of pills / patch, then an IUD is an excellent choice in properly
selected patients. (see Appendix II - ACOG)

**Dietary advice:**

Eat foods rich in calcium and vitamin D

Providers may also recommend supplemental calcium and vitamin D. There
are combined pharmaceutical products with both calcium and Vitamin D
(see below)

**Pharmacologic supplementation**

The first approach should be increased dietary calcium intake. It that
is in adequate to provide one gram of elemental calcium per day, then
consider supplementation.

One simple approach is calcium supplementation alone. A common approach
is to prescribe either one tablet (1250 mg Calcium carbonate = has
roughly 500 mg of elemental calcium) twice a day, or one tablet each
day, depending on patient's dietary calcium intake.

Next, consider a combined Calcium and Vitamin D agent. The most common
preparation has 1250 mg of calcium carbonate, so the dosing is similar
to the above.

Lastly consider estrogen supplementation. Cromer et al (below) report a
successful randomized controlled trial with monthly estrogen injections
(estradiol cypionate).

**What about a DEXA scan?**

If prolonged Depo Provera therapy is deemed medically necessary, or the
patient has other risk factors for osteoporosis, then consider a DEXA
scan to determine bone mineral density (BMD). Please note the results
need to interpreted considering

The following are risk factors for osteoporotic fracture:

-   Female

-   Advanced age (greater than 65)

-   Body habitus (weight less than 127 pounds; or body mass index
    \[BMI\] [\<]{.underline}20)

-   Caucasian or Asian race

-   Family history of osteoporosis

-   Hypogonadism (estrogen or testosterone deficiency)

-   Sedentary lifestyle

-   Smoking (greater than or equal to one pack per day)

-   Excessive alcohol intake (greater than two drinks per day)

-   Diet deficient in calcium or vitamin D without adequate
    supplementation

-   Increased likelihood of falling

There are also numerous medical conditions associated with osteoporosis
(see Appendix I)

**Patient Education:**

Here are some issues to begin your discussion with the patient

-Depo-Provera may decrease the amount of calcium stored in your bones

-The longer you use this medication, the more the amount of calcium in
your bones may decrease

-The amount of calcium in your bones may not return to normal even after
you stop using the drug

-A decrease in bone calcium during teenage years may be especially
serious (bone calcium normally increases during these years)

-It is not known whether your risk of developing osteoporosis later in
life is greater if you start to use medroxyprogesterone injection when
you are a teenager

-Tell your doctor if you or a family member has osteoporosis; if you
have any other bone disease or anorexia nervosa; or if you drink a lot
of alcohol or smoke a great deal

-Tell your doctor if you take any of the following medications:

Corticosteroids,

Anti-seizure medications

-You should not use medroxyprogesterone injection for a long time (e.g.,
more than 2 years) unless no other method of birth control is right for
you

-Keep all appointments with your doctor and the laboratory, as they may
test your bones to be sure they are not becoming too thin before you
continue to use medroxyprogesterone

-Talk with your doctor about the risks of using medroyprogesterone
injection to prevent pregnancy

**Medline: Patient Education**

<http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a604039.html>

**Biochemical markers: NTX**

Lastly an approach that some have considered is the monitoring of
biochemical markers. This has an uncertain role in postmenopausal
patients and would need further study to consider in this group of
patients.

Some providers are currently using to follow folks on antiresorptive
therapy with DEXAs in postmenopausal patients. It remains to be
determined if this approach would have a role in the group of patients
using Depo Provera for birth control or menstrual management.

The first NTX is a baseline. The second measurement is the measurement
that has clinical value

Another approach use it in between DEXAs or as poor man's DEXA. For
instance, obtain a baseline NTX, start therapy, and then get second NTX.
If one sees a good response, then skip the next DEXA as that test is
only covered q 24 months under Medicare and some contract health case
managers are refusing to pay for follow-up DEXAs anyway.

**UpToDate**

**"Recommendation** --- Although the optimal approach is uncertain, we
recommend the second approach in which monitoring with markers is
performed. We measure either urinary NTX or serum CTX and look for a 50
percent decline with therapy as an index of adequate treatment.
Follow-up with a measurement of bone density in two to three years, to
make sure that the predictions about bone loss were correct, is
advised."

**Use of biochemical markers of bone turnover in osteoporosis**

<http://www.uptodateonline.com/application/topic.asp?file=minmetab/17366&type=A&selectedTitle=3~3>

**"SUMMARY** --- Measurements of biochemical markers of bone turnover
reflect the rates of bone resorption and bone formation. The most
important clinical use for these tests is in monitoring patients taking
antiresorptive therapy for osteoporosis. Other uses include following
patients with Paget\'s disease, metastatic bone disease, and
inflammatory arthritis. Measurements of urinary NTX and SERUM CTX
excretion are the most specific and clinically useful markers for bone
resorption, while bone-specific alkaline phosphatase is the most
clinically useful marker of bone formation."

**Bone physiology and biochemical markers of bone turnover**

<http://www.uptodateonline.com/application/topic.asp?file=minmetab/19988&type=A&selectedTitle=1~3>

**Biochemical markers of bone turnover** --- Measurements of biochemical
markers of bone turnover can be used to complement measurements of BMD:

  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} If the BMD is in the upper tertile, we
consider the woman at low risk for osteoporosis and drug therapy to
prevent bone loss is not needed.\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} If the BMD is in the lowest tertile, we
consider the woman at high risk for osteoporosis and we recommend
preventive therapy.\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} If the BMD is in the middle tertile, we
recommend measuring a marker of bone turnover such as the urinary
excretion of DPD or NTX; we treat women with a value above the upper
limit of normal for premenopausal women.

**Screening for osteoporosis**

<http://www.uptodateonline.com/application/topic.asp?file=minmetab/19499&type=A&selectedTitle=2~3>

**[Resources]{.underline}**

**FDA 'Black Box' Warning**

<http://www.fda.gov/medwatch/SAFETY/2004/DepoProvera_Label.pdf>

**Bone mineral density changes over two years in first-time users of
depot medroxyprogesterone acetate**

OBJECTIVE: To compare longitudinal changes in bone mineral density (BMD)
among first-time depot medroxyprogesterone acetate (DMPA) users to women
using no hormonal contraception, and evaluate user characteristics
associated with that BMD change. DESIGN: Prospective longitudinal study.
SETTING: Healthy volunteers in an academic research environment.
PATIENT(S): Women, aged 18 to 35, choosing DMPA for contraception (n =
178) and women using no hormonal contraception (n = 145). MAIN OUTCOME
MEASURE(S): Hip and spine BMD measured, at three-month intervals for 24
months, by dual energy x-ray absorptiometry. RESULT(S): Mean hip BMD
declined 2.8% (SE = 0.034) 12 months following DMPA initiation and 5.8%
(SE = 0.096) after 24 months. Mean spine (L1-L3) BMD declined 3.5% (SE =
0.022) and 5.7% (SE = 0.034), respectively, after one and two years of
DMPA use. Mean hip and spine BMD of control participants changed less
than 0.9% over the same period. Among DMPA users, body mass index (BMI)
change was inversely associated with BMD change at the hip, but not at
the spine. Calcium intake, physical activity, and smoking did not
influence BMD change in either group. CONCLUSION(S): Hip and spine BMD
declined after one DMPA injection and this decline continued with each
subsequent injection for 24 months. With the exception of increasing BMI
among DMPA users, no user characteristics offered protection against
DMPA-related BMD loss.

Clark MK, et al Bone mineral density changes over two years in
first-time users of depot medroxyprogesterone acetate. Fertil Steril.
2004 Dec;82(6):1580-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15589863>

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

Objective The purpose of this clinical trial was to evaluate the effect
of estrogen supplementation on bone mineral density in adolescent girls
who received depot medroxyprogesterone acetate for contraception. Study
design One hundred twenty-three adolescents who began receiving depot
medroxyprogesterone acetate injections every 12 weeks were assigned
randomly to receive monthly injections of estradiol cypionate or
placebo. The main outcome was bone mineral density that was measured by
dual energy x-ray absorptiometry for 12 (n = 69) to 24 (n = 36) months.
Participants, technicians, and physicians were blinded to estrogen
treatment. Results Over the 24-month period, the percentage of change
from baseline bone mineral density at the lumbar spine was 2.8% in the
estradiol cypionate group versus -1.8% in the placebo group ( P \<.001).
At the femoral neck, the percentage of change from baseline bone mineral
density was 4.7% in the estradiol cypionate group versus -5.1% in the
placebo group ( P \<.001). Conclusion Our results suggest that estrogen
supplementation is protective of bone in adolescent girls who receive
depot medroxyprogesterone acetate injections.

Cromer BA; Lazebnik R; Rome E; Stager M; Bonny A; Ziegler J; Debanne SM
Double-blinded randomized controlled trial of estrogen supplementation
in adolescent girls who receive depot medroxyprogesterone acetate for
contraception. Am J Obstet Gynecol 2005 Jan;192(1):42-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672001>

**Menopausal bone loss in long-term users of depot medroxyprogesterone
acetate contraception.**

OBJECTIVE: The purpose of this study was to determine the rate of early
postmenopausal bone loss in women who had used depot medroxyprogesterone
acetate contraception through to menopause. STUDY DESIGN: Bone mineral
density at the lumbar spine and femoral neck was assessed prospectively
over 3 years in 15 women who reached a natural menopause and who did not
undergo hormone replacement therapy and in 16 long-term users of depot
medroxyprogesterone acetate who discontinued depot medroxyprogesterone
acetate only on reaching menopause. Of the latter, 5 women subsequently
underwent hormone replacement therapy. RESULTS: Early menopausal bone
loss was rapid in the control group (6% from both sites over 3 years),
but the users of depot medroxyprogesterone acetate (who did not take
hormone replacement therapy) showed little change in bone mineral
density. Between-group differences were statistically significant at
years 2 and 3 at both sites (P \<.03-\<.002). In the users of depot
medroxyprogesterone acetate who underwent hormone replacement therapy,
bone mineral density increased significantly (P \<.03) at the lumbar
spine and was stable at the femoral neck. CONCLUSION: Women who use
depot medroxyprogesterone acetate through to menopause have attenuated
rates of bone loss from the lumbar spine and femoral neck, presumably
because they have already lost the estrogen-sensitive component of bone.

Cundy T; Cornish J; Roberts H; Reid IR Menopausal bone loss in long-term
users of depot medroxyprogesterone acetate contraception. Am J Obstet
Gynecol 2002 May;186(5):978-83    

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12015524>

**Bone mineral density in a cohort of adolescent women using depot
medroxyprogesterone acetate for one to two years.**

The purpose of this study was to examine estradiol and bone mineral
density (BMD) in a cohort of adolescents using depot medroxyprogesterone
acetate (DMPA) for one to two years. BMD was significantly decreased in
the femoral neck and lumbar spine at year one. Estradiol levels
suggested hypoestrogenization among subjects

Busen NH; Britt RB; Rianon N Bone mineral density in a cohort of
adolescent women using depot medroxyprogesterone acetate for one to two
years. J Adolesc Health 2003 Apr;32(4):257-9  

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12667729>

  

**Bone mineral density at various anatomic bone sites in women receiving
combined oral contraceptives and depot-medroxyprogesterone acetate for
contraception**

The association between users of combined oral contraceptives and
depot-medroxyprogesterone acetate (DMPA) for contraception and bone
mineral density (BMD) has been controversial because of variations among
studies. Like other studies, this cross-sectional study compares BMD in
users of combined oral contraceptives and DMPA with that in nonusers.
Unlike previous studies, we defined long-term use as \>2 years, and we
measured more bone sites than previous studies including lumbar spines,
femurs, and forearms. The study group consisted of 59 women aged 30
years to 34 years who had been using combined oral contraceptives for
57.36 +/- 27.02 months with a minimum period of 24 months, 34 women of
the same age who had been using DMPA as contraceptive for 55.76 +/-
35.31 months, and 62 women of the same age who had not used any steroid
hormonal contraceptives for more than 6 months. BMD was measured by dual
energy photon absorptiometer at lumbar spine 2-4, neck of femur, Ward\'s
triangle of femur, greater trochanter of femur, ultradistal radius, and
distal ulnar, respectively. Age, body mass index, and lifestyles of both
groups were matched with nonusers. Mean BMD at lumbar spine (L2-4) in
the DMPA users was significantly lower than in the controls (1.031 +/-
0.090 vs. 1.096 +/- 0.116, p = 0.007). There were no significant
differences in BMD values at bone sites other than lumbar spine between
DMPA users and the controls. There were no significant differences in
BMD values at all bone sites between combined oral contraceptives users
and the controls. We conclude that combined oral contraceptives are not
associated with changes in values of BMD, while DMPA is associated with
decreased BMD only at lumbar spine. We comment that steroid hormonal
contraceptives are safe to use for long-term contraception regarding
bone mass effects

Wanichsetakul P; Kamudhamas A; Watanaruangkovit P; Siripakarn Y;
Visutakul P Bone mineral density at various anatomic bone sites in women
receiving combined oral contraceptives and depot-medroxyprogesterone
acetate for contraception. Contraception 2002 Jun;65(6):407-10 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12127638>

   

**Substantial Bone Loss Seen with Depo-Provera Use (Medscape)**

The results of a new study confirm that using the contraceptive
Depo-Provera is associated with bone loss. Depo-Provera, also known as
DMPA, is a long-lasting contraceptive hormone that is injected every
three months.

Dr. M. Kathleen Clark and colleagues at the University of Iowa in Iowa
City compared changes in bone mineral density in 178 women starting on
Depo-Provera for the first time and 145 women not using hormonal
contraception.

Average bone density at the hip fell 2.8 percent one year after starting
Depo-Provera and 5.8 percent after two years. Loss of bone density in
the spine was similar.

In contrast, average bone loss at the hip and spine was less than 0.9
percent among the comparison group of women, the team reports in the
medical journal Fertility and Sterility.

\"We clearly show that bone density is lost with DMPA use,\" Clark told
Reuters Health.

She also noted that in mid-November, the U.S. Food and Drug
Administration
([news](http://us.rd.yahoo.com/DailyNews/manual/nm/hl_nm/depo_bones_dc/13786954/*http:/news.search.yahoo.com/search/news?fr=news-storylinks&p="Food and Drug%0AAdministration"&c=&n=20&yn=c&c=news&cs=nw) -
[web
sites](http://us.rd.yahoo.com/DailyNews/manual/nm/hl_nm/depo_bones_dc/13786954/*http:/search.yahoo.com/search?fr=web-storylinks&p=Food and Drug Administration))
issued a black box warning on Depo-Provera stating, in essence, that
bone density is lost and may not be regained, particularly when it is
used for more than two years.

\"Without information on the magnitude of bone mineral density loss,
clinicians cannot weigh the potential benefits of a highly effective
method of contraception to the potential problems associated with bone
loss. Our study provides this information,\" Clark said.

She emphasized that most women between the ages of 18 and 35 who are
using Depo-Provera for contraception will not have immediate problems
related to osteoporosis. However, whether there are long-term problems
following menopause will depend on whether lost bone is regained when
Depo-Provera is discontinued.

Clark\'s team is close to completing the phase of their study that is
looking at what happens to bone density when women stop using the
contraceptive. \"It is hard to speculate on recovery without complete
data,\" she said.

The results of a study released in 2002 hint that bone density returns
to normal about 15 months following discontinuation.

However, Clark sees a problem with that study. \"Most of the women were
enrolled after they had been on DMPA for a while, so they did not have
baseline data and would have no way of knowing what the true bone loss
was since beginning DMPA,\" she commented.

SOURCE: Fertility and Sterility, December 2004.

**When to Cease Depot Medroxyprogesterone Acetate (DMPA)? (Medscape)**

![](media/image2.png){width="1.0416666666666666e-2in"
height="0.10416666666666667in"}**Question**\
Can you recommend a protocol for ceasing injectable progesterone
contraceptives when a woman living in a developing country is reaching
menopausal age? When women have long-standing amenorrhoea, it is
difficult to assess when menopause occurs, and we have had a number of
patients become pregnant through mistakenly ceasing the method too
early.

I agree that it can be a challenge to know when a woman using depot
medroxyprogesterone acetate (DMPA) birth control should stop her
injections. The median age of menopause in nonsmoking women is 52 years.
This means that 50% of 52-year-old women still may ovulate (and
therefore need birth control). Rather than focusing on assessing FSH
levels, a more convenient approach to management is simply to continue
injections until 55 years of age, when the likelihood of ovulation and
pregnancy off DMPA is low. DMPA usually suppresses menopausal vasomotor
symptoms. However, if a perimenopausal woman using DMPA experiences hot
flashes, oral estrogen (eg, conjugated equine estrogen 0.625 mg, or
estradiol 1 mg) can be added, provided there are no contraindications.
**Posted 08/03/2004**

[**Ask the Experts about Gynecology and Reproductive
Endocrinology**](http://www.medscape.com/pages/editorial/ate/public/index/1928)

<http://www.medscape.com/viewarticle/496705>

**Diabetes and depot medroxyprogesterone contraception in Navajo women**

BACKGROUND: Depot medroxyprogesterone acetate contraception is widely
used in Navajo women, a high-risk population for diabetes mellitus.
However, depot medroxyprogesterone may lead to weight gain and
independently decrease insulin sensitivity. We studied the association
between depot medroxyprogesterone and development of diabetes in Navajo
women. METHODS: We studied Navajo women aged 18 to 50 years who had seen
a health care provider at a Navajo Area Indian Health Service clinic at
least once in 1998. Diabetic cases (n = 284) and nondiabetic controls (n
= 570) were matched by age. Medical records were reviewed to determine
contraception use before the diagnosis date of diabetes. RESULTS: Users
of depot medroxyprogesterone were more likely to develop diabetes than
patients who had used combination estrogen-progestin oral contraception
only (odds ratio \[OR\], 3.8; 95% confidence interval \[CI\], 1.8-7.9).
The excess risk persisted after adjustment for body mass index (OR, 3.6;
95% CI, 1.6-7.9). Longer use was associated with greater risk of
diabetes. Users of depot medroxyprogesterone were also more likely to
develop diabetes than patients who had never used hormonal
contraception, although excess risk was smaller (OR, 2.4; 95% CI,
1.4-3.6). CONCLUSIONS: Depot medroxyprogesterone contraception was
associated with a greater risk of diabetes compared with combination
oral contraceptive use only. Risk was associated with length of use and
persisted after adjustment for body mass index. Additional research is
needed for confirmation, but this risk should be considered in
contraceptive choice for women at high risk for diabetes.

Kim C; Seidel KW; Begier EA; Kwok YS Diabetes and depot
medroxyprogesterone contraception in Navajo women. Arch Intern Med 2001
Jul 23;161(14):1766-71  

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11485510>

  

**FDA**

<http://www.fda.gov/>

**FDA 'Black Box' Warning**

<http://www.fda.gov/medwatch/SAFETY/2004/DepoProvera_Label.pdf>

**Appendix I**

**Medical conditions that may be associated with an increased risk of
osteoporosis in adults**

-   Acquired Immunodeficiency Syndrome

-   Amyloidosis

-   Chronic obstructive pulmonary disease

-   Congenital porphyria

-   Cushing's syndrome

-   Eating disorders

-   Female athlete triad

-   Gastrectomy

-   Gaucher's disease

-   Hemochromatosis

-   Hemophilia

-   Hyperparathyroidism

-   Hypogonadism, primary or secondary

-   Hypophosphatasia

-   Idiopathic scoliosis

-   Inadequate diet

-   Inflammatory bowel disease

-   Insulin-dependent diabetes mellitus

-   Lymphoma and leukemia

-   Malabsorptive syndromes

-   Mastocytosis

-   Multiple myeloma

-   Multiple sclerosis

-   Pernicious anemia

-   Rheumatoid arthritis

-   Severe liver disease, especially primary bilary cirrhosis

-   Spinal cord transsection

-   Sprue

-   Stroke

-   Thalassemia

-   Thyrotoxicosis

-   Tumor secretion of parathyroid hormone related peptide

-   Weight loss

**Appendix II**

#### ACOG {#acog .Style-Heading-4-+-Arial-14-pt-Underline}

**Intrauterine Device**

**ACOG Practice Bulletin NUMBER 59**

**Conclusions**

-   Pelvic inflammatory disease complicating IUD insertion is uncommon,
    and the risk of PID decreases to the background risk after the first
    20 days after insertion.

-   Nulligravid and multiparous women at low risk of STDs who desire
    long-term reversible contraception are good candidates for IUDs.

-   

**Summary of Recommendations**

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

-   Routine use of prophylactic antibiotics at the time of IUD insertion
    confers little benefit.

-   The copper T380A is very effective for postcoital emergency
    contraception and is most effective if inserted within 5 days after
    unprotected intercourse.

-   

***The following recommendations are based on limited or inconsistent
scientific evidence (Level B):***

-   Intrauterine devices may be offered to women with a history of
    ectopic pregnancy.

-   The levonorgestrel intrauterine system may be an acceptable
    alternative to hysterectomy in women with menorrhagia.

-   

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

-   The FDA recommends that IUDs be removed from pregnant women when
    possible without an invasive procedure.

-   An IUD placed for contraception should be removed in a woman who has
    become menopausal.

-   Contraception counseling should include information about risk
    factors for STDs and PID.

Intrauterine device. ACOG Practice Bulletin No. 59. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005;105:223--32.

Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15625179>

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb059.cfm>