Oral Contraceptive use and Fracture Risk in Women- A Systemic Review

 

Banita Rana*, VKSK Priyanka Kavuluru*

Dept of Obstetric and Gynecological Nursing, Shri Mata Vaishno Devi College of Nursing (SMVDCON), Kakryal, Jammu, J&K.

 

ABSTRACT:

Background: Most of the oral contraceptive (OC) users are under 30 years of age and in the critical period for bone mass accrual. Osteoporosis is a major health problem that leads to a high incidence of spine, radial and hip fractures. It is well recognized that a chronically hypoestrogenic state increases bone turnover that, in turn, causes a critical decrease in bone mineral density (BMD) an important determinant of fracture risk. During the premenopausal period, hypogonadism can have deleterious effects on skeletal health by reducing peak bone mass or inducing precocious bone loss.  In young women, the most plausible intervention for this disorder at the moment seems to be the use of hormone replacement. Oral contraceptives are associated with an improvement in BMD. In perimenopausal oligomenorrheic women, the use of oral contraceptives seems to have bone-sparing effects. In conclusion, the protective role of oral contraceptives on bone density is biologically plausible, since this treatment represents a replacement therapy with continuous exposure to exogenous estrogens. People lose bone mass or density as they age, especially women after menopause lose calcium and other minerals. This study was carried out to investigate the oral contraceptive use and fracture risk within an obstetric population and to identify the severity of fracture risk and associated factors around women in a view of limited studies and resources, important consideration on literature review taken. Aim of Study: This systemic review aims to review the available studies to investigate the Oral contraceptive use and fracture risk in women.
Methods and Material: A narrative review undertaken using the following databases in the end (August-December) of 2020, Pub Med, CINHAL, MEDLINE, National, International Journals and published articles regarding Oral contraceptive use and fracture risk in women. Results: Twelve research studies from databases regarding Oral contraceptive use and fracture risk among women concluded use of oral contraceptives and fracture risk among women. Out of 12 studies taken, nine studies revealed that use of oral contraceptives more than one year of age among women associated with lower risk of bone fractures and three studies revealed that increased risk for recent contraceptive users or in early age and risk is lower in post-menopausal women

 

 

 

INTRODUCTION:

“Women’s health need to be front and center-it often isn’t, but needs to be”

Oral contraceptives are highly effective method of birth control available in two types. The most widely used combination oral contraceptives, consist of both an estrogen and progestin component and are taken for 21-28 days of each menstrual cycle¹. Oral contraceptives are commonly used by numerous women very often throughout a prolonged period of time in early reproductive years. According to the close relationship between estrogen and bone metabolism, the question of the impact of combined oral contraceptive (COC) on bone needs to be addressed women. Most studies have reported that use of COC during adulthood had neutral possibility beneficial effect on bone health, in adolescent girls skeletal effect is of greater concern, in perimenopausal years prevents that activation of bone metabolism and decrease in bone mass and in teens within the first 3 years after the menarche would be a strong determinant of bone mass acquisition impairment².

 

A prospective study conducted on oral contraceptive pill use and fractures in women as it has been suggested that use of the oral contraceptive pill confers protection against osteoporosis in later life of women. In this study they investigated the relationship between pill use and subsequent occurrence of fracture in a cohort of 46,000 women enrolled in the Royal College of General Practitioners Oral Contraception study during 482,083 person-years of follow-up. The study results revealed that fracture risk was lower among multiparous women, nonsmokers and those of lower socio-economic class. The risk of subsequent fractures among the women who had ever used the oral contraceptive pill was significantly greater than that among women who had never used it. Although the study only includes limited observation of older women to date, these data do not support the hypothesis that pill use protects women against the occurrence of osteoporotic fracture in later life.³

 

A large cohort study on oral contraception and other factors in relation to hospital referral for fracture explored the relationship between Oral Contraceptive (OC) use and fractures occuring at various sites among the 17,032 participants in the oxford-family planning association contraceptive study, which now includes information accumulated during 310,000 woman. In total 1308 women suffered at least one fracture during the follow-up period, which is largely confined to pre-menopausal years. When all fractures were combined there was a modest but highly increasing risk with total duration of oral contraceptive use. The highest relative risk (95%) was for current or recent oral contraceptive users as a whole and no clear pattern of risk was apparent.⁴

 

In systematically reviewed evidence from observational studies which included 14 (7cohort and 7 case-control) studies on hormonal contraceptives use and   risk of   bone fractures in women. Interventions included comparisons of a hormonal contraceptive with a nonhormonal contraceptive, no contraceptive or another hormonal contraceptive. The primary outcome was the risk of fracture. the quality of evidence was examined by using the Newcastle-Ottawa Quality Assessment Scale (NOS), developed for case-control and cohort studies and no meta-analysis was included. The study results focusing on six studies which examined oral contraceptive use revealed that one study with few association and two studies had little association with fracture risk and one cohort study found OC ever-users had increased risk for all fractures. Another cohort study of postmenopausal women found no increased fracture risk for OC use after excluding women with prior fracture. A cohort study noted increased risk for subgroups, such as those with longer use or specific intervals since use.⁵

 

A population-based case-control study was conducted by a pacific northwest HMO, group health cooperative to determine the association between OC use during later reproductive life and risk of fracture across the menopausal transition. The study population includes 1204 case women (69%) aged 45 to 59 years with incident fractures, and 2275 control women (64%) were enrolled. Data analysis is done by entry of potential cases with fracture codes in automated data were adjudicated by electronic health record review. Potential control women without fracture codes were selected concurrently, sampling based on age. Participants received a structured study interview. Study results concluded that the most common fracture site for cases was the wrist/forearm (32%). Adjusted fracture risk did not differ between cases versus controls for OC use in the 10 years before menopause (OR 0.90, 95% CI0.74, 1.11); for OC use after age 38(OR 0.94, 95% CI 0.78, 1.14); for duration of use, or for other OC exposures. The present study shows no association between fractures near the menopausal transition and OC use in the decade before menopause or after age 38. For women considering OC use at these times, fracture risk does not seem to be either reduced or reassuringly-increased.⁶

 

A retrospective was conducted on oral contraceptive use and fracture risk among 12,970 women in the UK.  The aim of this analysis was to compare the risk of bone fracture in women using hormonal contraception with that in women who have never used hormonal contraception. A total of 6485 women (mean age 37.8 years) with an initial diagnosis of fracture between January 2010 and December 2015 were identified. The present study revealed that women without bone fractures were significantly more likely to have had exposure to combined oral contraception. Women without bone fractures were significantly more likely to have used oral contraception (OR 0.81). it was concluded that usage of oral contraception was associated with a significantly lower risk of bone fracture (OR 0.81, 95% CI 0.74-0.90). This effect was strongest in the age groups 18-25 and 26-35 and in patients with OC treatment duration of more than 1 year.⁷

 

This review followed the PRISMA Guidelines as in Figure

 

METHOD:

A systemic review was undertaken by PRISMA guidelines using the following databases in the end (August to December) of 2020, Pub med, CINHAL, MEDLINE, national, international journals and magazines regarding oral contraceptive use and fracture in women.

 

DATA SOURCES AND SEARCHES:

Data collected from the Pub Med, CINHAL, MEDLINE, Local Newspaper, National and International Journal, and Magazines.

 

SELECTION CRITERION OF THE STUDY AND DATA EXTRACTION:

The selection criteria for the systemic review using PRISMA guidelines regarding oral contraceptive use and fracture risk among women

·      Articles and publications related tooral contraceptive use and fracture risk among women.

·      Hormonal contraceptive use and fracture risk in women.

·      Studies related to oral contraceptive use and risk of hip fracture.

·      Studies related to steroidal contraceptives and bone fracture.

·      Studies related to use of DMPA contraception and incidence of bone fracture

 

The data extraction criteria for the systemic review regarding oral contraceptive use and fracture risk include two authors independently extracted the data. One author coded the data in tabular form using PRISMA guidelines the data was analyzed.

 

FINDINGS:

Through all these literature review, the investigator concluded that oral contraceptive and fracture risk among women out of 12 studies taken, nine studies revealed that use of oral contraceptives more than one year of age among women associated with lower risk of bone fractures and three studies revealed that increased risk for recent contraceptives users or in early age and risk is lower in post-menopausal women.

 

CONCLUSION AND FUTURE PERPECTS:

·       Twelve research studies from databases regarding oral contraceptive use and fracture risk in women concluded that the use of OCs among women in desired doses significantly decreases (1.20, 95% CI 1.08-1.34) the overall fracture risk than woman never used Oral contraceptives

·       The associated factors for the fracture risk includes age of initiation of usage, age of women, duration of usages, type of oral contraceptives, dosage, interval between usage, and Peri Menopausal women additionally never usage of any kind of Contraceptives is also considered in few research studies.

·       Health care practitioners should the above factors while prescribing the Oral contraceptives to woman and proper interval should be given in between the usage.

·       The information from the current review can be used as source while planning a treatment or while dealing with obstetric population and Peri menopausal women.

 

CONFLICT OF INTEREST STATEMENT:

All contributions of this review articles did not have any financial difficulty to carry out this systemic review regarding oral contraceptive use and fracture risk. There was not any hindrance to write an article and to publish in your journal.

 

ETHICAL CLEARANCE:

Since it is a self review paper, ethical clearance is not needed.

 

REFERENCES:

1.     Nancy C. Lee, Herbert B. Peterson, and Susan Y. Chu. Health effects of Contraception. Contraception use and controlled fertility: Health issues for women and children background Papers. https://www.ncbi.nlm.nih.gov/books/NBK235083/#_ddd00066_, accessed on 08-August- 2020.

2.     Florence tremollieries, Impact of oral contraceptive on bone metabolism. Best practice and research. Clinical Endocrinology & Metabolism. 2013 Feb; vol 27(1): 47-53.

3.     C. Cooper, P Hannaford, P Croft, C.R. Kay. Oral contraceptive pill use and fractures in women: A prospective study. Vol 14, Issue 1, January-February 1993, Pages 41-45. https://doi.org/10.1016/8756-3282(93)90254-8.

4.     Martin Vessey, Jonathan Mant, Rosemary Painter. Oral contraception and other factors in relation to hospital referral for fracture: Findings in a large cohort study. Volume 57, Issue 4, April 1998, Pages 231-235. https://doi.org/10.1016/S0010-7824(98)00026-2.  

5.     Lopez LM, Chen M, Mullins S, Curtis KM,   Helmerhorst FM. Steroidal Contraceptives and bone fractures in women: evidence from observational studies. Cochrane Database of Systemic Reviews 2015,Jul 21, Issue 7, article no: CD009849. DOI:10.1002/14651858.CD009849.

6.     Delia Scholes, Andrea Z. LaCroix, Rebecca A. Hubbard,Laura E. Ichikawa,Leslie Spangler, Belinda H. Operskalski, MPH, Nancy Gell,Oral Contraceptive Use and Fracture Risk around the Menopausal Transition, PMCID: PMC4731309,NIHMSID: NIHMS737379,PMID: 26757274Menopause. 2016 Feb; 23(2): 166–174.doi: 10.1097/GME.0000000000000595

7.     Dombrowski S, Jacob L, Hadji P, Kostev K. Journal of Osteoporosis International. April 2017. Vol 28(8):1-7. DOI:10.1007/s00198-017-4036-

 

 

 

 

Received on 10.12.2020           Modified on 17.01.2021

Accepted on 12.02.2021         © RJPT All right reserved