Lopez Laureen M, Grimes David A, Schulz Kenneth F, Curtis Kathryn M
Behavioral and Biomedical Research, Family Health International, P.O. Box 13950, Research Triangle Park, North Carolina 27709, USA.
Cochrane Database Syst Rev. 2009 Apr 15(2):CD006033. doi: 10.1002/14651858.CD006033.pub3.
Steroidal contraceptive use has been associated with changes in bone mineral density in women. Whether such changes increase the risk of fractures later in life is not clear. However, osteoporosis is a major public health concern. Age-related decline in bone mass increases the risk of fracture, especially of the spine, hip, and wrist. Concern about bone health influences the recommendation and use of these effective contraceptives globally.
To evaluate the effect of using hormonal contraceptives before menopause on the risk of fracture in women
We searched for studies of fracture or bone health and hormonal contraceptives in MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS, as well as in clinical trials databases (ClinicalTrials.gov and ICTRP). We wrote to investigators to find additional trials.
Randomized controlled trials were considered if they examined fractures, bone mineral density (BMD), or bone turnover in women with hormonal contraceptive use prior to menopause. Studies were excluded if hormones were provided for treatment of a specific condition rather than for contraception. Interventions could include comparisons of a hormonal contraceptive with a placebo or with another hormonal contraceptive. Interventions could also include the provision of a supplement versus a placebo.
We assessed for inclusion all titles and abstracts identified through the literature searches with no language limitation. The mean difference was computed with 95% confidence interval (CI) using a fixed-effect model.
We found 13 RCTs, 2 of which used a placebo. No trial had fracture as an outcome but most measured BMD. Combination contraceptives did not appear to affect bone health. Of progestin-only methods, depot medroxyprogesterone acetate (DMPA) was associated with decreased bone mineral density, while results were inconsistent for implants. The two placebo-controlled trials showed BMD increases for DMPA plus estrogen supplement and decreases for DMPA plus placebo.
AUTHORS' CONCLUSIONS: Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.
使用甾体类避孕药与女性骨矿物质密度的变化有关。这种变化是否会增加日后生活中骨折的风险尚不清楚。然而，骨质疏松症是一个主要的公共卫生问题。与年龄相关的骨量下降会增加骨折的风险，尤其是脊柱、髋部和腕部骨折。对骨骼健康的关注影响了这些有效避孕药在全球的推荐和使用。
评估绝经前使用激素避孕药对女性骨折风险的影响。
我们在MEDLINE、POPLINE、CENTRAL、EMBASE和LILACS以及临床试验数据库（ClinicalTrials.gov和ICTRP）中搜索了关于骨折或骨骼健康与激素避孕药的研究。我们写信给研究人员以寻找其他试验。
如果随机对照试验研究了绝经前使用激素避孕药的女性的骨折、骨矿物质密度（BMD）或骨转换情况，则予以考虑。如果激素是用于治疗特定疾病而非避孕，则排除该研究。干预措施可以包括将一种激素避孕药与安慰剂或另一种激素避孕药进行比较。干预措施还可以包括提供补充剂与安慰剂的比较。
我们评估了通过文献检索确定的所有标题和摘要，无语言限制。使用固定效应模型计算平均差异及95%置信区间（CI）。
我们找到了13项随机对照试验，其中2项使用了安慰剂。没有试验将骨折作为结局指标，但大多数测量了骨矿物质密度。复方避孕药似乎不影响骨骼健康。在仅含孕激素的方法中，醋酸甲羟孕酮长效注射剂（DMPA）与骨矿物质密度降低有关，而植入剂的结果不一致。两项安慰剂对照试验显示，DMPA加雌激素补充剂可使骨矿物质密度增加，而DMPA加安慰剂则使其降低。
根据现有信息无法确定甾体类避孕药是否会影响骨折风险。由于干预措施不同，无法将试验合并进行荟萃分析。许多试验的参与者数量较少，一些试验有大量失访情况。医疗保健提供者和女性应考虑这些有效避孕药的成本和益处。例如，注射用避孕药和植入剂可提供有效、长期的避孕效果，且无需每日服药。仅含孕激素的避孕药被认为适合因医疗状况应避免使用雌激素的女性。
