GRADE table 2, (Question 2): Are women who use combined hormonal contraceptives (CHCs) at increased risk for decreased bone mineral density compared with women who do not use CHCs, with a specific focus on adolescents? (Indirect evidence) - Medical Eligibility Criteria for Contraceptive Use

Outcome	Type and number of studies (number of participants)	Limitations	Inconsistency	Imprecision	Indirectness	Other factors	Quality	Estimate of effect
Oral combined hormonal contraceptive use vs non-use in adolescent women
Bone mass density (BMD)	1 RCT (n=83), 1 non-randomized trial (n=84); 11 cohort studies (n=3242)	Serious limitations (2 good, 5 fair, 6 poor)	Serious inconsistency	No serious imprecision	Serious indirectness (intermediate outcome)	1 study showed duration-response effect; variability in duration of follow-up	Low	9 studies showed oral CHC use associated with less BMD gain (or greater loss) than non-use, including the 2 good-quality studies; 4 studies showed no difference^a
Patch use vs non-use in adolescent women
BMD	1 non-randomized trial (n=10)	Very serious limitations (1 poor)	Cannot determine (1 study)	Very serious imprecision	Serious indirectness (intermediate outcome)	None	Very low	1 study found no effect of patch on BMD vs non-use

Outcome

Type and number of studies (number of participants)

Limitations

Inconsistency

Imprecision

Indirectness

Other factors

Quality

Estimate of effect

Oral combined hormonal contraceptive use vs non-use in adolescent women

Bone mass density (BMD)

1 RCT (n=83), 1 non-randomized trial (n=84); 11 cohort studies (n=3242)

Serious limitations
(2 good, 5 fair, 6 poor)

Serious inconsistency

No serious imprecision

Serious indirectness
(intermediate outcome)

1 study showed duration-response effect; variability in duration of follow-up

Low

9 studies showed oral CHC use associated with less BMD gain (or greater loss) than non-use, including the 2 good-quality studies; 4 studies showed no difference^a

Patch use vs non-use in adolescent women

BMD

1 non-randomized trial (n=10)

Very serious limitations
(1 poor)

Cannot determine
(1 study)

Very serious imprecision

Serious indirectness
(intermediate outcome)

None

Very low

1 study found no effect of patch on BMD vs non-use

From: I, Development of the Medical eligibility criteria for contraceptive use, fifth edition

Cover of Medical Eligibility Criteria for Contraceptive Use

Medical Eligibility Criteria for Contraceptive Use. 5th edition.

Geneva: World Health Organization; 2015.

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GRADE table 2(Question 2): Are women who use combined hormonal contraceptives (CHCs) at increased risk for decreased bone mineral density compared with women who do not use CHCs, with a specific focus on adolescents? (Indirect evidence)