The use of long-acting contraceptives in adolescents

DMPA and implants have played an important role in the attempt to prevent teenage pregnancies. Adolescent health care providers should provide continued counseling to girls using DMPA or implants and should promptly address any concern associated with these methods. Future studies are warranted to explore ways to prevent or reduce the side effects of DMPA and implants, as well as to develop new, optimal, long-acting contraceptives. Detailed baseline information should be obtained in every future study that explores the presence of side effects during the use of long-acting contraceptives.

Effect on stroke of different progestagens in low oestrogen dose oral contraceptives. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception

The multicentre WHO collaborative case-control study had limited power to differentiate stroke risks by progestagen component in low dose combined oral contraceptives. Given this caveat, odds ratios for ischaemic, haemorrhagic, and all strokes combined associated with use of oral contraceptives containing desogestrel or gestodene ("third generation") were found to be similar to those containing levonorgestrel in this study.

Risk of idiopathic cerebral haemorrhage in women on oral contraceptives with differing progestagen components

The risk of idiopathic cerebral haemorrhage in users of third-generation oral contraceptives compared with that of users of second-generation oral contraceptives was evaluated using data from the General Practice Research Database. We found no increased risk for third-generation oral contraceptives, compared with second-generation oral contraceptives.

Hormone replacement therapy and lipid-lipoprotein concentrations

OBJECTIVE

To evaluate the links between hormone replacement therapy and lipid-lipoprotein concentrations (total cholesterol [T.Ch] triglycerids, high density lipoprotein cholesterol [HDL-C], low density lipoprotein cholesterol [LDL-C] and very low density lipoprotein cholesterol [VLDL-C]) in a total of 6416 postmenopausal women.

STUDY DESIGN

Open prospective longitudinal study. Of the 2184 surgical postmenopausal women, 1102 received conjugated equine estrogen (CEE), and 1082 transdermal estradiol (TDE2). Of the 4232 natural postmenopausal women: 1073 received CEE+medroxyprogesterone acetate (MPA), 1068 CEE+dydrogesterone (DD), 1044 TDE2+MPA, 1047 TDE2+DD. Lipid-lipoprotein concentrations were evaluated by using a SPSS program at 1,2,3,4,5,6,7 years of therapy and cumulatively.

RESULTS

Cumulative evaluation of the data on estrogen only replacement therapy revealed a significant decrease in T.Ch, LDL-C and VLDL-C, and an increase in HDL-C; however, the increase in HDL-C and triglycerids was significantly higher in CEE than TDE2 (P<0.01). Cumulative evaluation of the data on estrogen progestin hormone replacement therapy revealed a significant decrease in T.Ch, LDL-C and an increase in HDL-C for all; however, triglycerides and VLDL levels decreased in TDE2+MPA and TDE2+DD groups (P<0.05).

CONCLUSION

Both the natural and surgical menopause patients were found to have more favorable lipid profiles after treatment with estrogen progesterone combined formulations and estrogen only replacement.

A randomized multicenter study comparing the efficacy and bleeding pattern of a single-rod (Implanon) and a six-capsule (Norplant) hormonal contraceptive implant

To compare the contraceptive efficacy, tolerability, and bleeding patterns, 200 healthy female volunteers received, in an open, comparative, randomized, multicenter study in China, either a single-rod (Implanon) or a six-capsule (Norplant) contraceptive implant for 2 years with an optional extension of up to 4 years. Women were exposed to Implanon for 341.6 woman-years and Norplant for 329.1 woman-years. There were no pregnancies during the study. Per 90-day reference period, the median number of bleeding/spotting days with Implanon decreased from 33.5 in the first period to 19.0-21.5 days in the last year. Similarly, with Norplant, the median number of bleeding/spotting days decreased from 34.5 to 18.0-23.0 days, respectively. The number of bleeding/spotting episodes during year 1 was 2.0 per 90-day reference period with Implanon and 3.0 per period with Norplant (p < 0.05 for periods 1-4). For the remaining 90-day periods, there was no statistical difference between the two groups. In general, there was less frequent bleeding with Implanon compared with Norplant, whereas the incidences of amenorrhea and infrequent bleeding were higher with Implanon than with Norplant. The mean overall incidence of prolonged bleeding fell markedly during the study, from 66.0% in reference period 1 to 27.3% in period 16 with Implanon and from 69.0% to 21.7% with Norplant, respectively. The most common adverse events were related to disturbed bleeding patterns, which were also the major reasons for discontinuation (Implanon n = 8; Norplant n = 14). Normal menses returned in almost all subjects within 3 months after removal of the implants. Implanon was inserted in a mean time of 0.61 min and Norplant in 3.90 min (p < 0.001). Similarly, the mean time required to remove the implant was significantly shorter for Implanon than for Norplant (2.18 min vs 11.25 min, p < 0.001). The maximum time required for removal of the implant was 10 min for the Implanon group and 60 min for the Norplant group. In both groups, blood pressure and hemoglobin were not affected, whereas body weight tended to increase. It can be concluded that both contraceptive systems demonstrated excellent contraceptive efficacy and were well tolerated. Compared with Norplant, there was less frequent bleeding with Implanon, whereas the incidence of infrequent bleeding and amenorrhea was higher. Implanon was significantly quicker to insert and to remove than was the multiple capsule system.

Hormone replacement therapy causes a respiratory alkalosis in normal postmenopausal women

Menopause is associated with an increase in venous bicarbonate concentrations that is reversible with hormone replacement therapy (HRT). However, the mechanism underlying this effect is not known. To address this question, we studied the changes in acid-base indexes in the arterialized venous blood of normal postmenopausal women commencing conjugated equine estrogen (0.625 mg/day), medroxyprogesterone acetate (MPA; 5 mg/day), their combination, or placebo, in a double blind randomized controlled study over 3 months. Serum bicarbonate concentrations decreased significantly in the groups receiving either MPA or estrogen plus MPA (P = 0.008). This trend was apparent as early as 2 days and reached 2.7 and 2.3 mmol/L in the respective groups by 3 months. Similar changes were seen with partial pressure of carbon dioxide (P = 0.04); a change of -0.7 kPa occurred in the estrogen plus MPA group at 3 months. There were no changes in bicarbonate concentrations or partial pressure of carbon dioxide in those receiving estrogen alone or placebo. Accompanying changes in blood pH were apparent in the estrogen plus MPA group, where there was an upward trend at 1 week (P = 0.056) and a significant change from baseline (+0.013) at 3 months (P = 0.03). In the whole group, the changes in pH were inversely correlated with those in urinary excretion of hydroxyproline (r = -0.44; P = 0.01). We conclude that HRT using conjugated estrogens and MPA produces small, but sustained, changes in acid-base status. These may contribute to the effects of HRT and menopause on many tissues and disease processes, including the development of osteoporosis.

Severe gastrointestinal bleeding in a uremic patient treated with estrogen-progesterone therapy

Gastrointestinal bleeding is a frequent complication in hemodialysis patients; angiodysplasia is a potential cause, with a higher incidence in uremic patients. We describe a case of severe anemia (Hemoglobin up to 3.5 g/dl) secondary to diffuse angiodysplastic lesions in a hemodialysis patient with mixed connective tissue disease. The case is characterised both by the severity of the clinical picture (extension and entity of angiodysplastic lesions, frequency of bleeding episodes) and by the patient's religious faith which made her reject blood transfusions. We underline the efficacy of estrogen-progesterone therapy in view of the modest results obtained with other therapeutic strategies on bleeding.

Cirrhosis in a child with hypothalamic syndrome and central precocious puberty treated with cyproterone acetate

Before the advent of gonadotropin-releasing-hormone analogues, cyproterone acetate (CPA) had been widely prescribed for the treatment of precocious puberty. Although it is usually well tolerated, liver toxicity has been recognized as a complication of its long-term use. We report the occurrence of cirrhosis in a 10-year-old boy with hypothalamic syndrome and precocious puberty who was treated with CPA for over 50 months. Despite discontinuation of the medication, the liver disease progressed. The patient died of sepsis and multiorgan failure at the age of 14 years. This is the first paediatric report of substantial liver damage and liver toxicity progressing to cirrhosis associated with CPA treatment.

CONCLUSION

Prolonged cyproterone acetate treatment may induce cirrhosis. Monitoring of liver function both during treatment and for several months after discontinuation of therapy is recommended.

Continuous combined hormone replacement therapy compared with tibolone

OBJECTIVE

To compare relief of vasomotor symptoms, changes in lipoproteins, and bleeding patterns in postmenopausal women receiving either continuous combined hormone replacement therapy (HRT) of estradiol valerate and norethisterone or tibolone 2.5 mg/day.

METHODS

In a multicenter, randomized, open-label study, 235 postmenopausal women received one of the above-mentioned treatments. Fasting lipoproteins were measured at baseline and at 3, 6, and 12 months. At each visit, participants completed Greene climacteric questionnaires and recorded any bleeding episodes. Data are presented as mean +/- standard deviation if normally distributed, median and interquartile range if non-normally distributed, or as frequency count. For menopausal symptoms and diary card data, the differences were tested by Wilcoxon rank-sum test.

RESULTS

One hundred sixteen women received continuous combined HRT and 119 women received tibolone; 72 and 76 women, respectively, completed 12 months of therapy. Both treatments effectively relieved vasomotor symptoms and reduced serum total cholesterol. Continuous combined HRT, but not tibolone, significantly reduced low-density lipoprotein levels. Both treatments reduced high-density lipoprotein levels, but the effect was more profound with tibolone. The initial bleeding score was higher for women taking continuous combined HRT; however, by the end of the study, the percentages of amenorrheal women were comparable. Endometrial histology was similar for both treatments at the end of the study, although two cases of proliferative endometrium were found in the tibolone group.

CONCLUSION

Estradiol valerate-norethisterone continuous combined HRT controls symptoms and is associated with a safe lipid profile.

Progestogens and cardiovascular disease. A critical review

Although progestational hormones are clearly beneficial in preventing estrogen-induced endometrial hyperplasia and cancer, their effect on other areas is far less clear. Of particular interest is the attenuating effect medroxyprogesterone acetate (MPA) has on the cardiovascular benefits of postmenopausal estrogen treatment. MPA reduces the dilatory effect of estrogens on coronary arteries, increases the progression of coronary artery atherosclerosis, accelerates low-density lipoprotein uptake in plaque, increases the thrombogenic potential of atherosclerotic plaques and promotes insulin resistance and its consequent hyperglycemia. These effects may be largely limited to MPA and not shared with other progestogens.

Two-year prospective, randomized trial comparing an innovative twice-a-week progestin regimen with a continuous combined regimen as postmenopausal hormone therapy

OBJECTIVE

To compare compliance, symptom control, bleeding patterns, endometrial response, and lipid changes in postmenopausal women treated with transdermal E2 and a regimen of either intermittent or continuous dosing of progestin.

DESIGN

Randomized, prospective study.

SETTING

Menopausal Outpatient Clinic at an academic tertiary care hospital.

PATIENT(S)

One hundred women who had reached menopause naturally and had been amenorrheic for at least 1 year. Fifty women were randomly assigned to receive each regimen.

INTERVENTION(S)

All patients received 50-microg E2 patches and medroxyprogesterone acetate, either 5 mg twice per week or 2.5 mg daily. The bleeding pattern was registered in diary cards. Endometrial status was assessed by vaginal ultrasound and endometrial biopsy. Lipid levels were measured by ELISA.

MAIN OUTCOME MEASURE(S)

The number of patients who dropped out of the study and the number of days each patient reported spotting or bleeding were recorded. Endometrial thickness was measured and histologic examination of the endometrial tissue was performed. Plasma levels of total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were measured.

RESULT(S)

Fourteen women dropped out of the intermittent dosing group and 13 dropped out of the continuous dosing group. Irregular spotting or bleeding occurred at a similar rate in both groups. Biopsies performed at the end of the study showed adequate endometrial stabilization in both groups. No significant changes in lipid levels were detected with either regimen.

CONCLUSION(S)

Both regimens were similarly effective. The high rate of atrophic endometria suggests the possibility of further reduction of the progestin dose.

Mammary gland uptake of sodium Tc-pertechnetate in a cat with a drug-induced gynecomastia

Sodium Tc-pertechnetate accumulated in the mammary glands of a male cat. It was determined that the uptake was attributable to gynecomastia induced by medroxyprogesterone acetate injections. Gynecomastia and pertechnetate uptake resolved following cessation of medroxyprogesterone acetate treatment.

Research, introduction, and use: advancing from Norplant

As the first real contraceptive innovation in over 20 years, and as a long-acting method requiring clinical intervention for insertion and removal, Norplant raised an especially wide range of issues. It also encountered a number of difficulties. In April 1997, an Institute of Medicine (IOM) workshop on implant contraceptives reviewed newly available data on Norplant's efficacy, safety, and use; considered lessons learned from the method's development, introduction, and market experience; and explored approaches based on those lessons that could improve the environment for contraceptive research and development and make market entry for new contraceptive technologies less troubled. In addition to presenting the IOM workshop findings, the present article calls attention to the rich scientific prospects available for development of the next generation of contraceptives, and notes signs of an evolving new paradigm, essential if those prospects are to be realized to any significant extent.

Insertion and removal of Implanon

Implanon is a single-rod contraceptive implant containing the progestin etonogestrel. Implants require insertion and removal by medical professionals. Detailed and unbiased counseling before insertion is essential, and should include contraceptive efficacy, insertion and removal procedures, and possible adverse events. Insertion and removal times have been measured in six open studies and in seven comparative studies in which Norplant (the six-capsule levonorgestrel implant) was used as the reference product. In comparative studies, the mean time needed for insertion of Implanon was 1.1 min and removal took 2.6 min. Insertion as well as removal of Implanon was four times faster than with Norplant. Complications with insertion and removal are rare in the hands of medical professionals familiar with the techniques.

An integrated analysis of vaginal bleeding patterns in clinical trials of Implanon

The vaginal bleeding patterns observed during the use of the single-rod progestin-only implant, Implanon, compared with those seen during the use of the six-capsule implant, Norplant, have been analyzed. The acceptability of these bleeding patterns was also assessed. An integrated analysis of 13 different trials was done, studying reference periods (RP) of 90 days. These trials included totals of 1716 Implanon users and 689 Norplant users. There were statistically significant lower mean values over RP 2-8 the range over RP 2-8 is presented) for Implanon, for the number of bleeding-spotting days (15.9-19.3 vs 19.4-21.6; p = 0.0169), the number of bleeding days (7.5-10.0 vs. 11.7-13.1; p < 0.001), and the number of bleeding-spotting episodes (2.2-2.7 vs. 3.1-3.3; p < 0.0001). The bleeding patterns of Implanon users appeared to be more variable than those observed with Norplant: Implanon users had more amenorrhea, and slightly more infrequent bleeding, frequent bleeding, and prolonged bleeding than Norplant users. The difference was only statistically significant for amenorrhea (17.9%-24.8% with Implanon compared with 2.0%-7.0% for Norplant over RP 2-8). There were no statistically significant differences in the acceptability of the two products as indicated by the discontinuation rates, which were 30.2% and 0.9% in Europe and Southeast Asia, respectively, for Implanon, and 22.5% and 1.4%, respectively, in the two regions, for Norplant. The individual bleeding pattern was not predictable. However, in general, it can be stated that women initially without bleeding or with infrequent bleeding have only a small chance of becoming frequent bleeders, and vice versa. Dysmenorrhea clearly improved during use of both Implanon and Norplant. Neither Implanon nor Norplant caused anemia.

A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 micrograms/day or levonorgestrel 30 micrograms/day. Collaborative Study Group on the Desogestrel-containing Progestogen-only Pill

OBJECTIVE

To compare the contraceptive efficacy, bleeding pattern, acceptability and safety of desogestrel 75 micrograms/day (Cerazette) as a progestogen-only formulation to levonorgestrel 30 micrograms/day in healthy female subjects.

METHODS

In a double-blind, randomized, group-comparative, multicenter trial, 989 subjects were randomized to desogestrel 75 micrograms/day and 331 to levonorgestrel 30 micrograms/day. The women were observed during 13 consecutive treatment periods of 28 days.

RESULTS

The Pearl indices for in-treatment pregnancies, excluding gross non-compliance, were 0.14 (one pregnancy in 727 woman-years) in the desogestrel group and 1.17 (three pregnancies in 257 woman-years) in the levonorgestrel group. Using the 90-day reference period for assessing the bleeding pattern, desogestrel users had a higher incidence of amenorrhea and infrequent bleeding on the one hand, and of frequent bleeding and prolonged bleeding on the other hand, at the beginning of the study period. In contrast to the levonorgestrel group, a tendency towards less bleeding over time was observed in the desogestrel group. The frequency and pattern of adverse experiences were comparable for desogestrel 75 micrograms/day and levonorgestrel 30 micrograms/day.

CONCLUSIONS

Desogestrel 75 micrograms/day is a reliable and safe progestogen-only pill with a contraceptive efficacy superior to levonorgestrel 30 micrograms/day. These was a similar overall acceptability of desogestrel 75 micrograms/day and levonorgestrel 30 micrograms/day.

A comparison of the cycle control and tolerability of two ultra low-dose oral contraceptives containing 20 micrograms ethinylestradiol and either 150 micrograms desogestrel or 75 micrograms gestodene

OBJECTIVE

To compare the cycle control and tolerability of two oral contraceptives containing 20 micrograms ethinylestradiol and either 150 micrograms desogestrel or 75 micrograms gestodene.

METHODS

A randomized, multicenter study was conducted in which 1016 healthy adult women received the desogestrel (n = 509) or the gestodene (n = 507) preparation for six treatment cycles.

RESULTS

No significant differences in bleeding patterns were detected between the two treatments. The incidence and duration of irregular bleeding decreased markedly, and to a similar extent, during each treatment. The occurrence of irregular bleeding per cycle decreased from 24.6 to 9.4% in the desogestrel group and from 19.7 to 8.6% in the gestodene group. Its duration fell from 1.1 to 0.2 days and from 0.9 to 0.3 days, respectively. There was a consistently low incidence of amenorrhea (1.0-2.8%). There were no significant differences between treatments for the incidence, intensity or emergence of dysmenorrhea. During both treatments, the incidence of premenstrual syndrome and complaints such as breast tenderness, nausea and headache dropped markedly.

CONCLUSION

Ultra low-dose oral contraceptives containing desogestrel or gestodene offer equivalent, good cycle control and improvements in dysmenorrhea and premenstrual syndrome and have similar, excellent tolerability profiles.

An integrated analysis of nonmenstrual adverse events with Implanon

This integrated analysis evaluates nonmenstrual adverse events, blood pressure, and body weight changes during the use of the single-rod etonogestrel-containing contraceptive implant, Implanon; these aspects are compared for Implanon and Norplant, the six-capsule implant containing levonorgestrel. Overall, 47% of Implanon users had drug-related adverse events, whereas in the comparative studies the figure for those using Implanon (61%) was slightly lower than that for Norplant users (69%). In all Implanon studies, 12 of 1716 women (0.7%) were affected by serious adverse events that were considered drug related. In comparative studies three of the 689 Implanon users (0.4%) and one of 689 Norplant users (0.1%) had such experiences. The most frequently reported drug-related adverse events were acne, breast pain, headache and weight gain. The adverse events that most often caused discontinuation of Implanon were weight gain and acne. The development or aggravation of acne was a frequent adverse event (in 18.5% of Implanon and 22.3% of Norplant users in the comparative studies) but individual studies indicated that there were also many subjects whose acne improved during implant use. There were gradual increases in body weight over time but these may be only partly attributable to implant use and partly attributable to normal increases over time.