Effectiveness of Cyclofem in the treatment of depot medroxyprogesterone acetate induced amenorrhea

A total of 100 women who were using depot medroxyprogesterone acetate (DMPA) for contraception and who had experienced at least 6 months of drug induced amenorrhea, were randomized to either switching their method of contraception to Cyclofem, or continuing with DMPA. At the end of 6 months, 82% of the Cyclofem users had experienced some vaginal bleeding, compared with 10% of DMPA users. Time to resumption of vaginal bleeding was related to the duration of DMPA use to the duration of DMPA induced amenorrhea, and to the body mass index of the user. Over the 6 months of follow-up, 94% of Cyclofem users complained of some side effects, compared with 22% of DMPA users. The most frequently cited problems among Cyclofem users included breast tenderness, abdominal pain, and dysmenorrhea; yet a third of these women opted to stay on Cyclofem at the end of the study. It is concluded that switching to Cyclofem is a new option for DMPA users who are concerned about amenorrhea. Although using Cyclofem in this setting will not meet the needs of all such women, its effectiveness in inducing vaginal bleeding justifies a trial in those who have no contraindication to estrogen treatment.

Effect of norethindrone acetate in the treatment of symptomatic endometriosis

OBJECTIVE

The purpose of the study was to evaluate the efficacy of norethindrone acetate (NA) treatment in 52 women with dysmenorrhea, dyspareunia, noncyclic pelvic pain who had a diagnosis of endometriosis by laparoscopy.

RESULTS

Dysmenorrhea and noncyclic pelvic pain were relieved in 48/52 (92.3%) and 25/28 (89.2%) of patients, respectively. Overall pain relief was obtained in 49/52 (94.2%) of patients. Breakthrough bleeding, of variable severity, was the most common side effect experienced by 30 patients (57.6%); however, only 4 patients (7.7%) dropped out for this side effect. One other patient dropped out for severe breast tenderness, and three for noncyclic pelvic pain. In general, treatment was successful in 44/52 (84.5%) of patients with the above symptoms.

CONCLUSION

NA seems to be a cost-effective alternative with relatively mild side effects in the treatment of symptomatic endometriosis.

Norplant consensus statement and background review

This review has highlighted the attributes of a very important new method of contraception. The signatories to this document agree that, with the provision of appropriate information and instruction for the user, Norplant is a good contraceptive choice to be made available worldwide in family planning programs that have the resources for appropriate training and counseling. The signatories to this document are acting in their own personal capacity and not as representatives of any particular organization.

Menopausal hormone use and endometrial cancer, by tumor grade and invasion

We analyzed data from a population-based case-control study to investigate whether combined hormone replacement therapy influences the incidence of high-grade and -stage endometrial cancer. Subjects were women with epithelial endometrial cancer (N = 730) diagnosed during 1985-1991 and controls identified through random digit dialing (N = 1,002). Relative to hormone nonusers, women who took unopposed estrogens (mostly conjugated estrogens) for 3 or more years had a fivefold increase in the risk of tumors with myometrial invasion; the corresponding relative risk associated with combined therapy (estrogen and cyclic or continuous progestogen) for 3 or more years was only 1.3 (95% confidence interval = 0.8-2.2). We found a similar pattern of association for high-grade tumors.

Spacing-out of progestin--efficacy, tolerability and compliance of two regimens for hormonal replacement in the late postmenopause

Estrogen replacement therapy with sequential progestin at greater than monthly intervals has been frequently used in practice to reduce progestational side-effects and bleeding episodes, but clinical trials are still lacking. Two new regimens were tested. The main objective was to evaluate efficacy, predominantly in urogenital complaints, tolerability, and patient acceptance. Transdermal estradiol (0.05 mg/day) and norethisterone acetate orally (2.5 mg/day) were administered for 12 days every 2 or 3 months (group A, n = 83, group B, n = 89) to patients whose menopause had begun at least 4 years earlier. Study duration was three long cycles in each group within 7-10 months. Efficacy was good [group A/B = 94/92%], as was systemic tolerability [95/97%]; major skin reactions occurred in 7 and 4%, respectively. Patients' acceptance for continuation of spaced-out treatment was 88 and 87%, respectively. Progestin-associated withdrawal bleedings occurred in 66 (61%) of patients; mean duration 4.3 +/- 1.9/4.8 +/- 1.6 days, with no significant changes during therapy; intensity decreased during therapy. Breakthrough bleeding which required sonographic or histological work-up occurred in 8 and 13%, respectively. Despite the low dosage, transdermal estradiol proved to be efficacious in urogenital complaints. The high acceptance and the reduction of the overall progestin dose to avoid side-effects are of particular prognostic importance with regard to the prevention of cardiovascular diseases. Transdermal estradiol combined with 2- or 3-monthly progestin may be a valid regimen in the late post-menopause, but further studies using spacing-out regimens are urgently needed.

Effect of progestins on IGF-I serum level in estrogen-treated postmenopausal women

Insulin-like growth factor I (IGF-I) has a role in the whole-body anabolism and promotes both normal and abnormal cell growth in several tissues. Although IGF-I is also synthesized locally at numerous other sites, the liver does constitute the major site of its synthesis, and circulating IGF-I is mainly of hepatic derivation. The production of IGF-I is stimulated by growth hormone (GH), the secretion of which is influenced by circulating IGF-I level through a negative feed-back mechanism. Oral estrogen treatment causes a significant decrease of the IGF-I serum level, probably through a hepatocellular effect due to the first hepatic passage. Treatment with transdermal estradiol (tdE2) at the currently used doses does not cause, on average, substantial variations in the IGF-I serum level. The addition of an androgenic progestin--with strong hepatocellular actions, opposite to those of estrogen--completely reverses the IGF-I decrease induced by oral estrogens, and even causes a trend to IGF-I increase when tdE2 is used. Conversely, the addition of a non androgenic progestin, like dydrogesterone, does not cause interference with the estrogen effect.

Progestins and breast cancer risk

There is still no clear account on the role that progestins play in human breast cancer, and the issue continues to be debated. The effects of progestins on breast cell proliferation have been investigated in a number of different experimental systems with conflicting results. Progesterone has been reported to both stimulate and inhibit the growth of experimental mammary tumors, depending upon the dose and the experimental models. Epidemiological studies on the effect of combined hormone replacement therapy (HRT) on breast cancer risk in menopausal women are limited because the use of a progestin in addition to estrogens was not widely adopted until 10 years ago. Taking meta-analysis into account estrogen-progestin use did conclude that there is not an excess risk in combined HRT users. Epidemiological studies have provided conflicting results, ranging from a protective effect to a deleterious effect of progestin addition on breast cancer risk. Progestins include a large family of molecules characterised by different binding capacities to androgen receptors. This implies that they should be considered as distinct yet related, therapeutic agents. The use of different progestins may account for the controversial results obtained in studies conducted in different geographic areas.

Lipid profile during hormone replacement therapy: effect of different progestins?

Oral estrogens cause a decrease of low density lipoprotein cholesterol (LDL-chol.) and, especially an increase of high density lipoprotein cholesterol (HDL-chol.) levels, which both have potentially favorable effects; they also cause a triglyceride level increase, which probably has no clinical relevance except in cases with basal hypertriglyceridemia. Transdermal estradiol causes generally a minor decrease in LDL-chol. and minor increase HDL-chol. levels, with no increase or even decrease in triglyceride levels. The addition of androgenic progestins at conventionally used doses, while not interfering with LDL-chol. variations, causes a HDL-chol. decrease, which contrasts the effect of oral estrogens and completely reverses the effect of transdermal estradiol. On the contrary, the addition of a non androgenic progestin does not interfere with any of the estrogen induced lipid profile modifications.

Progestins and bone

Since the introduction of hormone replacement therapy which combines administration of oestrogens with cyclic or continuous administration of progestins, attention has been paid to the possible modulating effect of the progestin on the beneficial effects of the oestrogens. In this review data regarding the effects of progestins and of oestrogen/progestin combinations on bone in women have been summarized. The conclusion is that there is no evidence for a negative influence of progestins on the beneficial effects of oestrogens on the bone. To the contrary, progestins seem to have additional bone sparing properties because they are capable of stimulating the formation of bone, but the exact mechanism is still under discussion.

Oestrogens, progestins and breast proliferation

Aspects of the relation between endogenous and exogenous female sex steroids and the normal and malignant growth of the human breast are described. Starting points are the natural history of tumours, distinguishing between initiation, promotion and progression, and the risk factors for breast cancer as identified by epidemiology. The role of sex steroid hormones during the pubertal growth of the breast, the importance of the time between first growth and first pregnancy and the effects of pregnancy on the composition of the lobular structures in the human breast are discussed. The background of the suggested role of growth promoting effects of locally produced active oestrogens, especially in postmenopausal women, is given. From the evidence obtained from biochemical studies on the importance of the oestrogen production by the breast itself a mechanism is suggested to explain the possible lack of effects of exogenous oestrogens on the incidence of breast cancer.

Sonographic measurement of endometrial thickness as a predictor of vaginal bleeding in women using continuous combined hormone replacement therapy

The development of unpredictable vaginal bleeding is one of the main reasons for the discontinuation of treatment in users of continuous combined hormone replacement therapy (HRT). There is no accurate method of predicting which women will develop bleeding on this regimen. The aim of this study was to determine whether sonographic assessment of the endometrium could be used as a predictor of bleeding after the commencement of this treatment. Sonographic measurements of the endometrium were performed before treatment and then every 3 months for 1 year. Measurements of the endometrium were taken in both the transverse and sagittal planes and a record of the frequency of bleeding was maintained. Pretreatment measurements tended to be greater in those who developed bleeding within 1 month of the commencement of treatment, but the difference in measurements between those who developed bleeding and those who did not was not statistically significant. Endometrial thickness tended to be greater at 3, 6, 9 and 12 months of treatment in those who had bleeding compared with those who did not, but again the difference was not statistically significant. It is concluded that whilst bleeding on continuous combined HRT is more common in women with a thicker endometrium, sonographic assessment of the endometrium is not an accurate enough predictor of bleeding to be used in this clinical setting.

Transdermal oestradiol gel in the treatment of the climacterium: a comparison with oral therapy

OBJECTIVE

To compare two doses of a transdermal oestradiol gel (Divigel/Sandrena) plus oral sequential medroxyprogesterone acetate (MPA) with oral oestradiol valerate plus oral sequential MPA (Divina/Dilena).

DESIGN

Two year, randomised, open-label, comparative study.

SETTING

Menopausal outpatient clinic in Helsinki.

SUBJECTS

Postmenopausal women with climacteric complaints or already using HRT.

INTERVENTIONS

(1) One gram gel containing 1 mg oestradiol for 3 months plus 20 mg oral MPA during the last 14 days; (2) 2 g gel containing 2 mg oestradiol for 21 days plus 10 mg oral MPA during the last 14 days; (3) 2 mg oestradiol valerate tablets for 3 weeks plus 10 mg oral MPA during the last 10 days. In all groups, each treatment period was followed by a 7-day medication-free interval.

MAIN OUTCOME MEASURES

Climacteric complaints, bleeding control, bone mineral density, biomarkers of bone metabolism, lipid profile, tolerability and safety.

RESULTS

With each preparation, climacteric complaints were significantly reduced and good bleeding control was obtained. In addition, maintenance of bone mineral density as well as a reduction of bone turnover was achieved in all groups. Lipid parameters showed no unfavourable changes. Continuation rates were similar in all groups with overall 74% of patients completing the first year, whereas 94% of patients who elected to continue completed the second year. Tolerability of the gel was good: only 1.7% of patients discontinued treatment due to skin irritation.

CONCLUSIONS

Transdermal oestradiol gel and oral oestradiol valerate tablets, used in combination with oral sequential MPA, are effective regimens of HRT in postmenopausal women. Transdermal oestradiol gel is an efficient, well-tolerated form of HRT.

Bone density in women receiving Norplant implants for contraception

The aim of this study was to determine whether long-term Norplant uses is associated with changes in bone density. The study group consisted of forty one healthy women aged 19-42 years who had used Norplant for 31.1 +/- 11.2 months with a minimum period of 12 months. Fifty current IUD users constituted the control group. The bone density was measured by dual energy X-ray absorptiometry (DEXA) at the non dominant distal and ultradistal forearm. Serum estradiol was measured by microparticle enzyme immunoassay technique. Age, parity, income, weight, height and body mass index (BMI) of both groups were no differences. Our analysis did not find any differences in bone mineral density of distal forearm and ultradistal forearm between Norplant and IUD users (95% CI -0.01, -0.03 and -0.02, 0.02 respectively). Serum estradiol was not different in the two groups (95% CI -24.9, 110). This study revealed that the Norplant implants do not have any adverse effect on bone mineral density.

[Effect of progestins on the breast--protective or proliferative?]

This survey reviews the published data on progesterone and progestins in normal, benign and malignant breast disease. Controversial data will be put together and the results demonstrating proliferative action and a proliferative and mitotic action on one hand and an inhibiting and protective action on the other hand will be presented.

Third-generation oral contraceptive and deep venous thrombosis: from epidemiologic controversy to new insight in coagulation

Four epidemiologic studies showed a twofold increase in risk of deep venous thrombosis with the use of oral contraceptives containing third-generation progestins, relative to second-generation products. These findings have been strongly debated ever since, and new studies have been added. In the current article we examine whether the findings can be explained by potential biases or other shortcomings of the epidemiologic studies. We conclude that complete certainty cannot exist but that the most rational conclusion from the epidemiologic findings and their discussion is that an increased risk of deep venous thrombosis with third-generation contraceptives is likely, especially in first-time and young users. The controversy has recently led to new insights in coagulation: Women who use third-generation contraceptives acquire a resistance to the blood's own anticoagulation system, similar to the activated protein C resistance that is seen in persons who carry the factor V Leiden mutation but different from that in women using second-generation contraceptives.

Follow-up study of children with precocious puberty treated with cyproterone acetate. Ad hoc Committee for CPA

A total of 1840 children and adolescents treated with cyproterone acetate (CPA) to block gonadal function, as a treatment for precocious puberty, short stature and other disorders, were registered to survey for the risk of developing hepatic tumors. Patients responding to follow-up numbered 1552 (85%). The cumulative dose and duration of CPA therapy for boys and girls were 110.4g and 2.6 years, and 122.9 g and 2.8 years, respectively. Among the 1552 patients, five hepatoma cases were found. Four underwent successful surgery and remain alive and well to date. Two of the 5 cases had been given more than 500g, the other 3 more than 1000 g, of CPA. Three had also been given androgens before CPA administration. Although further follow-up is necessary to monitor for the development of adenoma and hepatoma, the risk of developing these tumors among patients to whom limited doses of CPA were administered appears to be negligible.

Serial changes in plasma fibrinogen concentration and fibrinolytic activity in African women on oral contraceptive pills

Several retrospective epidemiological studies suggest that there is an association between the use of oral contraceptive pills and increased risk of intravascular thrombosis. The present study reports on several changes in fibrinogen concentration and fibrinolytic activity after prolonged use of oral contraceptives in African women. Fibrinolytic activity by euglobulin lysis time (ELT) and plasma fibrinogen concentration (PFC) by clot weighing method were assessed among 20 African women who were new users of combined oral contraceptives (OCP). They were tested at pre-treatment and serially at six monthly intervals over a three year period. There was consistently a significant increase in fibrinogen levels (p < 0.001) and euglobulin lysis time (p < 0.001) with increasing duration of use of oral contraceptive pills. There was a positive correlation between the mean fibrinogen levels and ELT (r = 0.89, p < 0.01), and a negative correlation between fibrinogen and plasminogen activator content of fibrinolytic system (r = -0.84, p < 0.01). The mean fibrinogen values during OCP use were substantially higher than at pre-treatment. We conclude that although African women may have a low predisposition to thrombosis, their risk of having fibrin defect is increased after prolonged use of oral contraceptive pills. We suggest a clinical epidemiological study to provide a better understanding of the haemostatic changes observed in African women.

Bone mineral density during long-term treatment with Norplant implants and depot medroxyprogesterone acetate. A cross-sectional study of Thai women

This cross-sectional study compares bone mineral density (BMD) in long-term Norplant implants and depot medroxyprogesterone acetate (DMPA) users. The objectives of this study were to evaluate and compare the bone mineral density between women using these contraceptives. Forty-one current users of Norplant implants and 50 DMPA users participated in the study. The BMD was measured by dual energy x-ray absorptiometry in the nondominant distal and ultradistal forearm. Serum estradiol was measured by microparticle enzyme immunoassay technique. The demographic characteristics were similar in both groups. The mean durations +/- SD of DMPA and Norplant implants were 59.14 +/- 30.73 and 31.1 +/- 11.2 months, respectively. The BMD of long-term Norplant implant and DMPA users was similar. The serum estradiol in the Norplant implant group was significantly higher than in DMPA users. However, the serum estradiol level in DMPA users ranged into normal for the follicular phase, which is higher than for postmenopausal women. This study suggests that two long-acting progestogen contraceptives do not differ with respect to their impact on BMD in long-term users.

Bone mineral density in long-term depot medroxyprogesterone acetate acceptors

The study of bone density in long-term DMPA users is reported. The aims were to study and compare bone density in long-term DMPA users with intrauterine device (IUD) users. Fifty current users of DMPA with a minimum 36 months previous use were compared to 50 current IUD users as control. The bone mineral density was measured by dual energy x-ray absorptiometry (DEXA) at the non-dominant distal and ultradistal forearm. Serum estradiol was measured by microparticle enzyme immunoassay technique in both groups. Age, income, weight, height, BMI, and parity of both groups were matched. The mean bone mineral density of distal forearm in DMPA and IUD users was 0.48 +/- 0.05 g/cm2 in both groups. The mean bone mineral density of ultradistal forearm was 0.38 +/- 0.06 g/cm2 in DMPA users and 0.4 +/- 0.05 g/cm2 in IUD users. No differences in mean bone mineral density of distal and ultradistal forearm between DMPA and IUD users was demonstrated (95% CI -0.02, 0.02 and -0.04, 0.001, respectively). However, the serum estradiol levels were significantly different between DMPA and IUD users (95% CI -122, -68.1). From this study, it is suggested that long-term DMPA use should not have any adverse effect on bone density even if it reduces serum estradiol.

Intracervical and fundal administration of levonorgestrel for contraception: endometrial thickness, patterns of bleeding, and persisting ovarian follicles

OBJECTIVE(S)

To study the prevalence of persisting ovarian follicles and to assess the endometrial changes and patterns of vaginal bleeding over 1 year of use of a 20 micrograms/24 h levonorgestrel-releasing intracervical contraceptive device.

DESIGN

Prospective, randomized study.

SETTING

Two family planning clinics in Helsinki, Finland.

PATIENT(S)

Women requesting intrauterine hormonal contraception.

INTERVENTION(S)

Insertion of a levonorgestrel-releasing intracervical contraceptive device into the cervical canal (group 1, n = 151) or fundally into the uterine cavity (group 2, n = 147) for contraception.

MAIN OUTCOME MEASURE(S)

Transvaginal ultrasonography of the ovaries and endometrium at insertion and 3, 6, and 12 months after insertion. Data on bleeding were collected using menstrual diary cards.

RESULTS

Persisting ovarian follicles were found in < 8% of women. In both groups, the amount of endometrial tissue decreased significantly in 3 months. The incidence of amenorrhea during the 1st year was higher in the fundal insertion group.

CONCLUSION(S)

The number of persisting follicles was low. Follicles resolved within 6 to 8 weeks. No association was found between persisting follicles and problems of bleeding. Compared with intracervical insertion, fundal insertion resulted in more uniform endometrial suppression and fewer days of bleeding and spotting.

A double-blind randomized study of the treatment of endometriosis with nafarelin or nafarelin plus norethisterone

The objective of this study was to compare the efficacy of nafarelin 200 micrograms (Group A), nafarelin 400 micrograms (Group B) and the combination of nafarelin 200 micrograms and norethisterone 1.2 mg (Group C) daily, in treating symptoms of endometriosis, American Fertility Society score and adverse events during 6 months of treatment. A prospective, randomized, double-blind parallel group study was performed in two centers and 49 women with endometriosis diagnosed laparoscopically were included. The patients were seen monthly for physical examination and records were taken for bleeding pattern, symptom score and adverse events. A control laparoscopy was performed at the end of 6 months of treatment. All patients were followed 6 months after treatment. At 3 and 6 months the pelvic examination total score had decreased significantly in all three groups. The total endometriosis score was significantly reduced in Groups B and C. After 2 months the total symptom score showed a significant decrease in Groups B and C. The frequency of hot flushes during the first month of treatment was lowest in Group C, but during the rest of treatment there were no differences between the groups. Best bleeding control was obtained in Group C. We conclude that nafarelin 200 micrograms daily has as good an effect on endometriosis symptoms as nafarelin 400 micrograms daily, and the addition of norethisterone 1.2 mg results in fewer hot flushes and better bleeding control.