Comparison of a triphasic oestradiol/norethisterone acetate preparation with and without an oestriol component in the treatment of climacteric complaints

This study was undertaken to evaluate the effects of oestriol in combination with oestradiol in the treatment of women with climacteric complaints. Forty-three post-menopausal women were randomly allocated to two groups on a double-blind basis. Over a 28-day cycle 23 of the women were treated sequentially for 12 days with 1 tablet containing 17 beta-oestradiol 2 mg plus oestriol 1 mg, then for 10 days with 1 tablet containing the same oestrogens plus norethisterone acetate 1 mg, thereafter for 6 days with 1 tablet containing 17 beta-oestradiol 1 mg plus oestriol 0.5 mg. The other 20 women received the same treatment but without the oestriol. No clinical, laboratory or histological differences were seen between the two groups. Both treatments were found to be equally effective in alleviating climacteric symptoms, with few side effects. It may be stated in conclusion that, on the basis of routine clinical and laboratory parameters no differences were found between the two preparations.

Endometrial changes after long-term use of continuous oestrogen and cyclic progestogen

Eight women with primary failure of ovarian function and twelve women undergoing the climacteric were treated sequentially with oestradiol-oestriol and norethisterone acetate (Trisequens and Trisequens Forte, Novo). After a mean treatment period of 5 yr (range 3-8 yr) endometrial biopsies were taken on day 11 or 12 at the end of an oestrogen-only phase. All biopsies showed the presence of a proliferative endometrium without any signs of hyperplasia or carcinoma in situ. Although cyclic oestrogen therapy can cause hyperplasia, a small dose of a progestogen (norethisterone acetate 1 mg) for 10 days in a 28-day cycle can prevent hyperplasia of the endometrium during long-term treatment.

Compliance difficulties with progestin-supplemented estrogen replacement therapy

Forty postmenopausal women were studied prospectively while undergoing estrogen replacement therapy (ERT). Eighteen women with an intact uterus were cycled with additional progestin therapy. All but three women of the estrogen-progestin group elected to discontinue therapy because of undesirable "physiologic" withdrawal bleeding. Future progestin-ERT recommendations should take these results into consideration. Wide-scale re-education of patients and physicians will be necessary if the existing recommended regimens are to be observed. Alternatively, new or different pharmacologic agents and regimens will be necessary to achieve the postulated benefits of progestin-ERT without undesirable side effects.

The human respiratory nasal mucosa in females using contraceptive pills. An ultramicroscopic and histochemical study

The ultrastructure and histochemical changes in 25 females using contraceptive pills were studied. Fifteen pill-using females developing no nasal symptoms showed similar changes to those observed in symptom-free pregnant females. Ten pill-using females developing nasal symptoms showed squamous metaplasia, interepithelial oedema, glandular hyperplasia, histiocytic proliferation and fibrous tissue deposition, all attributed to the action of oestrogen. Their histochemical reactions were similar to those of chronic hypertrophic non-allergic rhinitis.

Influence of oral contraceptives on the incidence of premalignant and malignant lesions of the cervix

The effect of oral contraceptive use on the development of severe dysplasia, carcinoma in situ and invasive carcinoma of the cervix was studied by a prospective longitudinal survey of 32,000 women. They were enrolled into the study between the ages of 15 and 39. Some had started oral contraceptive use before enrollment, others started after enrollment and some remained non-users throughout the study period. They were followed-up to 6-1/2 years. Analyses were performed on data from 24,784 women who met our criteria for incidence. Data were adjusted for years of follow-up, age at enrollment, age at first pregnancy, number of pregnancies, number of smears, and duration of use.

Breast cancer in young women and use of oral contraceptives: possible modifying effect of formulation and age at use

A case-control study of 314 breast cancer patients aged less than 37 at diagnosis and 314 individually matched controls was done to assess the influence of oral-contraceptive (OC) use on the risk of the disease. Long-term use before age 25 of combination-type OCs with a "high" content of the progestogen component was associated with increased risk of breast cancer: the relative risk was approximately 4 after 5 years of such use, and 9 cases and no controls had used such combination-type OCs for more than 6 years before age 25. Use of combination-type OCs with a "low" progestogen component appears to increase breast-cancer risk little or not at all.

A survey of different approaches to management of menstrual disturbances in women using injectable contraceptives

This report summarises a survey of the management of menstrual disturbances occurring during injectable progestogen use (depot-medroxyprogesterone acetate, DMPA, and norethisterone enanthate, NET-EN) by 35 investigators from 20 countries with ongoing experience of these contraceptives. A wide range of approaches are described. The most frequently emphasised aspect of management is thorough pre-treatment counselling with further support and counselling at follow-up visits. Oestrogens in various forms are widely used for the treatment of prolonged, frequent or heavy episodes of bleeding, but nowadays are not usually used for the induction of withdrawal bleeding in women with amenorrhoea. Heavy or "severe" bleeding appears to be very uncommon and figures of 1-2% were frequently mentioned. Anecdotal information suggests that intramuscular doses or longer courses (14-21 days) of oral oestrogen, including the combined pill, are more likely to successfully stop an episode of bleeding than short courses. However, there are no hard data to show that a course of oestrogen treatment has any beneficial effect on long-term bleeding patterns. Nevertheless, temporary cessation of spotting or light bleeding may be sufficiently reassuring to the patient to ensure continued use of the method. There appears to be very little risk associated with the short-term oestrogen regimens currently used. Dilatation and curettage is almost never necessary to stop an episode of bleeding, but may occasionally be recommended for diagnostic reasons. It is clear that the bleeding disturbances associated with DMPA and NET-EN use are poorly understood and that urgent research is necessary to clarify pathophysiological mechanisms and improve management.

Multinational comparative clinical trial of long-acting injectable contraceptives: norethisterone enanthate given in two dosage regimens and depot-medroxyprogesterone acetate. Final report

Final results are presented from a two-year WHO multinational comparative trial of three regimens: depot-medroxyprogesterone acetate (DMPA) given at 90-day intervals, norethisterone enanthate (NET-EN) given at 60-day intervals for the entire study period (NET-EN (60-day)), and NET-EN given at 60-day intervals for six months and thereafter at 84-day intervals (NET-EN (84-day)). 1587 DMPA subjects were observed for 20,550 woman-months, 789 NET-EN (60-day) subjects were observed for 10,361 woman-months, and 796 NET-EN (84-day) subjects were observed for 10,331 woman-months. This clinical trial represents the largest clinical trial undertaken on injectable contraceptives. After two years, the pregnancy rate with NET-EN (84-day) was 1.4 (+/- 0.6 S.E.) per 100 women, as compared with the two-year rates of 0.4 (+/- 0.3 S.E.) per 100 women observed with DMPA and 0.4 (+/- 0.2 S.E.) with NET-EN (60-day). Both discontinuation rates for amenorrhea and the prevalence of amenorrhea lasting more than 90 days were significantly higher with DMPA than with either NET-EN regimen. Terminations for bleeding problems were similar with the three treatments, despite a better cyclic pattern for the first six months with the NET-EN regimens. The three treatments were comparable with respect to discontinuation rates for other medical or personal reasons, and for all reasons combined. For family planning programs, NET-EN (60-day) has the advantage of low pregnancy rates compared to NET-EN (84-day), and a schedule of administration that does not change. Both NET-EN regimens produce less amenorrhea than DMPA. However, the NET-EN (60-day) regimen has the logistic and economic disadvantage of requiring more frequent injections. All three injectable regimens compare favourably with oral contraceptives in terms of pregnancy and total continuation rates observed in clinical trial settings.

A comparison of Norinyl and Brevicon in three sites in Sri Lanka

A set of 3 four-cell randomized, blind clinical trials was carried out in Sri Lanka to evaluate the impact of vitamin supplements and different oral contraceptive formulations. This paper concentrates on the comparisons of oral contraceptives. There seems to be no important difference between Norinyl, a standard-dose oral contraceptive, and Brevicon of a lower estrogen dosage--in either continuation or side effects. Continuation at one site was higher among Norinyl users, but several factors led us to the belief that this difference was due to differences in field worker performance rather than to the pharmacological properties of the drugs. Some differences in side effects were observable along predictable lines; breakthrough bleeding was more common among Brevicon users than Norinyl users, and most other side effects were more frequent among Norinyl users, although these latter differences were quite small, and there were several exceptions.

Effect of estrogen/progestin potency on lipid/lipoprotein cholesterol

We studied 374 women taking oral contraceptives, 284 women taking estrogen preparations after menopause, and 1086 women taking no hormones, to determine the relation of plasma lipids and lipoprotein cholesterol concentrations to various types of estrogen/progestin formulations. Premenopausal women, using oral contraceptives containing a relatively low dose of estrogen combined with a medium or high dose of progestin (Norlestrin, Ovral, or Demulen) had a 24 per cent higher median concentration of low-density-lipoprotein cholesterol than did those not using hormones (P less than 0.05). Women using oral contraceptives that are high in estrogen and low in progestin (Enovid or Oracon) had significantly higher concentrations of high-density-lipoprotein cholesterol than did nonusers; those using Ovral, a low-estrogen and high-progestin formulation, had significantly lower levels of high-density-lipoprotein cholesterol. In postmenopausal women the use of estrogen was associated with concentrations of low-density-lipoprotein cholesterol that were 11 to 19 per cent below the levels in postmenopausal women who did not use hormones. The effects of estrogen-progestin balance on low-density and high-density lipoproteins may underlie the increased incidence of stroke and myocardial infarction in women of childbearing age who take oral contraceptives.

Unilobar small hepatic vein obstruction: possible role of progestogen given as oral contraceptive

The case of a 33-yr-old woman with an obstruction of small hepatic veins limited to the right lobe of the liver is reported. Abdominal pain, fever, absence of ascites, and normality of liver biochemical tests were the most striking features. Abnormalities characteristic of lesions were observed on surgical wedge liver biopsy, hepatic phlebography, and computerized tomography. None of the usual causes of small hepatic vein obstruction were found. This patient had been taking an oral progestative compound as contraceptive therapy for 7 mo before evaluation. Because progestogens have recently been incriminated in the occurrence of vascular alterations, the possible role of this drug in our case is discussed.

The effect of various oral contraceptive combinations on premenstrual symptoms

The influence of different oral contraceptives on premenstrual complaints was examined in 191 randomly selected women from an urban population. Premenstrual depression and abdominal swelling was significantly more common in women taking oral contraceptives containing the progestogen component lynestrenol than those containing norgestrel. The reason for this difference is discussed. A deficiency of pyridoxine which affects tryptophan metabolism can explain the difference in premenstrual depression. However, it should be emphasized that the system which controls neuro-endocrine balance is extremely complicated and does not at the present time permit any definite conclusions regarding the influence of oral contraceptives on mental complaints.

Evaluation of a continuous oestrogen-progestogen regimen for climacteric complaints

Subjective complaints, endometrial histopathology, vaginal cytology and bleeding patterns were recorded in 26 patients treated with a continuous oestrogen-progestogen regimen for 12 mth. A marked reduction of hot flushes and sweats were noted and the evaluation of endometrial specimens revealed that the mucosae were mostly inactive-atrophic. The karyopyknotic index proved to be a poor indicator of oestrogenic activity. The number of recorded bleedings in the peri-menopausal women differed markedly from the post-menopausal women during treatment; they were very slight in the latter group. Even in those cases where bleeding occurred, the endometrial samples were found to be atrophic. Vaginal bleeding seemed to be an unreliable indicator of endometrial histopathology. The present combination of hormones used in a continuous regimen is a good alternative for post-menopausal women in need of hormonal therapy.

Hormone replacement treatment and benign intracranial hypertension

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Influence of oral contraceptive therapy on the activity of systemic lupus erythematosus

Since harmful effects of estrogens in murine lupus are well established, we studied the influence of oral contraceptive therapy on systemic lupus erythematosus activity in 26 female patients with lupus nephropathy. Combined preparations containing either 50 micrograms (14 patients) or 30 micrograms (7 patients) of ethinyl-estradiol were used in 21 courses in 20 patients. Initial manifestations or exacerbations of systemic lupus activity appeared within 3 months of beginning hormonal therapy in 9 patients, an overall incidence of lupus flare-up of 43%; there was major renal involvement in 4 patients. Conversely, evidence of lupus exacerbation did not develop in any of 11 patients who received pure progestogen oral contraceptive therapy with either continuous low-dose norsteroids (6 patients) or discontinuous progestogens at normal dosage (5 patients). These patients were followed for 5--30 months. Our data indicated that oral contraceptive therapy that used estrogens, even at low doses, often induced exacerbation of systemic lupus erythematosus activity. Pure progestogens, which were effective and devoid of such unfavorable effects, may be preferred in these patients.