Metabolic effects of low-dose fluconazole in healthy female users and non-users of oral contraceptives

1. Azole antifungal agents such as ketoconazole act by inhibiting cytochrome P-450 mediated sterol synthesis in the fungal cell membrane and thus have the potential to interfere with mammalian steroidogenesis. Fluconazole is a novel orally-effective antifungal triazole which has been reported to have more specific effects on the cytochrome P-450 enzymes involved in fungal sterol synthesis. 2. Due to the potential value of systemic antifungal agents in the treatment of infections commonly occurring in women, we assessed the effect of oral fluconazole on the metabolic profile of 18 healthy premenopausal women, 10 of whom were taking combined oral contraceptives (OC). Each woman acted as her own control, being studied both before and 21-28 days after fluconazole therapy (50 mg daily), in the luteal phase of consecutive menstrual cycles. 3. The endocrinological profile included measurement of serum oestradiol, progesterone, testosterone and sex hormone binding globulin (SHBG) concentrations, short tetracosactrin adrenal stimulation test and thyroid function tests. Carbohydrate metabolism was investigated by means of an oral glucose tolerance test with measurement of plasma glucose, insulin and C-peptide concentrations. Serum lipids, lipoproteins and apolipoproteins were analysed on samples taken after an overnight fast. 4. Minor biochemical changes associated with fluconazole treatment included increases in serum thyroxine and testosterone concentrations (but not in women taking OC as well as fluconazole) and in insulin and apolipoprotein B levels (but only in women taking OC as well as fluconazole). In general, these changes were small and of no clinical significance with the values remaining within the laboratory normal range. There were no adverse side-effects.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of steroids on the fine structure of the endometrium

This brief review illustrates the lack of ultrastructural studies on human endometrium, particularly on well-dated material from normal, fertile women. The glandular epithelium, with its triad of unusual organelles in the early luteal phase, poses fascinating problems in cell biology and, probably for this reason, has attracted the most work. Many problems in reproductive biology, in uterine pathology and in the study of unexplained infertility are crying out for detailed study of the luminal epithelium, the stroma and the blood vessels. If this review, by highlighting the gaps in our knowledge, stimulates research into these areas, it will have been successful.

Metabolism of the contraceptive steroid desogestrel by the intestinal mucosa

1. The intestinal mucosal metabolism of the progestogen oral contraceptive desogestrel (Dg) has been studied in vitro using the Ussing chamber technique. Histologically normal ileum or colon was obtained from eight patients undergoing various resections. The mucosal sheets were mounted between two perspex chambers. 2. Two hours after addition of [3H]-Dg (0.2 microCi; 100 ng) to the mucosal chamber, more than 90% of the steroid was present in that chamber. In studies with colon, metabolite analysis showed that 55.4 +/- 11.7% (mean +/- s.d.; n = 6) of drug present was Dg, 28.9 +/- 11.4% as unconjugated Phase I metabolites, 13.3 +/- 2.6% as sulphate conjugates and 2.5 +/- 1.5% as glucuronide conjugates. 3. By co-chromatography with authentic metabolites and mass spectrometry, it was shown that 3-keto desogestrel is formed in the mucosa. This is the active metabolite of desogestrel. A large peak of radioactivity did not co-chromatograph with any known metabolites and has been tentatively identified as ring hydroxylated products of 3-keto desogestrel. 4. The effect of the synthetic oestrogen ethinyloestradiol (EE2) on the metabolite profile of Dg was studied. In the presence of increasing concentrations of EE2 (100 ng, 1 and 10 micrograms), there was competition for sulphation such that the sulphate fraction decreased by 32, 49 and 48% respectively. 5. The results of this study indicate substantial first pass metabolism of desogestrel by the gut mucosa with evidence for the formation of the active metabolite. The extent of phase I metabolism is unusual.

Some metabolic and hormonal changes in women using long acting injectable contraceptives

Some metabolic and hormonal changes in women using longacting injectables as a contraceptive method were examined. The 2 main injectables utilized were depomedroxyprogesterone acetate (DMPA), given every 90 +or- 5 days, and norethisterone enanthate (NET/EN) injected every 60 +or- 5 days. None of the studied cases became pregnant during injectable use, indicating the high contraceptive efficacy of the method. No statistically significant changes were observed in hemoglobin, hematocrit, all protein fractions including albumin, alpha1, alpha2 beta, gamma immunoglobulins IgG, IgA, and IgM after 6 and 12 months in both groups of injectable users as compared with the preinjection values. Statistically significant suppression of the estimated hormones, Follitropin, Luteotropin, and Estradiol-17beta were detected in both groups of NET/EN and DMPA users, after 6 and 12 months, as compared with the preinjection values.

Effects of age, gender and oral contraceptives on intramuscular midazolam pharmacokinetics

The effects of age, gender and low-dose (50 mcg or less) oral contraceptive steroids (OCS) on the pharmacokinetics of midazolam were evaluated following a single 7.5 mg intramuscular dose to five groups (8/group) of healthy volunteers consisting of young males, young females, elderly males, elderly females, and young female users of oral contraceptives. Blood samples were collected at specified times over a 24-hour period, and plasma concentrations of midazolam and its 1-hydroxymethyl metabolite were determined by a GC-EC assay. Midazolam was rapidly absorbed following intramuscular administration to the different groups. Comparison of young men vs elderly men, young women vs elderly women, young men vs young women, elderly men vs elderly women, and young women OCS-users vs young women non-OCS users indicated no substantial differences in the pharmacokinetic profile of midazolam between groups except for the comparison between the young and elderly men groups. The rate of elimination of midazolam was significantly slower in the elderly males compared to the young men. The pharmacokinetic profile of 1-hydroxymethyl midazolam paralleled that of the parent compound. This is to be expected since this metabolite exhibits formation rate-limited kinetics. Except for one subject who reported hives and itching, considered to be remotely related to test drug, no other adverse experiences or laboratory abnormalities were reported.

Dynamics of estradiol and testosterone and seminal fluid indexes in smokers and nonsmokers

The serum levels of estradiol (E2) and testosterone (T), the metabolic clearance rates of estradiol (MCRE2) and testosterone (MCRT), and the production rates of estradiol and testosterone (PRE2) and (PRT) were examined in 22 male smokers and 21 male nonsmokers. Seminal fluid indexes (sperm count, % motility, grade of motility, and % of sperm with abnormal morphology) were also assessed. The mean E2 level and the mean PRE2 were significantly greater in smokers than in nonsmokers (P less than 0.001 and P less than 0.01, respectively); however, the means of MCRE2, MCRT, PRT, and T did not differ significantly in smokers compared to nonsmokers. No significant product-moment correlations were found between the various hormonal measures and the seminal fluid indexes in the overall sample. However, the smokers with sperm counts below the median sperm count of the sample had significantly higher mean levels of E2 and PRE2 than did the smokers with sperm counts above that median. Mechanisms that might mediate the greater PRE2 of smokers and a negative relationship between estradiol and sperm count are discussed.

The evaluation of the data collection process for a multicenter, population-based, case-control design

This report details the methods the authors used to conduct the Cancer and Steroid Hormone Study, a multicenter, population-based, case-control study of oral contraceptive use in relation to breast, endometrial, and ovarian cancer diagnosed during 1980-1982. The authors have documented their methods and rationale, and the results of their data collection efforts as a practical guide for the planning and conduct of large case-control studies. They observed the following: 1) the Surveillance, Epidemiology, and End Results program is a useful epidemiologic resource for identifying cases from which to evaluate risk factors for cancer in the United States; 2) random digit dialing is an effective and efficient method for screening for eligible controls for a population-based study; 3) with the cooperation of community pathologists, histologic specimen slides can be retrieved and reviewed for diagnostic confirmation and histologic subclassification of cancer for greater than 95% of the cases interviewed; and 4) data reported during personal interviews of study participants can be validated by reviewing medical records for more than 75% of study participants who reported medical events that occurred during the 10 years before the beginning of the study.

The antiglucocorticoid and antiprogestin steroid RU 486 suppresses the adrenocorticotropin response to ovine corticotropin releasing hormone in man

The glucocorticoid and progesterone antagonist RU 486 normalizes the clinical and biochemical features of hypercortisolism in patients with nonpituitary Cushing's syndrome, presumably by antagonizing the action(s) of cortisol. Since RU 486 has progesterone agonist activity in addition to its progesterone antagonist action, the possibility that it might have some glucocorticoid agonist action did not seem unreasonable. To test this hypothesis we examined the effects of RU 486 on pituitary ACTH secretion in 10 patients with primary adrenal insufficiency in whom glucocorticoid replacement was withheld for 36 h. Each patient received, in randomized sequence 3-7 days apart, an oral dose of placebo, RU 486 (20 mg/kg), cortisol (0.1 mg/kg), or a combination of RU 486 and cortisol at 1800 h. Two hours later, an iv bolus dose of ovine CRH (1 microgram/kg) was administered, and plasma ACTH levels were measured serially for 3 h. RU 486 suppressed ovine CRH-stimulated ACTH secretion, albeit less than cortisol. Its glucocorticoid agonist effect was calculated to be approximately 1/250th that of cortisol on a weight basis. Additionally, RU 486 partially antagonized cortisol-induced suppression of ACTH secretion. These findings suggest that RU 486 is a partial glucocorticoid agonist and offer some insight as to its action in patients with Cushing's syndrome. Whether this degree of glucocorticoid agonist activity is adequate to support life, however, is not known.

Effect of administration and withdrawal of oral contraceptive pills on serum lipids and lipoproteins

We studied the effects of oral contraceptive pills (OCP) supplied by the Govt of India in its Family Welfare Campaign, on serum lipid levels of women. The OCP, containing 30 micrograms ethinyl estradiol and 1 mg of norethisterone acetate were administered to the women for six months continuously and serum lipid levels were estimated after three and six months of the treatment. There were no significant changes in serum cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), serum triglycerides and very low density lipoprotein (VLDL). In a simultaneous study we also measured serum lipid levels at 3 and 6 months after withdrawal of the pills in women who had been receiving OCP containing 50 micrograms of ethinyl estradiol and 0.5 mg of one of the progesterones for the past 1 1/2 to 2 years continuously. Only serum LDL level fell significantly (P less than 0.01) on 3 months withdrawal period. It is concluded that 6 months of usage of the OCP marketed by the Govt. of India does not affect the serum lipid profile.

The interaction of alcohol consumption and oral contraceptive use on lipids and lipoproteins

Oral contraceptive (OC) use and alcohol consumption have been shown to alter the levels of lipids and lipoproteins in the blood. The effect of alcohol consumption on levels of total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, LDL-B, Apo-A1, the ratio of HDL cholesterol/total cholesterol, HDL cholesterol/LDL cholesterol, and the ratio of LDL cholesterol/LDL-B among normal healthy young women before initiation of oral contraceptives and after six months of oral contraceptive use are both described. Of primary interest is the mediating effect of alcohol consumption on the association between steroid usage and blood lipid values. At baseline, ethanol consumption was found to be positively associated with triglycerides, HDL-C, and Apo-A1 and negatively associated with LDL-C/LDL-B. After adjustment for several covariables, alcohol consumption was found to be positively associated with the increases in triglycerides and in Apo-A1 observed at 3 and 6 months after initiation of OCs. Since these two parameters are believed to have opposite relationships to cardiovascular disease, the effect of alcohol consumption remains uncertain.

Oral contraceptive-induced changes in plasma lipids: do they have any clinical relevance?

The plethora of published studies investigating oral contraceptive pill (OC)-induced changes of various plasma lipids and their ratios together with repeated reviews of these studies in the literature, are all based on the assumption that OC-induced favourable or unfavourable lipid profiles decrease or increase a pill-associated cardiovascular risk. Some authorities have been led to recommend choice of pill formulations based on such changes of plasma lipids. In a combined review of relevant cardiovascular and OC epidemiological studies no evidence is found for these assumptions and recommendations. There is no evidence of OC-induced atherosclerotic disease, and pill-induced changes of plasma lipids within normal limits are therefore probably without any clinical relevance. Profound changes towards a so-called favourable plasma lipid profile may, on the contrary, be detrimental in terms of pill-associated cardiovascular events.

Paracetamol interaction with oral contraceptive steroids: increased plasma concentrations of ethinyloestradiol

The effect of a single dose of paracetamol (1 g) on plasma concentrations of the oral contraceptive steroids ethinyloestradiol (EE2) and levonorgestrel (LNG) has been studied in six healthy female volunteers. The area under the plasma concentration-time curve (AUC0-24) of EE2 was significantly increased following paracetamol administration by 22% (control 2221 +/- 291; following paracetamol, 2702 +/- 452 pg ml-1 h; mean +/- s.d.; P less than or equal to 0.05). The greatest effect was evident in the time period 0-3 h. There was a significant decrease in the AUC of EE2-sulphate after paracetamol (7736 +/- 3791 pg ml-1 h) compared with control (13161 +/- 4535 pg ml-1 h; P less than or equal to 0.05). Plasma concentrations of LNG were unaltered by concurrent paracetamol administration. We conclude that the administration of a single 1 g dose of paracetamol causes an increase in plasma concentrations of EE2 as a result of a reduction in the sulphation of the steroid. This interaction may be of clinical significance in women on oral contraceptive steroids who regularly take paracetamol.

The characterization of sulphated metabolites of norethindrone in human milk after oral administration of contraceptive steroids

The excretion of ethynyl steroids in milk from a lactating woman taking a daily dose of an oral contraceptive (Conlumin) containing 1 mg of norethindrone and 50 micrograms of mestranol has been studied. Milk was diluted with aq. triethylamine sulphate and steroids were extracted on a Sep-Pak C18 cartridge at 60-64 degrees C. Groups of unconjugated steroids, glucuronides, mono- and disulphates were separated on triethylaminohydroxypropyl Sephadex LH-20. Following hydrolysis and further purification, steroids possessing an ethynyl-substituent were isolated by chromatography on sulphohydroxypropyl Sephadex LH-20 in silver form. Gas chromatographic-mass spectrometric analysis of the O-methyloxime-trimethylsilyl ether derivatives of these steroids, showed the presence of norethindrone and mestranol in the free fraction and of tetrahydro metabolites of norethindrone with 3 alpha,5 alpha, 3 alpha,5 beta and 3 beta,5 alpha configurations in the mono- and disulphate fractions. The disulphate of the 3 alpha,5 alpha isomer was the most abundant ethynyl steroid in milk after 13 days of administration. The site of conjugation of the monosulphates was established by acetylation prior to solvolysis and analysis by gas chromatography-mass spectrometry. This showed that the 3 alpha,5 alpha isomer was conjugated mainly in the 17 beta-position while the 3 alpha,5 beta isomer was conjugated at C-3.

Serum ovarian steroids, prolactin and prostaglandin metabolites in women using the inert intrauterine device

Serum levels of 17 beta estradiol, progesterone, prolactin and metabolites of prostaglandins E2 and F2a were investigated in 18 healthy women before and after the insertion of a Saf-T-Coil intrauterine device. The results suggest that the presence of an intrauterine device may cause hormonal changes affecting the luteal phase of the menstrual cycle.

The relative bioavailability of levonorgestrel and ethinyl estradiol administered as a low-dose combination oral contraceptive

The relative bioavailability of levonorgestrel (LNG) and ethinyl estradiol (EE) administered concomitantly both as an oral tablet and as a solution was assessed in a randomized two-period crossover study in 24 healthy women. Serum concentrations were monitored for 96 h after each administration. The relative bioavailability (Fr) of LNG in the tablet with respect to the solution was 107%; thus the two formulations were bioequivalent with respect to LNG. The relative bioavailability of EE, however, was significantly lower for the tablet (Fr 83%) compared to the solution. This difference may have been due to either decreased absorption or enhanced presystemic elimination of EE from the tablet formulation.

Selection of steroid combinations for oral contraceptives of maximum benefit

Low-dose oral contraceptives differ in the specific progestin component. Our review of available animal and human data revealed differences between the progestins as to their potencies for estrogenic, anti-estrogenic, androgenic and progesterone effects. Ideally, oral contraceptive formulations should have the minimal effective dose, sufficient to prevent pregnancy but with the fewest metabolic changes. The risk of cardiovascular disease may be predicted by changes in the composition and amount of circulating lipoproteins. Progestins with significant androgenic potency can lower high-density lipoprotein2; that is a possible adverse effect. Randomized, blind, comparative trials of the new multiphasic preparations are needed to determine which ones truly cause the fewest metabolic changes that might be of clinical significance.

Influence of gender and oral contraceptive steroids on the metabolism of salicylic acid and acetylsalicylic acid

Salicylic acid and acetylsalicylic acid (aspirin) disposition after an oral dose of aspirin, 900 mg (equivalent to 689.7 mg of salicylic acid) was studied in eight males, eight females and eight females receiving oral contraceptive steroids (OCS). Salicylic acid clearance was 61% higher in males compared to the control female group, an effect due largely to enhanced activity of the glycine conjugation pathway (salicyluric acid formation) in males. Salicylic acid clearance was 41% higher in OCS-users compared to the control female group due to increases in both the glycine and glucuronic acid conjugation pathways in the pill users. There was no difference in any salicylic acid disposition parameter between males and OCS-users. Area under the plasma concentration-time curve (AUC) and elimination half-life of aspirin was significantly greater and aspirin plasma hydrolysis rate was significantly lower in both female groups compared to males. There was no difference between OCS-users and the control female group in any of these parameters. Aspirin AUC and elimination half-life were significantly correlated with aspirin plasma hydrolysis rate. These data confirm the importance of hormonal factors in the regulation of drug conjugation reactions in humans and suggest that sex-related differences in salicylic acid and aspirin disposition may be of clinical importance.

Serum levels of progesterone and some of its metabolites including deoxycorticosterone after oral and parenteral administration

Single 100-mg doses of progesterone were given orally and as intramuscular injections to four women during the follicular phase of the menstrual cycle. After oral administration serum levels of progesterone increased rapidly to reach luteal phase values (mean maximum level 55.6 nM) within 1-4 h and were still elevated after 12 h. The serum concentrations of 20 alpha-hydroxy-4-pregnen-3-one showed a similar pattern while there were only minor transient changes in 17 alpha-hydroxyprogesterone concentrations. The serum levels of cortisol and 4-androstene-3,17-dione were unaffected. In comparison, after intramuscular administration values two to three times higher than by the oral route were achieved. A significant increase in serum deoxycorticosterone was recorded in all women. The mean ratio between the change in deoxycorticosterone and progesterone was increased after oral administration. Oral treatment with natural progesterone may develop into an attractive alternative to synthetic progestogens but the conversion of progesterone into a potent mineralocorticoid may be a potential disadvantage.

The new steroid analog RU 486 inhibits glucocorticoid action in man

RU 486 [17 beta-hydroxy-11 beta-(4- dimethylaminophenyl )-17 alpha-(prop-1- ynyl )-estra-4,9-dien-3-one] is a new steroid analog which antagonizes glucocorticoid action at the receptor level in animals. To assess its potential antiglucocorticoid activity in man we studied the pituitary-adrenal response to RU 486 in normal men. The compound was administered at 0200 h and plasma cortisol and lipotropins (LPH) were measured hourly for 10 h. After 400 mg RU 486 significant and sustained elevation of both hormones occurred during the 0700-1200 h period: mean (+/- SE) plasma levels after placebo or RU 486 during this interval were, respectively, for cortisol (ng/ml), 63.4 +/- 8.2 and 112.7 +/- 2.9 (P less than 0.02); and for LPH (pg/ml), 34.8 +/- 11.3 and 71.6 +/- 15.4 (P less than 0.01). The 200- and 100-mg doses induced only transient cortisol and LPH increases. Administration of RU 486 (400 mg) at 1400 h induced no increase in plasma cortisol compared to placebo in the corresponding 2000 to 2400 h period. When RU 486 was administered concomitantly with dexamethasone (1 mg) at 2400 h, dose-dependent blockade of the dexamethasone-induced cortisol suppression at 0900 h was found (r = 0.62, P less than 0.01); this blockade was partial after the 100-mg dose, but complete after the 400-mg dose. Plasma LPH and ACTH showed parallel variations. We conclude that RU 486 antagonizes the negative pituitary feedback of both the nocturnal endogenous cortisol rise and exogenously administered dexamethasone. These actions are consistent with an antiglucocorticoid activity of this compound in man.

Danazol binding to steroid receptors in human uterine endometrium

To understand the mechanism of action of danazol, the binding of danazol to multiple classes of intracellular steroid binding proteins was studied in the human uterine endometrium. Danazol bound to endometrial receptors for estrogen, progesterone, and androgen and seemed to bind to endometrial intracellular corticosteroid-binding globulin and sex-hormone-binding globulin. Danazol occupies almost all binding sites of steroids in the steroid target cells in spite of the presence of endogenous steroids. It is speculated that the binding behavior of danazol may be related to its therapeutic effect on endometriosis.