Efficacy and safety of a new 24-day oral contraceptive regimen of norethindrone acetate 1 mg/ethinyl estradiol 20 μg (Loestrin® 24 Fe)

BACKGROUND

New low-dose formulations of combination oral contraceptives (COCs) are safe and effective, but they may be associated with an increased risk of breakthrough bleeding. Extending the duration of active hormonal treatment may reduce the frequency of intracyclic bleeding/spotting while maintaining efficacy and tolerability.

METHODS

This 6-month, open-label, randomized, active-controlled study involved healthy women aged 18-45 years who were at risk for pregnancy. Women were randomized 4:1 to a 24-day regimen of norethindrone acetate 1 mg/ethinyl estradiol 20 micro g (NETA/EE-24) or to a 21-day regimen of the same combination (NETA/EE-21). The outcomes assessed included pregnancy and incidence, duration of bleeding and intensity of bleeding.

RESULTS

The cumulative risk of pregnancy in the NETA/EE-24 group (n=705) was 0.9% during six cycles of treatment. Compared with NETA/EE-21 (n=181), NETA/EE-24 was associated with significantly fewer intracyclic bleeding days (0.95 vs. 1.63; p=.005), fewer days of withdrawal bleeding (2.66 vs. 3.88; p<.001) and fewer total bleeding/spotting days for Cycles 2-6 (18.6 vs. 23.2; p<.001). NETA/EE-24 was well tolerated, and side effects were generally mild to moderate in severity.

CONCLUSIONS

NETA/EE-24 is an effective well-tolerated COC that is associated with a bleeding profile more favorable than that of NETA/EE-21.

[Clinical study of two monophase oral contraceptives with desogestrel]

AIM

To compare the influence of two contraceptive combinations with 20 microg EE/ 150 microg DSG u 30 microg EE/ 150 microg DSG upon menstrual cycle, BMI, blood pressure and the side effects.

MATERIALS AND METHODS

The study is prospective, continues one year and consisted of 70 clinically healthy women, who use two monophase oral contraceptives with desogestrel.

RESULTS

The use of both contraceptive formulas have PI = 0.00. The intermenstrual bleeding are more frequent at the group with 20 microg EE/ 150 microg DSG. The more frequent side effects were: headache and breast tenderness. We do not find statistically significant changes in the BMI and blood pressure with the use of the presented contraceptive combinations.

CONCLUSION

Contraceptive combinations with 20 microg EE/ 150 microg DSG u 30 microg EE/ 150 microg ensure good control upon the menstrual cycle, high contraceptive safety and good tolerance.

The effect of levonorgestrel-releasing intrauterine system use on menstrual blood loss and the hemostatic, fibrinolytic/inhibitor systems in women with menorrhagia

BACKGROUND

Menorrhagia is known to be associated with uterine fibroids, adenomyosis, pelvic infections, endometrial polyps and clotting defects. A viable alternative therapy to hysterectomy should alleviate heavy menstrual blood flow and consequently improve the quality-of-life measures in women presenting with menorrhagia. The levonorgestrel-releasing intrauterine system (LNG-IUS) ranks higher than medical treatments in terms of efficacy, comparable improvements in quality of life and psychological well-being.

OBJECTIVE

The purpose of the study was to determine the effects of 6 months of LNG-IUS use on menstrual blood loss and the hemostatic, fibrinolytic/inhibitor systems in blood and the endometrium in women with menorrhagia with known pathologic causes.

PATIENTS AND METHODS

Samples from 41 women were analyzed. Hemoglobin, hematocrit, thrombelastography, tissue-type plasminogen activator (t-PA), urokinase plasminogen activator (u-PA), u-PA receptor (u-PAR), plasminogen activator inhibitor-1/2 (PAI-1/2), D-dimer and von Willebrand factor (VWF) were determined, and t-PA, u-PA and PAI-1/2 were also determined in endometrial tissue extracts.

RESULTS

Menorrhagia was reduced in 89% of women by 3 months; by 6 months all women had no menorrhagia, and 39% of women had become amenorrhoeic. Hemoglobin and hematocrit levels showed improvement, and reached normal reference levels by 6 months. There were no systemic changes in the fibrinolytic/inhibitor systems and VWF, except for a decreased u-PAR level. However, in the endometrium, significant elevations in PAI-1/2 together with u-PAR levels were seen at 6 months.

CONCLUSIONS

The slow levonorgestrel-release intrauterine device use results in high expression of fibrinolytic inhibitors (PAI-1/2) and upregulated u-PAR expression in the endometrium. Systemic hemostasis was not significantly altered. The study demonstrated that LNG-IUS is highly effective in the treatment of menorrhagia with known pathologic causes.

Response of the female vocal quality and resonance in professional voice users taking oral contraceptive pills: a multiparameter approach

OBJECTIVE/HYPOTHESIS

The purpose of this study was to analyze the vocal quality and resonance (nasality and nasalance values) during the menstrual cycle in professional voice users using oral contraceptive pills (OCPs). Although professional voice users are more sensitive and aware of their vocal quality, no changes of voice and resonance characteristics were expected because OCPs create a stable hormonal balance throughout the menstrual cycle.

STUDY DESIGN

The authors conducted a comparative study of 24 healthy, young professional voice users using OCPs. One assessment was performed between the 10th and 17th day of pill intake, when hormonal levels reached a steady state. The second assessment was performed during the first 3 days of menses, when no pills were taken and hormonal levels were minimized.

METHODS

Subjective (perceptual evaluation of voice and nasality) and objective (aerodynamic, voice range, acoustic, Dysphonia Severity Index [DSI], nasometer) assessment techniques were used.

RESULTS

: The Mann-Whitney U test showed no significant difference between the perceptual evaluation of the voice and the nasality in the two assessments. The paired Student t test showed no significant difference regarding the maximum phonation time, the vocal performance, the acoustic parameters, and the DSI.

CONCLUSIONS

These findings indicate that OCPs do not have an impact on the objective and subjective voice and resonance parameters in young professional voice users. This information is specifically relevant to professional voice users who are more aware of vocal quality changes and ear, nose and throat specialists/voice therapists who treat professional voice users with voice problems/disorders. Further research regarding the impact of increased vocal load during the premenstrual or menstrual phase in professional voice users using OCPs should be considered.

[Regulon in the treatment of hyperandrogenism in teenage girls]

The aim of study was to assess the efficiency of the use of combined oral contraceptive with dezogestrel-regulon in the treatment of hyperandrogenism in teenage girls. 14-18 y.o. girls with signs of hyperandrogenism have been investigated. Investigation included: physical examination, assessment of body mass, hirsute number, ultrasonography, FSH, LH, prolactin, testosterone, 17 OH progesterone in blood.

RESULTS

All the patients received Regulon from the 5th up to 21st day of menstrual cycle during 6 months. After the 6 months of treatment the regulation of menstrual cycle have been registered in 91% of patients. Reduction of hirsute number (from 24.1+/-1.0 to 11.0+/-1.2 ), ovarian volume by ultrasound (from 16.7+/-3.0 sm(3) to 7.1+/-0.9 sm(3)), level of LH (from 12.7+/-2.4 to 8.0+/-1.2 IU/L) and testosterone (from 4.2 +/-0.2 to 2.8+/-0.6 nmol/l) were registered. Regulon is effective for the treatment of hyperandrogenism in teenage girls.

The use of levonorgestrel - IUD in the treatment of uterine myoma in Thai women

OBJECTIVE

This study was designed to evaluate the potential usefulness of the levonorgestrel-releasing intrauterine device (LNG - IUD ; Mirena) in treating women with uterine myomas.

DESIGN

Prospective before-and-after (comparing) study.

SETTING

Department of Obstetrics and Gynecology King Chulalongkorn Memorial Hospital.

SUBJECTS

Sixteen women with uterine myomas who intended to receive treatment with the LNG IUD.

INTERVENTION(S)

Clinical and ultrasound examinations were performed prior to and at 1, 3 and 6 months after the LNG IUD insertion.

MAIN OUTCOME MEASURES

Myoma and Uterine volume, menstrual blood loss assessed with pictorial blood loss assessment charts and hematocrit.

RESULTS

Use of the LNG IUD was associated with a statistically significant reduction in the total myoma volume, average uterine size and marked reduction in menstrual blood loss. After 6 months of use, the median total myoma volume decreased from 19.82 mL to 11.63 mL (p < 0.05), median pictorial blood loss assessment chart score declined from 89 to 3 (p < 0.05). Hematocrit level increased over 6 months of use. The most common side effects were bleeding disturbances (68.8%). No pregnancies occurred during the study.

CONCLUSION

The LNG IUD was associated with a profound reduction in myoma and uterine volume. For women with myomas of this size, the LNG IUD provides effective medical treatment of bleeding.

Women and von Willebrand Disease: Controversies in Diagnosis and Management

von Willebrand disease (vWD) is the commonest bleeding disorder in women. More than 70% of women with vWD suffer from menorrhagia and half of them suffer from dysmenorrhea. There is also the risk of hemorrhage with ovulation and mid-cycle pain. These have a significant effect on all aspects of quality of life. vWD also can be the underlying cause of menorrhagia in a small but significant proportion of women. There are still several unanswered issues in the diagnosis and management of menorrhagia in these women. There is no consensus whether testing for vWD should be part of the routine investigations in menorrhagia. Diagnosis of vWD is difficult. There are intraindividual variations in von Willebrand factor and factor VIII levels influenced by age, race, and blood group. This is further complicated in women because of the fluctuation of these factor levels during the menstrual cycle and possibly with hormonal therapy. The diagnosis of menorrhagia is also difficult due to the lack of a simple objective tool for the assessment of menstrual blood loss. In vWD, the treatment of menorrhagia is usually medical, but there is lack of prospective data on the efficacy of commonly used medical therapies in these women. The levonorgestrel intrauterine system, Mirena, is effective and should be considered prior to surgical management. Surgical interventions may be required in patients unresponsive to medical treatments. These procedures can be complicated by hemorrhage in these women. A multidisciplinary approach in the management of these women is essential in ensuring an optimal outcome. Multicenter clinical trials are required to answer the controversial issues in the management of women with vWD.

Preliminary report of treatment with oral contraceptive pills for intermenstrual vaginal bleeding secondary to a cesarean section scar

Uterine scar has been reported as a possible cause of intermenstrual bleeding in women with previous cesareans. We evaluated the effectiveness of combined hormonal therapy (estrogen and progesterone tablets containing 0.5 mg of norgestrel and 0.05 mg of ethynyl estradiol) in patients with recurring vaginal bleeding after cesarean section. Several cycles of the hormonal therapy eliminated the problem of abnormal vaginal bleeding, and the patients were satisfied with the treatment.

New interventional techniques for adenomyosis

This chapter demonstrates that new interventional techniques have been introduced over recent years in order to find an adequate non-invasive therapy for adenomyosis. There is no evidence-based medicine to guide us in the treatment of adenomyosis with minimally invasive therapy. In fact, most data regarding adenomyosis and these evolving therapies comes from the inadvertent treatment of adenomyosis in studies designed to treat uterine leiomyomas. Essentially, all data are from case reports or small case series. The problem is compounded by the fact that there is no agreed imaging definition of adenomyosis, and so therapies that do not excise the uterus have no 'gold standard' for comparison. Nonetheless, there are some reports suggesting that there may be efficacy in techniques such as medicated intrauterine devices, uterine artery embolization, and MRI-guided focused ultrasound surgery. Larger studies specifically treating adenomyosis are clearly required. As with every new approach, the widespread success of these techniques will depend on the general adoption of adequate diagnostic solutions and improvements in the technical parameters of these new regimens. Since the techniques presented in this chapter are new, they have not yet undergone the necessary thorough scientific scrutiny and discussion that is needed for their general acceptance. In the past, adenomyosis was mainly a 'post-factum' pathological diagnosis after extensive surgery. Based on the evidence presented in this chapter it seems that adenomyosis has become an entity that might be treatable by new, minimally invasive or non-invasive treatments.

Awareness of hormonal emergency contraception among married women in a Kuwaiti family social network

OBJECTIVE

Awareness and use of hormonal emergency contraception are not known in the Arab world. This study investigated awareness and perceptions of hormonal emergency contraception among women within a Kuwaiti extended family and their social contacts.

STUDY DESIGN

A cross-sectional survey was conducted using a self-administered questionnaire which was distributed to 66 married women within a Kuwaiti family's social network. The questionnaire provided a short explanation of hormonal emergency contraception and then elicited the respondent's prior awareness, concerns and perception on future availability.

RESULTS

The mean (S.D.) age of the respondents was 35.1 (6.3) years. Over 30% were currently using oral contraceptives; 28% were using no contraceptive method. Four women (6.1%) had heard of hormonal emergency contraception before, one had used it. Most respondents (65.2%) would not use or inform a friend about hormonal emergency contraception. Main concerns were risks to the health of the woman (83.3%) or the baby (54.5%) or that it was abortifacient (21.2%). However, 90.9% of respondents wanted hormonal emergency contraception to be available.

CONCLUSIONS

Awareness of hormonal emergency contraception is low among Kuwaiti women. Despite some concerns, they feel it should be made available. Health care providers and policymakers should address this situation.

Effects of biphasic oral contraceptives containing desogestrel (Oilezz) on cycle control facial acne and seborrhea in healthy Thai women

OBJECTIVE

To demonstrate the effects of a new biphasic oral contraceptive (Oilezz) on cycle control as well as mild to moderate acne and facial seborrhea of healthy fertile Thai women.

MATERIAL AND METHOD

The trial is a prospective, open, non-comparative, single center study. Fifty healthy, fertile Thai women with mild to moderate facial acne were recruited to study a specific drug (Oilezz) for 6 months.

RESULTS

At the beginning, 66% of the subjects had mild acne and 34% had moderate acne. Significant improvements in facial seborrhea grades (as indicated by Sebutape assessments) were found after the first cycle. These improvements increased steadily and were much larger after the sixth cycle. There were no statistically significant changes in body weight or blood pressure during the study. No serious adverse events were reported. There were no mood changes, migraine, rash, abdominal discomfort, malaise, nausea and decrease in libido during the study period The premenstrual symptoms at initiation were 21 cases (42%). The symptoms were 4 (8%) with headache, 8 (16%) with breast tenderness, 5 (10%) with dysmenorrhea and one (2%) with bleeding irregularity. These symptoms were improved in the third and the sixth cycles. The percentage of women with spotting or bleeding increased after first cycle, compared with baseline and gradually decreased during subsequent cycles. After the sixth cycle of treatment, all subjects had improvement of acne. 80% of cases recovered from acne and there were only 20% had mild acne.

CONCLUSION

Facial seborrhea and acne improved significantly with Oilezz. It is good to control cycle without change in body weight and blood pressure. Therefore, Oilezz can be used for treatment of seborrhea and acne and as a contraceptive.

Effects of two forms of combined oral contraceptives on carbohydrate metabolism in adolescents with polycystic ovary syndrome

OBJECTIVE

To compare the effects of combined oral contraceptives (OCs) containing cyproterone acetate or desogestrel on insulin sensitivity in adolescents with polycystic ovary syndrome (PCOS).

DESIGN

A prospective randomized clinical trial.

SETTING

Outpatient gynecological clinic of Aretaieion University Hospital.

PATIENT(S)

Thirty-six adolescent girls with hyperandrogenism and six or less menses in the preceding 12 months.

INTERVENTION(S)

Patients were separated in two groups: group A (n = 18) received 0.15 mg of desogestrel plus 0.030 mg of ethinyl E2 daily; and group B (n = 18) received 2 mg of cyproterone acetate plus 0.035 mg of ethinyl E2 daily, for 21 days followed by a 7-day rest, for 12 months.

MAIN OUTCOME MEASURE(S)

Hirsutism score, lipid, androgen, and sex hormone-binding globulin (SHBG) levels were evaluated at baseline. An oral glucose tolerance test (OGTT) was performed and metabolism indices, based on previously studied mathematical formulas, were assessed at baseline and at 12 months.

RESULT(S)

After 12 months of treatment, the homeostasis model assessment index of insulin resistance increased significantly in both groups. The fasting glucose-to-insulin ratio and predicted insulin sensitivity index decreased in group B. The delta of the area under the OGTT curve for insulin and predicted first and second phase insulin secretion indices increased significantly only in group B.

CONCLUSION(S)

We conclude that treatment of adolescent girls with PCOS with the two combined OCs administered, results in unfavorable changes of insulin sensitivity. In addition, cyproterone acetate is associated with an increase of insulin secretion and hyperinsulinemia.

Ethinylestradiol + etonogestrel contraceptive vaginal ring: new drug. Possibly useful in some situations

(1) The standard hormonal contraception consists of a combined oral contraceptive containing about 30 micrograms of ethinylestradiol and a well-evaluated and widely used progestin such as levonorgestrel or norethisterone. (2) A vaginal ring delivering about 120 micrograms of etonogestrel and 15 micrograms of ethinylestradiol daily for 3 consecutive weeks per cycle, which is then removed for one week, is now marketed in France as a contraceptive. Etonogestrel, a desogestrel metabolite, is classified as a 'third-generation' progestin. (3) On the basis of 2 non-comparative trials involving a total of 2322 women, the vaginal ring's contraceptive efficacy, as measured by the Pearl index, is about 1 per 100 woman-years, a value similar to that of other available combined hormonal contraceptives. (4) In total, 41% and 29.6% of women withdrew early from each of the two trials. In the two trials combined, 15.6% of women withdrew due to adverse events. (5) A comparative trial versus oral ethinylestradiol + levonorgestrel showed no difference in adherence rates, and similar Pearl index scores. (6) The most frequent adverse effects, occurring in about 20% of women using the vaginal ring, were gynecological disorders (vaginitis, leukorrhea or local discomfort). The other adverse effects were those common to all hormonal contraceptives. (7) The thromboembolic risk of etonogestrel, when administered in a contraceptive ring, has not been evaluated. (8) In practice, the standard hormonal contraceptive remains a combined oral contraceptive containing about 30 micrograms of ethinylestradiol plus a well-evaluated progestin such as levonorgestrel or norethisterone. The vaginal ring offers no advantage in terms of efficacy, adverse effects or adherence. However, it is an additional effective contraceptive and may be preferred by some women, at least temporarily, in certain situations.

Chlormadinone acetate (CMA) in oral contraception--a new opportunity

Chlormadinone acetate (CMA) is a derivative of naturally secreted progesterone that shows high affinity and activity at the progesterone receptor. It has an anti-estrogenic effect and, in contrast to natural progesterone, shows moderate anti-androgenic properties. CMA acts by blocking androgen receptors in target organs and by reducing the activity of skin 5alpha-reductase. It suppresses gonadotropin secretion and thereby reduces ovarian and adrenal androgen production. CMA shows high contraceptive efficacy by inhibiting ovulation due to its ability to suppress or disrupt endogenous gonadotropin secretion and, by this, inhibits follicular growth and maturation. In addition, it suppresses endometrial thickness and increases the viscosity of cervical mucus. Pharmacokinetic studies have shown rapid and almost complete absorption after oral administration, and CMA is being bound to albumin rather than SHBG (Sex-Hormone-Binding-Globulin). Multiple dosing studies have demonstrated that steady state is reached by day 7 after oral administration with peak plasma concentrations in the region of 2 ng/ml. After a single dose of CMA the half-life time is around 34 hours and after multiple dose administration approximately 38 hours. Safety studies have indicated that CMA has no clinically relevant effect on a wide range of metabolic parameters in normal subjects. Further studies in groups at high thromboembolic risk have shown that CMA alone produces a relative risk of 0.8 which is not considered significant. These results indicated the potential for CMA to be combined with ethinylestradiol in an oral contraceptive which provides highly effective contraception and excellent cycle control.

The effect of long-term use of progesterone therapy on proliferation and apoptosis in simple endometrial hyperplasia without atypia

The aim of this study was to evaluate the effect of long-term use of progesterone treatment on proliferation and apoptosis in simple endometrial hyperplasia without atypia. In this prospective control study, endometrial tissue samples of 19 patients with simple endometrial hyperplasia without atypia (group 1), posttreatment biopsy materials of the patients after 3 months of cyclic progesterone treatment with noretisterone for 10 days (group 2), and 18 endometrial biopsy materials of the control group (group 3) were examined for proliferative and apoptotic activities. There was a statistically significant difference between the median values of the proliferative index of the three groups (P = 0.000). The proliferative index was significantly higher in the endometrial hyperplasia group than in posttreatment group (P = 0.000). But there was no significant difference between posttreatment group and control group. The median value of apoptotic activity was significantly different between three groups (P = 0.000). Apoptotic index was highest in hyperplasia group. A significant decrease in apoptosis was observed after the progesterone treatment (P = 0.002). The lowest apoptotic activity was detected in the control group. In conclusion, 3 months of cyclic progesterone treatment reduces both proliferative and apoptotic activities in endometrial tissue with simple hyperplasia.

Emergency contraception - a human rights issue

Emergency contraception is the only resource that women can use to avoid becoming pregnant after having sexual intercourse without contraceptive protection. It could be a powerful means to prevent unwanted pregnancies and their devastating consequences for women's health, social wellbeing and life project, and for the unwanted child, if all people had ample access to good quality information, education and services for sexual and reproductive health. In spite of the preventive medicine value of emergency contraception, conservative sectors oppose its availability, appealing to moral values that are not universally shared in pluralistic societies. Excluding the only contraceptive that can be used after intercourse because some consider the mechanism of action to be unacceptable would mean restricting the right of choice of others, and imposing one particular belief or set of values on all members of the community, thus violating the freedom of conscience. Authorities have a moral obligation to protect human rights.

An assessment of the first 3 years' use of Implanon in Luton

OBJECTIVES

Implanon was introduced in the UK in September 1999. We present here the results of our first 106 Implanon insertions, performed over a period of 18 months. The aims of the study were to study the clinical and demographic profile of Implanon users, to assess the continuation rates of Implanon in the local population, and to identify the reasons for removal.

METHODS

This was a case note-based study in which the data were transferred to a standardised pre-tested proforma.

RESULTS

The age range of the 106 Implanon users was 15-43 years. Eighty-six of these clients had their Implanon removed and the Implanon status of 20 clients is not known since they were lost to follow-up by our service. Of these 86 cases, 26 had completed the full 3-year period; therefore, the continuation rate at 3 years was 30.2%. The continuation rate at the end of 1 year was 69.8% and at 2 years was 44.1%. Of the 60 women who had their Implanon removed before the recommended 3-year period, the most common reason was for bleeding irregularity (24 cases, 40%).

CONCLUSIONS

This is the first published study set in the UK within a real-life setting to follow up a cohort of Implanon users for the full 3-year period. No contraceptive failures were found, replicating previous clinical trials. The continuation rate in this real-life situation was quite low compared to clinical trials. This is frequently the case when comparing real-life situations with clinical trials and may be in part due to higher motivation on the part of clinical trial participants.

Neutral effect of prolonged transdermal hormone therapy on liver function of postmenopausal women with chronic active hepatitis

OBJECTIVE

To test whether transdermal hormone therapy can be safely administered to postmenopausal women with chronic viral hepatitis B and/or C.

DESIGN

Eighty-one postmenopausal women with chronic viral hepatitis B and/or C and with severe vasomotor symptoms were treated for 5 years with transdermal estradiol (50 microg/day) continuously and with transdermal norethisterone (250 microg/day) for 14 days of every 28-day cycle. Another 95 women with viral chronic hepatitis but without climacteric symptoms were used as controls. Liver enzymes (glutamic-oxalacetic transaminase, glutamic-pyruvic transaminase, gamma-glutamine-transferase, and alkaline phosphatase) were measured every year.

RESULTS

At baseline, liver enzymes were similar in the two groups, with the exception of gamma-GT, which was slightly higher in untreated women (P < 0.01). Liver enzymes did not significantly vary with time in hormone-treated and untreated women. No significant difference was observed between the two groups.

CONCLUSIONS

Transdermal estradiol and norethisterone can be safely administered for a prolonged period to postmenopausal women with chronic viral B and/or C hepatitis.