20 µg versus >20 µg estrogen combined oral contraceptives for contraception

Contraception Selection, Effectiveness, and Adverse Effects: A Review

IMPORTANCE

Many women spend a substantial proportion of their lives preventing or planning for pregnancy, and approximately 87% of US women use contraception during their lifetime.

OBSERVATIONS

Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. In the US, oral contraceptive pills are the most commonly used reversible method of contraception and comprise 21.9% of all contraception in current use. Pregnancy rates of women using oral contraceptives are 4% to 7% per year. Use of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis from 2 to 10 venous thrombotic events per 10 000 women-years to 7 to 10 venous thrombotic events per 10 000 women-years, whereas progestin-only and nonhormonal methods, such as implants and condoms, are associated with rare serious risks. Hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder. Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences.

CONCLUSIONS AND RELEVANCE

Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Contraception and mental health: a commentary on the evidence and principles for practice

Among the most prevalent and disabling chronic diseases affecting reproductive-aged women worldwide, depression and anxiety can contribute to adverse reproductive health outcomes, including an increased risk of unintended pregnancy and its health and social consequences. For women with these common mental health conditions who want to avoid an unintended pregnancy, effective contraception can be an important strategy to maintain and even improve health and well-being. Reproductive health clinicians play a critical role in providing and managing contraception to help women with mental health considerations achieve their desired fertility. In this commentary, we review the literature on relationships between mental health and contraception and describe considerations for the clinical management of contraception among women with depression and anxiety. We discuss issues related to contraceptive method effectiveness and adherence concerns, mental health-specific contraceptive method safety and drug interaction considerations, and clinical counseling and management strategies. Given important gaps in current scientific knowledge of mental health and contraception, we highlight areas for future research.

Choosing a combined oral contraceptive pill

The combined oral contraceptive pill is an effective contraceptive method which can also offer other benefits. However, other contraceptive options should be discussed. If the pill is the chosen method, prescribe a pill with the lowest effective dose of oestrogen and progestogen. Pills containing levonorgestrel or norethisterone in combination with ethinyloestradiol 35 microgram or less are considered first-line. They are effective if taken correctly, have a relatively low risk of venous thromboembolism, and are listed on the Pharmaceutical Benefits Scheme. The pill is usually taken in a monthly cycle. Some women may prefer an extended pill regimen with fewer or no inactive pills.

Clinical efficacy and metabolic impact of two different dosages of ethinyl-estradiol in association with drospirenone in normal-weight women with polycystic ovary syndrome: a randomized study

BACKGROUND

The estrogenic component of estro- progestin (EP) is responsible for a negative impact on the metabolic and lipid assessment in women with polycystic ovary syndrome (PCOS).

AIM

To evaluate the risk/benefit ratio of two EP combinations, containing the same progestin (3 mg drospirenone) and a different dose of ethinyl-estradiol (EE) (20 vs 30 μg) and to compare their effects on the clinical and endocrine-metabolic parameters in normal-weight PCOS women.

MATERIAL/SUBJECTS AND METHODS

In this randomized pilot study, we enrolled 30 young normal-weight PCOS women. Fifteen subjects were allocated to group A (20 μg EE) and 15 PCOS subjects to group B (30 μg EE). Hirsutism score, hormonal assays, oral glucose tolerance test, euglycemic hyperinsulinemic clamp and lipid profile were performed at baseline, and after 6 and 12 months of therapy. Main outcome measures were signs of hyperandrogenism, glucose and insulin metabolism, lipid profile.

RESULTS

Both treatment regimens induced a significant improvement in hirsutism score, testosterone, DHEAS, and SHBG levels. Androstenedione significantly dropped only in patients of Group A, while 17(OH)P only in those from Group B. Both the formulations did not significantly modify gluco-insulinemic metabolism. Total cholesterol, LDL cholesterol, and HDL cholesterol levels significantly increased in both groups. Triglycerides levels, which increased as well, resulted more markedly influenced by the formulation with 30 μg EE.

CONCLUSIONS

In association with drospirenone, 20 μg EE results as effective as 30 μg in improving clinical and hormonal features of normal-weight PCOS women, while exhibiting a milder influence on lipidic parameters.

Oral contraceptives in adolescent women

Taking into account the biological and psychosocial changes during the transition from childhood to adulthood adolescents would need a contraceptive method which ideally would be very effective, independent of compliance, without major health risks during use and no negative impact on the future health of the adolescent, protective against STI, favorable for bone development, with no or only few side effects and having some preventive and therapeutic potential with respect to frequent health problems of adolescent girls. Combined oral contraceptives (COC) used regularly and consistently have a more than 99% efficacy to prevent a pregnancy. COCs have a very low health risk (almost exclusively thromboembolic disease) which seems to differ marginally with respect to dosage and type of the components. Progestogen only oral contraceptives do not have any major negative health impact. The leading side effect is irregular bleeding which in COC users is mainly during the first 3 months and in progestogen only users during the period of use. Other side effects are reported but their frequency is similar to placebo. COC protect against endometrial and ovarian cancer and they may have beneficial effects on a variety of menstrual complaints and acne, which are frequent problems during adolescence. To be effective COCs have to be taken regularly which is frequently not the case. This diminishes considerably their effectiveness depending on the individual compliance. They do not protect against STI and may even have an inhibitory effect on the use of condoms. For most adolescents the risk benefit profile of oral contraceptives is favorable and makes this method valuable. At the same time the prescription of oral contraceptives for adolescents need to be individualized by taking into account the individual risk/benefit profile. Specialized counseling with a high degree of confidentiality adapted to the knowledge and needs of the individual adolescent is desirable.

A chewable low-dose oral contraceptive: a new birth control option?

A new chewable combined oral contraceptive pill containing ethinyl estradiol (EE) 0.025 mg and norethindrone (NE) 0.8 mg in a 24/4 regimen was approved for marketing in December 2010. Each of the four inactive tablets contains 75 mg ferrous fumarate, which has no therapeutic benefit. The tablet can be taken with food but not water as this affects the absorption of EE. The Pearl index based on intention to treat women aged 18-35 years has been reported at 2.01 (confidence interval [CI] 1.21, 3.14) and for the whole population 1.65 (CI 1.01, 2.55). The effect of a body mass index of >35 was not studied. Regular withdrawal bleeding occurred for 78.6% of women in Cycle 1, but by Cycle 13 almost half the women failed to have a withdrawal bleed. This new formulation provides an intermediate dose of an EE/NE combination that will be useful for women experiencing breakthrough bleeding on the lower-dose EE/NE pill. The convenience of a low-dose pill, which can be chewed without the need for water, will be useful to enable women who have forgotten a pill to take one whenever they remember, provided they carry it with them. The advantage of a 24/4 regimen is better suppression of follicular development in the pill-free interval and may be beneficial for women who experience menstrual cycle-related problems, such as heavy bleeding or dysmenorrhea.

Developmental exposure to xenoestrogens at low doses alters femur length and tensile strength in adult mice

Developmental exposure to high doses of the synthetic xenoestrogen diethylstilbestrol (DES) has been reported to alter femur length and strength in adult mice. However, it is not known if developmental exposure to low, environmentally relevant doses of xenoestrogens alters adult bone geometry and strength. In this study we investigated the effects of developmental exposure to low doses of DES, bisphenol A (BPA), or ethinyl estradiol (EE(2)) on bone geometry and torsional strength. C57BL/6 mice were exposed to DES, 0.1 μg/kg/day, BPA, 10 μg/kg/day, EE(2), 0.01, 0.1, or 1.0 μg/kg/day, or vehicle from Gestation Day 11 to Postnatal Day 12 via a mini-osmotic pump in the dam. Developmental Xenoestrogen exposure altered femoral geometry and strength, assessed in adulthood by micro-computed tomography and torsional strength analysis, respectively. Low-dose EE(2), DES, or BPA increased adult femur length. Exposure to the highest dose of EE(2) did not alter femur length, resulting in a nonmonotonic dose response. Exposure to EE(2) and DES but not BPA decreased tensile strength. The combined effect of increased femur length and decreased tensile strength resulted in a trend toward decreased torsional ultimate strength and energy to failure. Taken together, these results suggest that exposure to developmental exposure to environmentally relevant levels of xenoestrogens may negatively impact bone length and strength in adulthood.

Pharmacology and clinical use of sex steroid hormone receptor modulators

Sex steroid receptors are ligand-triggered transcription factors. Oestrogen, progesterone and androgen receptors form, together with the glucocorticoid and mineralocorticoid receptors, a subgroup of the superfamily of nuclear receptors. They share a common mode of action, namely translating a hormone-i.e. a small-molecule signal-from outside to changes in gene expression and cell fate, and thereby represent "natural" pharmacological targets.For pharmacological therapy, these receptors have originally been addressed by hormones and synthetic hormone analogues in order to overcome pathologies related to deficiencies in the natural ligands. Another major use for female sex hormone receptor modulators is oral contraception, i.e. birth control.On the other side, blocking the activity of sex steroid receptors has become an established way to treat hormone-dependent malignancies, such as breast and prostate cancer.In this review, we will discuss how the experience gained from the classical pharmacology of these receptors and their molecular similarities led to new options for the treatment of gender-specific diseases and highlight recent progress in medicinal chemistry of sex hormone-modulating drugs.

The state of hormonal contraception today: established and emerging noncontraceptive health benefits

In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.

Hormonal contraception--what kind, when, and for whom?

BACKGROUND

In Germany today, one-third of the 20 million women of child-bearing age use combined oral contraceptives (COCs). In this article, we summarize the current knowledge of the mode of action, wanted and unwanted side effects, and long-term risks of COCs. The levonorgestrel intrauterine device (IUD) and long-acting injectable or implantable monophasic progestogen preparations offer comparable contraceptive efficacy to COCs. Nonetheless, they are less frequently used in Germany than COCs, because of their propensity to cause breakthrough bleeding.

METHOD

Selective review of the literature.

RESULTS

COCs suppress gonadotropin secretion and thereby inhibit follicular maturation and ovulation. Their correct use is associated with 0.3 pregnancies per 100 women per year, their typical use, with 1 pregnancy per 100 women per year (Pearl index). COCs have effects on the cardiovascular and hemostatic systems as well as on lipid and carbohydrate metabolism. When given in the presence of specific risk factors, they significantly increase the likelihood of cardiovascular disease and thromboembolism. Women with persistent human papilloma virus (HPV) infection who take COCs are at increased risk of developing invasive cervical cancer. On the other hand, COCs lower the cumulative incidence of endometrial and ovarian cancer by 30% to 50%, and that of colorectal cancer by 20% to 30%. Other malignancies seem to be unaffected by COC use.

CONCLUSION

As long as personal and familial risk factors are carefully considered, COCs constitute a safe, reversible, and well-tolerated method of contraception.