Potencies of oral contraceptives

Development and validation of a multiplexed assay for the measurement of long-acting hormonal contraceptives in plasma via liquid chromatography-tandem mass spectrometry

BACKGROUND

Exogenous progestins are an effective tool for hormonal contraception and family planning. Progestins may be delivered as oral pills, intramuscular or subcutaneous injections, vaginal rings, or intrauterine devices. Drug concentrations may vary based on the route and duration of delivery. Measurement of synthetic steroids in blood plasma can aid in determination of product adherence, evaluation of drug-drug interactions, and investigation of unintended pregnancies.

METHODS

Drug-free K2EDTA plasma was spiked with the synthetic steroids etonogestrel (ETO), levonorgestrel (LNG), medroxyprogesterone acetate (MPA), and norethisterone (NET). Plasma was combined with isotopically labeled internal standards, and drugs were extracted via liquid-liquid extraction. Samples were then subjected to liquid chromatographic-tandem mass spectrometric (LC-MS/MS) analysis. The method was validated in accordance with regulatory recommendations. The assay was evaluated in a cohort of remnant plasma samples in individuals using one of the aforementioned progestins.

RESULTS

The analytical measuring range for ETO, MPA, and NET was 20-10,000 pg/mL; the primary linearity for LNG was 20-20,000 pg/mL. The method showed acceptable precision and accuracy for all progestins. Stability was established for 72 h with room temperature storage and through 3 freeze-thaw cycles. All analytes were stable in whole blood incubated at room temperature for 25 h, and at 40°C and 100% humidity for 2 h. Ion suppression was observed for all analytes spiked in plasma; average ion suppression was 31.6%, 66.6%, 32.1% and 41.2% for ETO, LNG, MPA, and NET, respectively. However, internal standards showed comparable ion suppression, and relative matrix effects were minimal. ETO, LNG, MPA, and NET could also be quantified accurately in K3EDTA plasma and serum. Progestins were successfully measured in remnant samples from individuals using hormonal contraceptives.

CONCLUSIONS

A multiplexed LC-MS/MS assay for the quantification of ETO, LNG, MPA, and NET has been developed and validated. The assay met acceptable performance characteristics and may be used in downstream studies to evaluate progestin pharmacology.

Design, Synthesis and Biological Evaluation of Novel Nonsteroidal Progesterone Receptor Antagonists Based on Phenylamino-1,3,5-triazine Scaffold

We report here the development of phenylamino-1,3,5-triazine derivatives as novel nonsteroidal progesterone receptor (PR) antagonists. PR plays key roles in various physiological systems, including the female reproductive system, and PR antagonists are promising candidates for clinical treatment of multiple diseases. By using the phenylamino-1,3,5-triazine scaffold as a template structure, we designed and synthesized a series of 4-cyanophenylamino-1,3,5-triazine derivatives. The synthesized compounds exhibited PR antagonistic activity, and among them, compound 12n was the most potent (IC₅₀ = 0.30 µM); it also showed significant binding affinity to the PR ligand-binding domain. Docking simulation supported the design rationale of the compounds. Our results suggest that the phenylamino-1,3,5-triazine scaffold is a versatile template for development of nonsteroidal PR antagonists and that the developed compounds are promising lead compounds for further structural development of nonsteroidal PR antagonists.

Novel Non-steroidal Progesterone Receptor Ligands Based on m-Carborane Containing a Secondary Alcohol: Effect of Chirality on Ligand Activity

The progesterone receptor (PR) controls various physiological processes, including the female reproductive system, and nonsteroidal PR ligands are considered to be drug candidates for treatment of various diseases without significant adverse effects. Here, we designed and synthesized m-carborane-based secondary alcohols and investigated their PR-ligand activity. All the synthesized alcohols exhibited PR-antagonistic activity at subnanomolar concentration. Among them, alcohols having a small alkyl side chain and a 4-cyanophenyl group also exhibited PR-agonistic activity in a relatively high concentration range. Optical resolution of secondary alcohols having a methyl side chain was performed, and the PR-ligand activity and PR-binding affinity of the purified enantiomers were examined. The chirality of the secondary alcohol appears to have a more significant influence on PR-agonistic activity than on antagonistic activity.

Development of N-(4-Phenoxyphenyl)benzenesulfonamide Derivatives as Novel Nonsteroidal Progesterone Receptor Antagonists

We report here development of N-(4-phenoxyphenyl)benzenesulfonamide derivatives as a novel class of nonsteroidal progesterone receptor (PR) antagonists. PR plays key roles in various physiological systems, including the female reproductive system, and PR antagonists are candidates for clinical treatment of multiple diseases, including uterine leiomyoma, endometriosis, breast cancer, and some psychiatric disorders. We found that the benzenesulfonanilide skeleton functions as a novel scaffold for PR antagonists, and we adopted 3-chlorobenzenesulfonyl derivative 20a as a lead compound for structural development. Among the synthesized compounds, 3-trifluoromethyl derivative 32 exhibited the most potent PR-antagonistic activity, with high binding affinity for PR and selectivity over androgen receptor (AR). It is structurally distinct from other nonsteroidal PR antagonists, including cyanopyrrole derivatives, and further modification is expected to afford novel selective PR modulators.

Development of 1,3-diphenyladamantane derivatives as nonsteroidal progesterone receptor antagonists

Nonsteroidal progesterone receptor (PR) full antagonists are needed as tools for elucidating the physiological functions of PR and as candidates for treatment of various diseases. We designed and synthesized 1,3-diphenyladamantane derivatives, and investigated their PR-antagonistic activity in comparison with our recently developed boron cluster-based PR antagonists. Among the synthesized adamantane derivatives, compound 9a exhibited the most potent PR-antagonistic activity (IC50: 25nM) and showed high binding affinity for the PR ligand-binding domain, comparable with that of the boron cluster-based PR antagonists. These results suggest that disubstituted adamantane, like the boron cluster m-carborane, is a promising hydrophobic pharmacophore for further structural development of nonsteroidal PR antagonists.

Effect of oral contraceptives on the production and composition of human milk

One hundred and thirty six lactating women were studied, 42 controls and 94 taking oral contraceptives. Combination pills of oestrogen and progestogen (Primovlar and Minovlar) and a low dose progestogen pill (Norgestrel) were used. The selection of a particular formulation was based on the endocrine profile of an individual; this reduced drop-outs due to side effects.

The change in the quantity of milk was assessed by test-feeding followed by manual expression. Milk was also analysed quantitatively. Significant reduction in the milk yield was found with the Primovlar and Minovlar groups but no change was observed with Norgestrel. No change in the quality of milk was found for any of the three groups.

2-Amino-9-aryl-3-cyano-4-methyl-7-oxo-6,7,8,9-tetrahydropyrido[2',3':4,5]thieno[2,3-b]pyridine derivatives as selective progesterone receptor agonists

High throughput screening of the corporate compound collection led to the identification of a novel series of 2-amino-9-aryl-3-cyano-4-methyl-7-oxo-6,7,8,9-tetrahydropyrido[2',3':4,5]thieno[2,3-b]pyridine derivatives as selective PR agonists. Initial SAR exploration leading to potent and selective agonists 9 and 11, X-ray crystal structure of 9 bound to PR-LBD and preliminary developability data are described.

Carbopol-based gels for nasal delivery of progesterone

The purpose of this study was to investigate the nasal absorption of progesterone from carbopol-based nasal gels in rabbits. Progesterone nasal gels were prepared by dispersing carbopol 974 (1%, 1.5%, and 2%) in distilled water followed by addition of progesterone/progesterone-beta cyclodextrin complex dissolved in propylene glycol then neutralization. The potential use of beta cyclodextrin (CD) as nasal absorption enhancer by simple addition, as a physical mixture and as a complex with progesterone was investigated. The absolute bioavailability of progesterone from nasal gels in rabbits was studied by estimating the serum progesterone level by competitive solid-phase enzyme immunoassay in comparison to intravenous injection. The carbopol gel formulations produced a significant increase in bioavailability. CD complex promotes the nasal absorption of progesterone from carbopol gels as compared with gels where the CD is added by simple addition and gels which do not contain CD. This method of addition of CD as an inclusion complex in the gels could be considered as a preferred platform in nasal drug administration.

5-(3-Cyclopentyl-2-thioxo-2,3-dihydro-1H-benzimidazol-5-yl)-1-methyl-1H-pyrrole-2-carbonitrile: A novel, highly potent, selective, and orally active non-steroidal progesterone receptor agonist

We have recently discovered 5-(3-cyclopentyl-2-thioxo-2,3-dihydro-1H-benzimidazol-5-yl)-1-methyl-1H-pyrrole-2-carbonitrile (14) as a potent, selective, and orally active non-steroidal progesterone receptor (PR) agonist. Compound 14 and its analog 13 possessed sub-nanomolar in vitro potency (EC(50) 0.1-0.5nM) in the T47D alkaline phosphatase assay, similar to that of the steroidal PR agonist medroxyprogesterone acetate (MPA). In contrast to MPA, 14 was highly selective (>500-fold) for the PR over both glucocorticoid and androgen receptors. In the rat uterine decidualization and complement component C3 models, 14 had oral ED(50) values of 0.02 and 0.003mg/kg, respectively, and was from 6- to 20-fold more potent than MPA. In the monkey ovulation inhibition model, compound 14 was also highly efficacious and potent with an oral ED(100) of 0.03mg/kg.

Association of estrogen and progestin potency of oral contraceptives with ovarian carcinoma risk

OBJECTIVE

To estimate the association of the estrogen and progestin potency of combined oral contraceptive pills (OCPs) with epithelial ovarian carcinoma risk.

METHODS

This population-based case-control study included 745 women with incident, histologically confirmed epithelial ovarian carcinoma and 943 controls, matched on age and ethnicity. Data were collected using a standard questionnaire, picture albums, and calendars. The association of OCP potency with epithelial ovarian carcinoma risk was modeled using unconditional logistic regression.

RESULTS

When compared with women who never used hormonal contraception, users of OCPs with low estrogen (equal to or less than 0.035 mg ethinyl estradiol) and low progestin (less than 0.3 mg norgestrel) were at significantly reduced risk of ovarian carcinoma (odds ratio 0.19; 95% confidence interval 0.05-0.75). The risk among these women was lower than among users of estrogen or progestin of high potency, but the difference was not statistically significant. However, in a subset of 205 women who reported exclusive use of norethindrone, users of 0.5 mg or less, had a significantly reduced risk of ovarian cancer compared with women using 10 mg of this progestin. Increased norethindrone dose resulted in a significant increase in ovarian carcinoma risk, indicating a dose-response association.

CONCLUSION

Combined OCPs were effective at decreasing the risk of epithelial ovarian carcinoma, with the strongest risk reduction associated with low-potency formulations.

LEVEL OF EVIDENCE

II.

Thiolated polymers: development and evaluation of transdermal delivery systems for progesterone

PURPOSE

To evaluate the possible use of polycarbophil-cysteine (PCP-Cys) as polymeric matrix for transdermal progesterone application.

METHODS

Thiolated polycarbophil was synthesised by the covalent attachment of cysteine to the basis polymer. The adhesive properties of PCP-Cys in comparison to polyvinylpyrrolidone/hydroxypropylmethylcellulose (PVP/HPMC) and polyvinylpyrrolidone/polyvinylalcohol (PVP/PVA) were investigated by testing the total work of adhesion (TWA) on porcine skin. Release studies in Franz diffusion cells and standard in vitro permeation experiments with porcine skin were performed analysing the progesterone content by high-performance liquid chromatography.

RESULTS

Films based on PCP-Cys displayed very high cohesive properties due to the formation of interchain disulfide bonds. The TWA of the thiolated polymer on porcine skin was significantly (P <0.05) the highest. In addition progesterone permeation was also the highest from PCP-Cys compared with PVP/HPMC and PVP/PVA within 24 hours.

CONCLUSION

PCP-Cys--a partly thiolated polymer--might be a novel polymer matrix for transdermal progesterone delivery with excellent adhesiveness on porcine skin.

Percutaneous progesterone use and risk of breast cancer: results from a French cohort study of premenopausal women with benign breast disease

Percutaneous progesterone topically applied on the breast has been proposed and widely used in the relief of mastalgia and benign breast disease by numerous gynecologists and general practitioners. However, its chronic use has never been evaluated in relation to breast cancer risk. The association between percutaneous progesterone use and the risk of breast cancer was evaluated in a cohort study of 1150 premenopausal French women with benign breast disease diagnosed in two breast clinics between 1976 and 1979. The follow-up accumulated 12,462 person-years. Percutaneous progesterone had been prescribed to 58% of the women. There was no association between breast cancer risk and the use of percutaneous progesterone (RR = 0.8; 95% confidence interval 0.4-1.6). Although the combined treatment of oral progestogens with percutaneous progesterone significantly decreased the risk of breast cancer (RR = 0.5; 95% confidence interval 0.2-0.9) as compared with nonusers, there was no significant difference in the risk of breast cancer in percutaneous progesterone users versus nonusers among oral progestogen users. Taken together, these results suggest at least an absence of deleterious effects caused by percutaneous progesterone use in women with benign breast disease.

The collection and interpretation of epidemiological data about the cardiovascular risks associated with the use of steroid contraceptives

A variety of epidemiological approaches have been used to assess the safety of steroid contraceptives. Each study design has its own strengths and weaknesses, especially with respect to susceptibility to bias and confounding. Randomized controlled trials provide the strongest evidence of a cause and effect relationship, but the low incidence of cardiovascular disease in women of reproductive age precludes the use of this study design to examine these clinical endpoints. Consequently, observational cohort and case-control studies have provided the most useful clinical information about the main cardiovascular effects of steroid contraceptives. Data from epidemiological research need to be interpreted carefully taking into consideration which of the potential biases or sources of confounding are likely to have affected a particular study, and what effect these may have on any inferences from the study. Additional factors that need to be considered before deciding whether a causal relationship exists include evidence that the exposure preceded the disease, the strength of association, consistency of findings with other studies, presence of dose gradients, and agreement with animal or laboratory research. Even if a casual link is thought to be plausible, the public health implications may be minimal; absolute (attributable) risks are required in order to assess these. An understanding of these epidemiological issues will enable clinicians to advise their clients whether steroid contraceptives alter the risk of cardiovascular disease and, if so, the clinical significance of such changes.

Transdermal application of steroid hormones for contraception

The concept of transdermal delivery (TD) for steroid application has nowadays been largely accepted for hormone replacement therapy in the menopause. It is only recently that the same concept has been envisaged for contraception. The skin can be penetrated by both estrogens and progestins, provided they are delivered in an appropriate solvent. About 10% of the total dose applied topically is actually absorbed. The transdermal delivery systems (TDS) presently available are either of the reservoir type (membrane-moderated system) or of the matrix dispersion type where the drug is dispersed into a polymer matrix. Estradiol (E2) is the most appropriate steroid for TD and can be combined with progestins to ensure a contraceptive effect. Only potent progestins should be used to achieve effective plasma levels with low doses in order to maintain an acceptable small surface of TDS. TDS changed weekly and delivering both E2 and levonorgestrel (L-NG) at daily dosages of 38.4 (+/- 7.5) and 28.8 (+/- 7.2) micrograms/10 cm2 per day respectively, showed ovulation suppression. Another progestin derived from norprogesterone (ST 1435) has been shown to penetrate the skin when suspended in acetylated lanolin or dissolved in a hydroalcoholic gel and to ensure ovulation suppression at a dose of 2 mg per day in a small number of cycles. These preliminary data demonstrate the feasibility of suppressing ovulation in women by transdermal absorption of steroids. Using TDS for contraception implies that such systems should be perfectly adhesive, well tolerated locally and achieve nearly 100% efficacy. These targets are very challenging, however, the potential advantages are so high that the concept deserves further development.

Sex steroids and lipoprotein metabolism

Lipoprotein metabolism is involved in atherogenesis. Female sex-hormones have substantial effects on both lipoprotein metabolism and the vessel wall. Cholesterol, one of the major lipids in lipoproteins, is both the substrate for, and the target of, the steroidal sex hormones.

Progestogen use and decreased risk of breast cancer in a cohort study of premenopausal women with benign breast disease

A cohort study of 1,150 premenopausal French women with benign breast disease diagnosed in two breast clinics between 1976 and 1979 was carried out to analyse the relationship between progestogen use and the risk of breast cancer. The follow-up accumulated 12,462 person-years. The risk of breast cancer was estimated using a Poisson regression analysis on person-time data and the proportional hazards model. In the latter analysis, cumulated progestogen use and age were considered as time-varying covariables and adjustment was performed on the main risk factors for breast cancer. Neither overall progestogen use nor the duration of use was found to be significantly associated with the risk of breast cancer. When progestogens were classified into two categories according to their hormonal potency (19-nortestosterone derivatives vs other progestogens), 19-nortestosterone derivative use was found to be significantly associated with a lower risk of breast cancer. In the adjusted model, the corresponding risk of breast cancer was 0.48 (95% confidence interval 0.25-0.90). In addition, there was a linear trend in the decrease of the relative risk of breast cancer with the duration of use (P = 0.02). These results do not support the hypothesis that progestogens might increase the breast cancer risk. They suggest, instead, that treatment with 19-nortestosterone derivatives might have a beneficial effect on the risk of breast cancer in women with benign breast disease.

New knowledge in the physiology of hormonal contraceptives

The present review addresses some of the new knowledge regarding the physiology and mechanisms of action of hormonal contraceptives. Specific topics that are discussed include oral contraceptives, intravaginal rings, long-term contraception, gonadotropin-releasing hormone agonists and antagonists, and antiprogestins. It has been shown that in combined oral contraceptives, lower doses of the new progestins (desogestrel, norgestimate, and gestodene) can be used to inhibit ovulation compared with norethindrone and levonorgestrel. In addition, lower doses of ethinyl estradiol are now used with progestins. Estrogen has been added to intravaginal rings containing levonorgestrel or norethindrone acetate to reduce frequency of bleeding. A new ring containing 3-keto-desogestrel is under evaluation. The use of subdermal implants containing levonorgestrel is currently a popular and highly effective method of long-term contraception. Studies show that gonadotropin-releasing hormone agonists and antagonists can provide ovarian suppression, and antiprogestins such as RU486 effectively block the midcycle gonadotropin surge. These and other novel methods of hormonal contraception are still years away from general use.

Recency, duration, and progestin content of oral contraceptives in relation to the incidence of endometrial cancer (Washington, USA)

Women who have used combined oral contraceptives (COC) have a reduced risk of endometrial cancer relative to that of women who have never used oral contraceptives, but it is unclear whether the size of the reduction is influenced by the progestin content of the preparation. We analyzed data from two population-based case-control studies of endometrial cancer to investigate this question. Among women aged 40 to 59 years who were residents of King or Pierce Counties, Washington (United States), incident cases who were diagnosed during 1975-77 or 1985-87 were identified. Personal interviews were conducted with 316 such women and their responses compared with those of 501 controls who were selected by household surveys or random-digit dialing. A reduced risk of endometrial cancer associated with COC use was present only among users of five or more years' duration, and even then only in women who were not long-term users of unopposed postmenopausal estrogens. Among these women, the relative risk (RR) of endometrial cancer did not differ according to the progestin potency of the COC used: it was equally low for women who had used a COC with low progestin content (RR = 0.2, 95 percent confidence interval [CI] = 0.1-0.8) as for women who had used a COC with high progestin content (RR = 0.3, CI = 0.1-0.9). Our results argue that, if the reduced risk of endometrial cancer in long-term users of COCs is due to the progestins contained in these preparations, that amount of progestin in most COCs exceeds the threshold amount needed to produce this beneficial effect.

Oral contraceptives and breast disease

Epidemiologic data support the hypothesis that the types of OCs used before the mid-1970s protected against most forms of benign breast disease. It is unclear whether current low-dose progestogen OCs will confer the same protection. Further studies are necessary to clarify this. For breast cancer, the relationship is more complex. It is possible that prolonged use of high-dose OCs exert a small increased risk for breast cancer development in women before age 45. Furthermore, prolonged use before a first term pregnancy may result in a small increase in risk for breast cancer before age 45. Studies evaluating the effect of current low-dose OCs are necessary to elucidate what, if any, effect they may have on breast cancer development. Furthermore, as our population ages, studies will be able to determine what effect, if any, may be present in women over age 60, those women with the highest underlying risk of breast cancer. And finally, more research of basic breast tissue physiology and the effect of endogenous and exogenous hormones on this complex organ is needed.

Oral contraceptives and neoplasia of the uterine corpus

Effects of oral contraception on neoplasia of the uterine corpus are reviewed on the basis of epidemiologic studies reported to date. A duration-related protective effect against endometrial cancer occurs from use of combined oral contraceptives, those in which each active pill contains both estrogen and progestogen. The risk before age 60 years is reduced by about 38% with two years of use; use of combined OCs for 4, 8, and 12 years, respectively, confers an estimated 51%, 64%, and 70% reduction in endometrial cancer risk. The protective effect appears not to be diminished by discontinued use, even 15 or more years after stopping. Whether protection continues throughout the entire postmenopausal period, even in the presence of long-term hormone replacement therapy, remains to be seen. Use of combined OCs may protect against uterine leiomyomas ("fibroids"), but the evidence is not conclusive. The few findings about effects of oral contraception on the risk of adenomatous hyperplasia are of uncertain validity. Only one study, with few patients, has considered oral contraception in relation to uterine sarcomas.

Estrogenic effect of gestodene- or desogestrel-containing oral contraceptives on lipoprotein metabolism

In a randomized comparative study, changes in lipoprotein metabolism during the use of two low-dose oral contraceptives with similar doses of ethinyl estradiol but with different progestogenically active compounds were evaluated for their effective estrogen/androgen balance. Sixty-eight healthy women who did not take hormonally active drugs or were pregnant the previous 3 months took either 75 micrograms of gestodene + 30 micrograms of ethinyl estradiol or 150 micrograms of desogestrel + 30 micrograms ethinyl estradiol during 12 cycles. During the first three cycles serum levels of the following parameters increased: triglycerides, cholesterol in high-density lipoprotein, and apolipoproteins A1, A2, and B. Additional increase was observed in apolipoprotein B only after three and six cycles. The induced changes were not significantly different in the two groups, and the levels generally remained within normal limits. The changes seen with both pills reflect a mild estrogenic dominance. On the basis of current knowledge, moderately altered lipoprotein metabolism is not expected to impose an extra risk of atherosclerosis.

Bleeding patterns with low-dose, monophasic oral contraceptives

Cycle control over 12 months with low-dose oral contraceptives (OCs) was analyzed using calendars of bleeding on pill-taking days 1 through 21 (intermenstrual bleeding; IMB). One preparation contained 0.5 mg norethindrone and 0.035 mg ethinyl estradiol (NET + EE), the other 0.3 mg norgestrel and 0.03 mg ethinyl estradiol (Ng + EE). Half the subjects had previously used OCs containing greater than or equal to 0.05 mg estrogen (switch-over); the others had not previously used OCs for 2 months or more (fresh). Fresh subjects reported more IMB than switch-over subjects, especially during the first three cycles; IMB decreased over time for both groups. Ng + EE subjects had fewer IMB episodes during the early cycles than NET + EE subjects. Daily incidence of IMB formed a characteristic W-shaped curve in the NET + EE subjects that was most apparent in early cycles.

Oral contraceptive use and the risk of chlamydial and gonococcal infections

Oral contraceptive users were compared with nonusers with respect to the rate of cervical infections by Chlamydia trachomatis and Neisseria gonorrhoeae. The comparison was adjusted for differences in demographic and behavioral characteristics between the two groups. The rates of infection among oral contraceptive users were increased by approximately 70% (statistically significant) for both pathogens. Cervical ectopy was implicated in the increased rate of chlamydia but not gonorrhea. Rates of gonorrheal infection differed significantly among oral contraceptive formulations; rates were higher for formulations containing more androgenic progestins.

Oral micronized progesterone. Bioavailability pharmacokinetics, pharmacological and therapeutic implications--a review

Progesterone (P), the natural hormone, binds to its specific receptors to induce specific progestational effects. In addition to this binding, P is able to interfere with the binding sites of other steroids. Therefore the natural hormone exhibits an anti-estrogenic activity, and anti-androgenic activity and also exerts anti-mineralocorticoid effects. For a long time progesterone could not be used in clinical applications because of a rapid liver inactivation after oral administration. An oral micronized preparation of progesterone is now available which produces adequate plasma and tissue levels of progesterone. The preparation reproduces the anti-estrogenic effect of the natural hormone on the endometrium at the dose of 200 mg daily. It also reproduces the anti-mineralocorticoid effect and has no androgenic action. No side effects have been reported as far as lipids profile, coagulation factors and blood pressure are concerned. Therefore oral micronized progesterone appears suitable for hormonal replacement therapy in various areas, essentially postmenopause therapy, premenstrual syndrome, correction of irregular cycles and pregnancy maintenance.

A case-control study of oral contraceptive use in women with adenocarcinoma of the uterine cervix

To evaluate oral contraceptive (OC) use as a possible cause of the changed ratio between adenocarcinoma and squamous cell carcinoma of the uterine cervix a case-control study was performed. The OC use among 23 women with adenocarcinoma of the uterine cervix was compared with that of a matched group of 46 women with squamous cell carcinoma. No differences in percentage of OC use, duration of such use or period of OC use in relation to diagnosis could be demonstrated between the two groups compared.

Suppression of reproductive function in autoimmune NZB/W mice: effective doses of four contraceptive steroids

Oral contraceptives have been implicated in causing flares of systemic lupus erythematosus in humans, and studies of these agents in the NZB/W mouse model of lupus may help to elucidate mechanisms responsible for disease activation. To define doses which effectively suppress reproductive function in NZB/W mice, we implanted groups of NZB/W females with Silastic capsules containing increasing doses of four compounds: norethindrone (NE) 0.5-5.0 mg, norgestrel (NG) 1.0-7.5 mg, medroxyprogesterone (MP) 0.5-20.0 mg, and ethinyl estradiol (EE) 0.5-5.0 mg. Controls received empty implants. Serum concentrations of LH and FSH, uterine weight, endometrial proliferation, and luteal tissue were assessed after 3 weeks of treatment. Based upon these parameters, we determined that effective doses were 5.0 mg NE, 7.5 mg NG, and 0.5 mg EE given as single implants and 10.0 mg MP given in two 5.0-mg implants. This is the first dosing study of contraceptive steroids in a murine model of lupus. Effective, nontoxic doses of these drugs can now be employed in studies of interactions between gonadal hormones and autoimmunity.

Breast cancer and oral contraceptives: a review

The relationship between oral contraceptive use and breast cancer was investigated in 22 major epidemiological studies, which are reviewed in this paper. The overall risk ratio was never found to increase when computed among all users vs. nonusers. Risk increases were found in some studies within specific subgroups; but in general, if any risk exists, it is not much more than one. Future studies should focus specifically on women under age 25, on women before a first full-term pregnancy and, to a lesser extent, on perimenopausal women and on women who have had a benign breast disease.

Relative potency of progestins used in oral contraceptives

Epidemiologic studies indicate that the risk of complications with oral contraceptive use is related to the steroid content and potency of the various formulations. This paper summarizes human data in which potencies of progestins in oral contraceptives can be compared. Data on delay of menses and endometrial subnuclear vacuolization, an indirect assessment of glycogen deposition, are presented. The relative effects of various progestins on serum lipids and lipoproteins are also summarized. The object of this review is to examine the available scientific evidence which generally supports the conclusion that there is a marked similarity of potency of the dose of various progestins used in many of the formulations currently available in the U.S. The progestins norethindrone, norethindrone acetate and ethynodiol diacetate are roughly equivalent in potency while norgestrel is roughly five to ten times and levonorgestrel ten to 20 times as potent.

Oral glucose tolerance and the potency of contraceptive progestins

Two-hour oral glucose tolerance test results from the Walnut Creek Contraceptive Drug Study, a 10-year prospective follow-up study on the metabolic and medical effects of the "pill," were analyzed to determine the contribution of six progestins and synthetic estrogen to an observed decrease in glucose tolerance. Glucose tolerance data and specific oral contraceptive formulation data were obtained for 354 oral contraceptive users and 1732 nonusers. Multiple linear regression analyses, using age, body mass index, and specific progestin and estrogen dosages as independent variables, were undertaken to define dose-response relationships between the contraceptive steroids and fasting, 1-hr and 2-hr glucose values. The results of these analyses were consistent with the observation that the mean 1- and 2-hr values were higher in users of the "pill." The 16% prevalence of impaired glucose tolerance in pill users was substantially higher than that of 8% in the nonusers. Examination of the regression coefficients suggested that one progestin (norgestrel) was more metabolically "potent" than the others. The remaining progestins appeared to have either a modest or no metabolic effect, in terms of 1- and 2-hr glucose values. Synthetic estrogens were shown not to be related to measures of glucose tolerance.

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.

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.

Progestogens and arterial disease--evidence from the Royal College of General Practitioners' study

In the course of a large-scale prospective study of the health of oral contraceptive users, the rate of reporting of arterial diseases was examined in two groups of users of pill brands that permitted the effect of the progestogen to be assessed independently of estrogen effect. The rate of reporting was consistently higher with the brands with the higher progestogenic activity. The reports of cerebrovascular diseases showed a significant trend in relation to the dose of norethindrone acetate as well as in relation to total arterial diseases. Total arterial diseases were also reported more frequently in association with brands containing 250 microgram of levonorgestrel than with those containing 150 microgram of this progestogen. The mean serum levels of high-density lipoprotein cholesterol in users of the brands described show a striking inverse relationship to the rate of reporting of arterial diseases and to the progestogenic activity of the pills.

Serum high-density-lipoprotein cholesterol in women using oral contraceptives, estrogens and progestins

To determine the associations between high-density-lipoprotein cholesterol levels and use of oral contraceptives or of noncontraceptive estrogens and progestins we analyzed the serum levels of this lipid in 4978 women, 21 to 62 years of age. In estrogen users, the mean level was 6.7 to 15.1 mg per deciliter above the nonuser level (P less than 0.001), whereas in a group of progestin users it was 15.8 mg per deciliter below (P less than 0.001). In women using combination oral contraceptives, the level varied with the type and dose of the component steroids, in general increasing with increasing dose of estrogen and decreasing with increasing dose or potency of progestin. Thus, the net effect of use of a combination oral contraceptive on high-density-lipoprotein cholesterol depends on its formulation.