Phasic contraceptive pills and functional ovarian cysts

A review of ovary torsion

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Oral contraceptive use and mortality after 36 years of follow-up in the Nurses' Health Study: prospective cohort study

OBJECTIVE

To determine whether use of oral contraceptives is associated with all cause and cause specific mortality.

DESIGN

Prospective cohort study.

SETTING

Nurses' Health Study, data collected between 1976 and 2012.

POPULATION

121,701 participants were prospectively followed for 36 years; lifetime oral contraceptive use was recorded biennially from 1976 to 1982.

MAIN OUTCOME MEASURES

Overall and cause specific mortality, assessed throughout follow-up until 2012. Cox proportional hazards models were used to calculate the relative risks of all cause and cause specific mortality associated with use of oral contraceptives.

RESULTS

In our population of 121,577 women with information on oral contraceptive use, 63,626 were never users (52%) and 57,951 were ever users (48%). After 3.6 million person years, we recorded 31,286 deaths. No association was observed between ever use of oral contraceptives and all cause mortality. However, violent or accidental deaths were more common among ever users (hazard ratio 1.20, 95% confidence interval 1.04 to 1.37). Longer duration of use was more strongly associated with certain causes of death, including premature mortality due to breast cancer (test for trend P<0.0001) and decreased mortality rates of ovarian cancer (P=0.002). Longer time since last use was also associated with certain outcomes, including a positive association with violent or accidental deaths (P=0.005).

CONCLUSIONS

All cause mortality did not differ significantly between women who had ever used oral contraceptives and never users. Oral contraceptive use was associated with certain causes of death, including increased rates of violent or accidental death and deaths due to breast cancer, whereas deaths due to ovarian cancer were less common among women who used oral contraceptives. These results pertain to earlier oral contraceptive formulations with higher hormone doses rather than the now more commonly used third and fourth generation formulations with lower estrogen doses.

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.

Contraceptive needs of the perimenopausal woman

Although there are many definitions of the perimenopause, all include the concept of transition from physiologic ovulatory menstrual cycles to hyperestrogenic anovulation and ultimately to hypoestrogenic ovarian shutdown. With this comes a transition from childbearing, and its requirement for contraception, to the infertility of menopause. There is no contraceptive method that is contraindicated merely by age. The contraceptive needs of the perimenopausal woman, however, may be better suited to some methods over others. This article explores various methods of contraception for the perimenopausal woman, including female sterilization, barrier methods, intrauterine devices, injectables, implants, and oral contraceptives.

Descriptive studies: what they can and cannot do

Descriptive studies often represent the first scientific toe in the water in new areas of inquiry. A fundamental element of descriptive reporting is a clear, specific, and measurable definition of the disease or condition in question. Like newspapers, good descriptive reporting answers the five basic W questions: who, what, why, when, where. and a sixth: so what? Case reports, case-series reports, cross-sectional studies, and surveillance studies deal with individuals, whereas ecological correlational studies examine populations. The case report is the least-publishable unit in medical literature. Case-series reports aggregate individual cases in one publication. Clustering of unusual cases in a short period often heralds a new epidemic, as happened with AIDS. Cross-sectional (prevalence) studies describe the health of populations. Surveillance can be thought of as watchfulness over a community; feedback to those who need to know is an integral component of surveillance. Ecological correlational studies look for associations between exposures and outcomes in populations-eg, per capita cigarette sales and rates of coronary artery disease-rather than in individuals. Three important uses of descriptive studies include trend analysis, health-care planning, and hypothesis generation. A frequent error in reports of descriptive studies is overstepping the data: studies without a comparison group allow no inferences to be drawn about associations, causal or otherwise. Hypotheses about causation from descriptive studies are often tested in rigorous analytical studies.

Oral contraceptive use and benign gynecologic conditions. A review

The following review considers the main epidemiologic data on oral contraceptives (OC) and the risk of major benign gynecologic diseases. Earlier studies investigating the relationship between OC use and functional ovarian cysts indicated that the use of high-dose combination OC have a protective effect, whereas low-dose monophasic or multiphasic pills have little or no effect. With regard to seromucinous cysts, the scanty data available are consistent with the notion of some protection of OC in current but not in former users, although possible effects of diagnostic and selection bias should be considered. Published data on the relationship between fibroids and OC appear too scattered to allow a precise quantification of risk. In any case, any relationship is moderate and, hence, of limited clinical and public health relevance. The data on OC and benign gynecologic conditions are reassuring in their absence of any consistent excess risk.

Inhibition of follicular growth by two different oral contraceptives (monophasic and triphasic) containing ethinylestradiol and gestodene

OBJECTIVE

To evaluate the inhibition level of ovarian follicular growth produced by a triphasic oral contraceptive (OC) containing ethinylestradiol and gestodene vs. the level produced by a monophasic OC containing the same components.

METHODS

A randomized, blind, cross-over trial was performed in a sample of 56 women. The follicular diameters were measured in 56 cycles under triphasic contraceptive treatment, and the other 56 under monophasic contraceptive treatment, using vaginal ultrasound. The statistical analysis was performed using the Student's t test.

RESULTS

The mean follicular diameter under monophasic OC treatment was found to be 8.16 mm (standard deviation 4.5), and while under triphasic OC treatment was found to be 7.44 mm (standard deviation 2.8) (p > 0.05). In 17 out of 112 cycles (15%), a certain degree of follicular activity was found (follicular diameter more than 10 mm), 10 cycles under monophasic OC and 7 cycles under triphasic OC.

CONCLUSIONS

The triphasic OC provides good inhibition of follicular growth and excellent contraceptive efficacy.

A comparative randomized trial on the impact of two low-dose oral contraceptives on ovarian activity, cervical permeability, and endometrial receptivity

In a double-blind randomized study, the suppression of ovarian activity and anti-conceptive effects on the cervix and endometrium were assessed during administration of two low-dose monophasic oral contraceptives (20 micrograms ethinyl estradiol [EE], 500 micrograms norethisterone--Eve 20 [Grünenthal, Aachen, Germany]; 20 micrograms EE, 150 micrograms desogestrel --Lovelle [Organon, Munich, Germany]). One hundred eighteen healthy women (ages: 18-35 years) were studied in 10 investigation centers during medication with either Eve 20 (n = 59) or Lovelle (n = 59). During three treatment cycles, ovarian activity was evaluated by sonographic determination of follicle-like structures (FLS) and by simultaneous assessment of serum endocrine profiles (gonadotropins LH and FSH, ovarian steroids estradiol [E2] and progesterone [P]). While on either treatment, no ovarian activity (as judged by no FLS and/or reduced sex steroid levels) was found in 90.8% (Eve 20) and 97.2% (Lovelle) of all investigated cycles. Follicular activity or cyst formation were detected in 18 of 173 cycles (Eve 20) and in 5 of 175 cycles (Lovelle), respectively. Gonadotropin levels were suppressed (LH < 6 IU/L, FSH < 8 IU/L) in most treatment cycles (Eve 20 76.6% vs. Lovelle: 84.8%). Serum E2 concentrations exceeding 0.1 nmol/L indicated residual follicular activity in 19.3% (Eve 20) versus 12.2% (Lovelle) of all cycles. An estimated by serum P levels over 5 nmol/L, ovulation had presumably occurred in 4.1% (Eve 20) versus 2.9% (Lovelle) of treatment cycles. However, when the sonographical and endocrinological data were combined, no ovulation was documented in any pill cycle. The quality and quantity of the cervical mucus was found to be minimal in the majority of women. Moreover, the endometrial layer was determined to be low by ultrasound during most pill cycles, indicating equally strong suppressive effects on endometrial receptivity by the two contraceptives. These observations suggest that ovarian activity is suppressed in the majority of cycles during use of low-dose contraceptives. This effect may mainly be medicated by pronounced suppression of serum gonadotropin levels. Strong anti-conceptive effects of these formulations on both cervical permeability and endometrial receptivity are additional factors ensuring the contraceptive efficacy of these formulations.

Ovarian activity suppression by two different low-dose triphasic oral contraceptives

In an open, randomized study in an outpatient clinic of a large teaching hospital, thirty-one female volunteers with regular cycles and established ovulation by ultrasonography were given one of two triphasic oral contraceptives containing ethinylestradiol combined with levonorgestrel or desogestrel during six cycles of treatment. The main outcome measures were transvaginal ultrasonography and serum E2 and P measurements in pill cycles 1, 3 and 6. No ovarian activity was found in 10 subjects. Among the remaining 21 women who showed ovarian activity, most follicle-like structures developed in the pill-free week and decreased in size or disappeared in the first pill week. One women taking triphasic desogestrel had evidence of a luteinized unruptured follicle and one women taking triphasic levonorgestrel had a possible ovulation. The latter women also showed symptoms of lower abdominal pain. A statistically significant difference in ovarian activity between the two oral contraceptives could not be established. The two triphasic oral contraceptives suppressed ovarian activity to the same degree. A trend was seen towards increasing ovarian activity with duration of use in both treatment groups.

Enlarged follicles in women using oral contraceptives

Ultrasound examination of the ovaries was performed in the first and/or second half of three consecutive cycles in 3 groups of women; Group T who had been using a levonorgestrel triphasic oral contraceptive for at least 6 months, Group P who had been using a progestogen-only pill for at least 6 months, and Group C, a control group. Any follicles greater than 10 mm in diameter and any cysts were measured. Fifty-three scans were performed in Group T, 45 in Group P and 31 in Group C. Only 4 follicles were detected in 17 women in Group T compared to 10 follicles in 15 women in Group P and 7 follicles in the women in Group C; all follicles were 25 mm or less in diameter except for 3 follicles in 2 women. The differences between the groups were not statistically significant. Four enlarged follicles were detected in 3 women during 53 scans in Group T, 15 in 8 women (45 scans) in Group P, and only 1 in 31 scans in Group C. Based upon the proportions of scans with enlarged follicles, the difference between Groups T and P was statistically significant, indicating that the incidence of enlarged follicles was lower in women using a combined oral contraceptive than in those using a progestogen-only pill. Furthermore, the study shows that any enlarged follicles which occurred were transient.

Ovarian function during low-dose oral contraceptive use

Lowering the total steroid dose in modern oral contraceptives (OCs) has been connected with a higher incidence of ovarian follicle and cyst formation. To investigate the presence of ovarian follicles and cysts by means of vaginal ultrasonography and serum hormone determinations during use of two low-dose OCs, 65 volunteers were randomized to receive either 20 micrograms ethinylestradiol (EE) + 150 micrograms desogestrel (group A) or 35 micrograms EE + 250 micrograms norgestimate (group B) for a 2-month study period. At baseline, 39% of women in group A and 31% in group B exhibited at least one follicle < 35 mm in diameter. By the end of the second treatment cycle, the frequency of these follicles had decreased to 14% in each group. Only one subject in the higher estrogen group developed an ovarian cyst > 35 mm. One subject in each group demonstrated hormone levels characteristic of ovulation; no pregnancy occurred in either group. The 20 micrograms EE preparation was not found to lead more often to ovarian follicles or cysts when compared with a 35 micrograms EE preparation, possibly because of the type and dose of the progestogen used.

Combined oral contraceptives: do we know all of their effects?

Combined oral contraceptives are undoubtedly popular. By the end of the 1980's, an estimated 63 million married women around the world were using this method of contraception. In Britain, perhaps 95% of all sexually active women have used the pill at some time before their 30th birthday. Commensurate with such widespread usage, huge amounts of money have been spent during the past 35 years investigating the health effects of this method of contraception. Since it appears that all of the potential risks and benefits have now been identified, can we divert resources from pill-related research into new areas of activity. While this proposition may be attractive to funding bodies, and other researchers competing for increasingly scarce resources, it ignores the fact that several major uncertainties remain concerning the safety of combined oral contraceptives.

Expectant management of functional ovarian cysts: an alternative to hormonal therapy

OBJECTIVE

We studied whether the administration of oral contraceptives facilitates the disappearance of spontaneously formed functional ovarian cysts.

METHODS

Eighty patients in whom ultrasonography revealed unilateral, mobile, unilocular, thin-walled ovarian cysts without internal echoes and greater than 30 mm but not exceeding 60 mm in diameter were enrolled into the study. Patients were randomized by stratification to receive a low-dose monophasic pill, a high-dose monophasic pill, a multiphasic pill or no therapy. Patients were re-evaluated after 5 weeks of therapy and at the end of therapy (10 weeks).

RESULTS

The mean ages and the mean cyst diameters of the patients for each group were not significantly different. We did not find a significant effect of oral contraceptive administration on the disappearance rate of functional ovarian cysts over that of expectant management.

CONCLUSION

We conclude that oral contraceptive therapy even with multiphasic pills is very effective in the management of functional ovarian cysts but expectant management achieves similar success rates and may be a good alternative to oral contraceptive therapy.

Frequency and treatment of ovarian cysts in adolescence

Ultrasound examination of the ovaries was performed monthly in the follicular phase of 139 healthy adolescents for one year. In 17 girls (12.2%) ovarian cysts spontaneously disappeared within 3 months of first observation. In 6 subjects, treatment with the combined estrogen/progestogen pill was given. The treatment was effective in 4 girls after 2-6 months while 2 subjects required surgical intervention for a cystic teratoma and a simple follicular cyst respectively. A spell of serial sonographic observation of ovarian cysts would seem appropriate in adolescents.

Ultrasound evaluation of ovarian activity under oral contraceptives

The trend towards changing the composition of the contraceptive pill in order to decrease side effects might lead to increased ovarian activity. This may decrease reliability. Therefore, a non-invasive method for monitoring the suppressive effect of the pill on ovarian function is warranted. The aim of the present study was to investigate whether or not diagnostic ultrasound might be the method of choice for studying residual ovarian activity during pill use. In 89 women on a low-dose oral contraceptive (30 mcg ethinyl-estradiol (EE)/75 mcg gestodene), the first two months of pill-intake were monitored extensively with diagnostic ultrasound. The study revealed that only one ultrasound investigation was needed during the first week of pill intake to discover all relevant cases of residual ovarian activity. Follow-up investigations are needed to quantify this activity more specifically.

A randomized, double-blind, placebo-controlled comparison of the impact of low-dose and triphasic oral contraceptives on follicular development

OBJECTIVE

This investigation tests the hypothesis that triphasic oral contraceptives are associated with the development of large, persistent ovarian cysts.

STUDY DESIGN

Weekly vaginal ultrasonography was used in a randomized, double-blind, placebo-controlled, parallel-group, single-center study that compared the incidence, risk, size, and time to resolution of ovarian follicles in healthy women who took Estrostep or Loestrin oral contraceptives (manufactured by Parke-Davis) or a placebo during three consecutive menstrual cycles.

RESULTS

Sixty-three percent of placebo-treated subjects developed follicles greater than 18 mm, compared with 39% and 23% in the Estrostep and Loestrin groups. The risks for each group of developing a large follicle during a single cycle were not different. No dominant follicle persisted for greater than 2 weeks for any subject.

CONCLUSION

These results demonstrate that follicular development continues during treatment with oral contraceptives. In addition, the findings fail to support the hypothesis that triphasic oral contraceptives result in persistent ovarian cysts.

The safety of oral contraceptives: epidemiologic insights from the first 30 years

Because oral contraceptives are used by tens of millions of healthy women, their safety for short-term and long-term use is an important issue that has been examined in a large number of epidemiologic studies. These studies have become more rigorous and have increased in size and analytic sophistication over the years. Although breast cancer remains the most important safety concern, the bulk of recent data suggests that oral contraceptives have no overall impact on a woman's risk of developing this disease. The results are less clear on the risk of cervical cancer and its precursors because of methodologic problems. However, the newer oral contraceptive formulations no longer appear to be associated with an increased risk of myocardial infarction or stroke.

Oral contraceptive type and functional ovarian cysts

OBJECTIVE

We tested the hypothesis that multiphasic, low-dose monophasic, and high-dose monophasic oral contraceptives share a common protective effect against functional ovarian cysts.

STUDY DESIGN

We conducted a cohort study using the automatic files of Maine Medicaid to assemble a population of 7462 women between the ages of 15 and 44 who were prescribed an oral contraceptive between Jan. 1, 1987, and Dec. 31, 1988. We included as cases 32 women with a principal diagnosis of a functional ovarian cyst confirmed by medical records as being greater than 20 mm in diameter.

RESULTS

At comparison with the absence of an oral contraceptive prescription, we observed decreasing rates of functional ovarian cysts among women prescribed multiphasic pills (rate ratio 0.91, 95% confidence interval 0.3000 to 2.31), low-dose monophasic pills with less than or equal to 35 micrograms estrogen (rate ratio 0.52, 95% confidence interval 0.17 to 1.33), and high-dose monophasic pills with greater than 35 micrograms estrogen (rate ratio 0.24, 95% confidence interval 0.01 to 1.34).

CONCLUSIONS

The protective effect of oral contraceptives against functional ovarian cysts reported previously for high-dose monophasic pills may be attenuated with newer pills of lower hormonal potency.

Effects of intranasal administration of norethisterone on folliculogenesis, cervical mucus, vaginal cytology, endometrial morphology and reproductive-endocrine profile in women

The effects of intranasal administration of norethisterone (NET) on menstrual cycle length, folliculogenesis, serum levels of estradiol, FSH, LH and progesterone, vaginal cytology, cervical mucus and endometrial morphology were studied in 8 volunteers (age 28 to 39 years, weighing between 46 and 54 kg). The study period comprised 4 consecutive menstrual cycles. In the first cycle (pretreatment cycle), only the vehicle (alcohol, propylene glycol, water; 3:3:4) was sprayed intranasally (100 microliters in each nostril), using a metered nebulizer, once daily from day 3 to the last day of menstrual cycle. In the next two cycles (treatment cycles), NET (300 micrograms/day) was administered once daily, starting from day one of menstrual cycle, between 9 and 10 a.m. The fourth cycle was a post-treatment cycle in which the volunteers were monitored for recovery. Blood samples (about 5 ml each) were collected once daily from day 8 to 24 and thereafter on alternate days until the last day of cycle during all the 4 cycles. Levels of estradiol, FSH, LH and progesterone were measured in the serum samples by radioimmunoassay methods. Cervical mucus samples and vaginal smears were collected once daily starting from day 7 or 8 of each cycle until the mucus was very scanty. Serial pelvic ultrasonography was performed starting from day 7 or 8 until the growing follicle disappeared or throughout the cycle in case a growing follicular cyst was observed. Endometrial aspirates were collected once around day 22 in each cycle and processed for routine histological examination.

Trends in the content and use of oral contraceptives in the United States, 1964-88

Drug marketing and physician survey data were used to examine trends in the use and hormonal content of oral contraceptives in the United States between 1964 and 1988. Retail prescriptions for oral contraceptives peaked at approximately 68 million in 1973 and have remained between 50 million and 60 million since 1981. Despite this relative consistency in the number of prescriptions, physician "mentions" of oral contraceptives have increased by approximately 75 percent. This increase may reflect closer monitoring of women on oral contraceptives. Use of multiphasic formulations has steadily risen, accounting for 37 percent of the oral contraceptive prescriptions in 1988. Mean estrogen and progestin doses in all types of formulations have steadily declined. A change in the type of estrogen and progestin used in preparations has coincided with this decline in dose. The association between age and use of high-dose formulations seen in the past was no longer evident in 1988. The data demonstrate that oral contraceptive formulations in wide use today differ in hormone content from those of the past, when most of the major studies addressing the risks associated with oral contraceptive use were completed. There is therefore a need to determine the risks and long-term effects associated with these newer formulations.

Extending the duration of the pill-free interval during combined oral contraception

The effect of increasing the duration of the pill-free interval from 7 to 9 and 11 days during the first 4 months of combined oral contraceptive therapy was studied by hormonal, ovarian follicle and mucus changes. Increasing the pill-free interval allowed more follicular development and more estradiol production. In some cases, pre-ovulatory values were achieved although ovulation did not occur. No differences could be detected between different types of combined oral contraceptive, including monophasic, triphasic, levonorgestrel-containing and gestodene-containing. The variation between individuals in the group of 28 was far greater than any variation in dose.

Longitudinal ultrasonographic study of the ovarian suppressive activity of a low-dose triphasic oral contraceptive during correct and incorrect pill intake

A longitudinal study was conducted to evaluate the ability of a low-dose triphasic oral contraceptive to suppress ovulation as documented by frequent ultrasonographic scanning and progesterone determinations, even in the event of a missed pill. The extent of follicular growth and maturation, the incidence of escape ovulation, and the effect of correct and incorrect pill intake were assessed in 30 evaluable women during two consecutive spontaneous menstrual cycles. After the first cycle, 11 of 30 women (36.6%) had follicle-like structures of at least 10 mm in diameter. Ten of 11 structures gradually disappeared during the second cycle, with one persistent structure remaining through the second cycle. Seven of 30 women (23%) developed follicle-like structures during the second cycle. Of these, one woman had a probable ovulation, and another had an elevated progesterone level without follicle rupture, suggesting the luteinized unruptured follicle syndrome. Both of these women missed a pill on day 1 of the second cycle. In all cases cervical scores indicating hostility were noted. Thus, although suppression of ovarian activity may have been incomplete when oral contraceptives were incorrectly taken, secondary mechanisms of contraception remained operant. When they were correctly taken, low-dose triphasic oral contraception consistently prevented ovulation.

Ovarian follicles during oral contraceptive cycles: their potential for ovulation

Ovarian follicles of a preovulatory size were encouraged to develop by extending the pill-free period of combine, triphasic oral contraceptive (OC) cycles. Despite recommencement of OC therapy, most follicles continued to grow and then respond to gonadotropin administration by both rupture and luteinization. It is concluded that follicles developing during OC cycles have the potential for ovulation, but this is of doubtful clinical significance for the vast majority of women.

"Sunday start" multiphasic oral contraception: ovulation prevention and delayed follicular atresia in primates

Utilization of the "sunday start" method for oral contraceptive therapy can result in the initiation of oral contraceptive administration as late as day 6 of the ovarian/menstrual cycle. Potentially, "breakthrough" ovulations could occur due to rapid follicular progression, especially if the dominant follicle is overtly established prior to the onset of estrogen-progestin administration. Here, we examined the efficacy of two new oral contraceptive regimens on potential "breakthrough" ovulations in the first cycle of treatment begun on cycle days 1 or 6 in cynomolgus monkeys having normal menstrual cycles. Our endocrine findings show that follicular recruitment, and probably selection of the dominant follicle, had occurred by day 6 of the follicular phase. Both oral contraceptive treatments (Loestrin 5/7/9R, LoDose 5/7/9R, Parke-Davis) were effective in blocking preovulatory-like gonadotropin and estradiol surges as well as luteal phase progesterone elevations, whether treatment was begun on day 1 or day 6 of the menstrual cycle. Despite hormonal evidence of significant maturational progression, oral contraceptive administration successfully blocked the completion of follicular maturation, thereby sustaining contraceptive reliability, even in the initial cycle of treatment using a "sunday start" regimen. Under these conditions, dissolution of the failed dominant follicle within ovarian stroma may be characterized by delayed follicular atresia.