Lipid metabolism effects with desogestrel-containing oral contraceptives

Variations in lipid levels according to menstrual cycle phase: clinical implications

Understanding variations in lipoprotein cholesterol levels throughout the menstrual cycle is important because there may be clinical implications regarding the appropriate timing of measurement and implications on the design and interpretation of studies in women of reproductive age. Our objective was to review the evidence comparing lipoprotein cholesterol levels throughout the menstrual cycle among premenopausal women. Overall, lipoprotein cholesterol levels were observed to vary in response to changing estrogen levels. Taken together, the evidence suggests that total cholesterol and LDL-C tend to be highest during the follicular phase and to decline during the luteal phase, with HDL C highest around ovulation. Based on these findings, the menstrual cycle phase should be taken into account when evaluating lipoprotein cholesterol levels among reproductive-aged women. Measuring cholesterol levels during menses is recommended for consistent comparisons as this phase can be more reliably identified than other phases, although women within National Cholesterol Education Program acceptable ranges, but near the boundaries when tested during menses, should undergo additional tests.

Influence of a new oral contraceptive with drospirenone on lipid metabolism

The present study aimed to evaluate the effect of an oral contraception formulation with drospirenone (Yasmin) on lipid metabolism. An open-label, non-comparative clinical trial was conducted. One hundred women, who desired oral contraception for at least 6 months, were recruited. The subjects received a blister pack which contained 21 tablets of 3 mg drospirenone/30 mug ethinyl estradiol for the first four cycles (1 cycle = 28 days). Cycle 5 and 6 blister packs were dispensed during the next visit in cycle 4. Serum from each subject was collected and analyzed for lipid profile levels at baseline and at cycle 6. The mean differences in lipid profile levels at cycle 6 compared with baseline were assessed. Of the total 100 subjects, 92 (92%) completed the study. There was no significant change in total cholesterol. At cycle 6, high-density lipoprotein cholesterol (HDL-C) and triglycerides increased significantly by 25.7% and 42.0%, respectively, compared with baseline. However, low-density lipoprotein cholesterol (LDL-C) decreased significantly by 9.9% at cycle 6 compared with baseline. Our results show that the new oral contraception formulation with drospirenone (Yasmin) is well tolerated and has good contraceptive efficacy. The observed favorable changes in HDL-C and LDL-C suggest a potential cardioprotective benefit.

Effects of two combined oral contraceptives containing ethinyl estradiol 20 μg combined with either drospirenone or desogestrel on lipids, hemostatic parameters and carbohydrate metabolism

OBJECTIVE

To compare the effect of ethinyl estradiol 20 microg/drospirenone 3 mg (EE 20 microg/DRSP 3 mg) administered according to a 24/4 regimen with ethinyl estradiol 20 microg/desogestrel 150 microg (EE 20 microg/DSG 150 microg) administered according to the conventional 21/7 regimen on lipid, carbohydrate and hemostatic parameters.

STUDY DESIGN

In this open-label study, healthy women were randomized to EE 20 microg/DRSP 3 mg or EE 20 microg/DSG 150 microg for seven cycles. Mean differences in high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol levels at cycle 7 compared to baseline were assessed. Secondary variables included changes in other lipid, hemostatic and carbohydrate parameters.

RESULTS

Both treatments increased HDL-cholesterol, but decreased LDL-cholesterol by a comparable extent. Although slightly elevated in both groups, blood glucose and C-peptide levels measured during oral glucose tolerance tests were within normal reference ranges at cycle 7. Overall, the differences in lipid, hemostatic or carbohydrate parameters were not significant between the two treatments.

CONCLUSION

EE 20 microg/DRSP 3 mg has a good safety profile comparable with EE 20 microg/DSG 150 microg.

Enhancing oral contraceptive success: the potential of new formulations

Reductions in oral contraceptive (OC) estrogen dose and the development of new progestins have resulted in formulations that maintain acceptable cycle control while improving safety. However, the potential safety benefits of low-estrogen doses may be offset by less acceptable cycle control. These observations have led to the development of 2 triphasic OC formulations containing norgestimate and desogestrel in combination with 25 microg ethinyl estradiol (EE). Both of these 25-microg EE triphasic OCs balance fewer estrogen-related side effects with good cycle control comparable to OCs containing higher estrogen doses. However, questions remain about the risk of venous thromboembolism associated with OCs containing desogestrel. A new monophasic 30-microg EE OC contains drospirenone, a spironolactone analogue with which there is limited experience. Although initial data with this OC are intriguing, product labeling highlights safety issues related to its antimineralocorticoid effects and the potential for hyperkalemia. Further experience with this formulation will determine its role in contraceptive practice.

Effect of second and third generation oral contraceptives on lipid metabolism in the absence or presence of the factor V Leiden mutation

OBJECTIVES

The effect of a second and third generation oral contraceptive and of the progestagens used in these pills on lipid metabolism was studied in the absence or presence of the factor V Leiden mutation.

DESIGN

A single centre, double blind randomized trial.

SETTING

University Medical Centre.

SUBJECTS

A total of 51 women without and 35 women with the factor V Leiden mutation.

INTERVENTIONS

A second generation (30 microg ethinylestradiol/150 microg levonorgestrel) or a third generation (30 microg ethinylestradiol/l 50 microg desogestrel) oral contraceptive. After two cycles of use and a wash-out period of two cycles, the participants received the corresponding progestagen-only preparation containing 150 microg levonorgestrel or 150 microg desogestrel.

MAIN OUTCOME MEASURES

Mean difference in changes between the treatment groups on total cholesterol, HDL, LDL, triglycerides and total/HDL cholesterol ratio.

RESULTS

Compared with levonorgestrel, desogestrel-containing oral contraceptives caused in women without the factor V Leiden mutation significant changes in HDL (0.43; 95% confidence interval [CI] 0.25-0.61), LDL (-0.55; 95% CI -0.90 to -0.20), triglycerides (0.19; 95% CI 0.06-0.32) and total/ HDL cholesterol ratio (-0.87; 95% CI -1.21 to -0.53). When the progestagen-only preparations were used, differential changes were found for HDL (0.16; 95% CI 0.03-0.29), LDL (-0.31; 95% CI - 0.56 to -0.05) and total/HDL cholesterol ratio (-0.55; 95% CI -0.84 to -0.26). Desogestrel-only caused changes opposite to those of desogestrel-containing oral contraceptives. For cholesterol and triglycerides, this effect was also found for levonorgestrel-only in comparison with levonorgestrel-combined oral contraceptives. Levonorgestrel appeared to induce the effect on HDL. Almost all results were similar for women with the factor V Leiden mutation.

CONCLUSION

It appears that desogestrel counteracts the effects of oestrogens to a lesser extent than levonorgestrel. Desogestrel-containing oral contraceptives have therefore a more favourable influence on cholesterol metabolism in comparison with levonorgestrel-containing oral contraceptives.

The effects of nomegestrol acetate subdermal implant (Uniplant) on serum cholesterol, triglycerides, and lipoproteins in Nigerian users

The study was conducted to assess the effects of a nomegestrol acetate subdermal contraceptive implant (Uniplant(R)) on the lipid profiles of indigenous Nigerian women. Cholesterol content of the major lipoproteins, along with total cholesterol and triglycerides, were measured in fasting blood samples collected before implant insertion and then at months 1, 3, 6, and 12 of use. All volunteers were of the reproductive age, healthy, and had no contraindications to hormonal contraception. The mean levels of cholesterol and low density lipoprotein-cholesterol (LDL-C) increased gradually, albeit insignificantly, from insertion to month 12 of implant use. An initial decline in the mean levels of high density lipoprotein-cholesterol (HDL-C), reaching a minimal level (37.31 +/- 4.95 mg/dl) at month 3 of implant use, was observed. This was followed by a gradual rise that peaked (39.73 +/- 5.53 mg/dL) at month 12. These values were, however, not significantly different from the preinsertion value. The only significant difference (p <0. 005 ) was in the mean level of triglycerides at month 12 (90.90 +/- 17.75 mg/dL) when compared with the preinsertion mean level of 81.77 +/- 24.14 mg/dL. Both values were, however, within normal limits. These results indicate that Uniplant does not have a deleterious effect on the lipid profiles of Nigerian acceptors and can be safely prescribed to women seeking contraception.

Multicenter study of endocrine function and plasma lipids and lipoproteins in women using oral contraceptives containing desogestrel progestin. UK Desogen Study Group

We assessed endocrine function and plasma lipid and lipoprotein concentrations in 112 women given a monophasic oral contraceptive containing 30 micrograms ethinyl estradiol and 150 micrograms desogestrel. These women were participating in a larger trial of cycle control and safety. Plasma concentrations of gonadotrophins, estradiol, and progesterone fell over the 18 months of this study, consistent with suppression of the hypothalamic-pituitary-ovarian (HPO) axis. There was no consistent effect on plasma prolactin concentrations. Concentrations of total triiodothyronine, thyroxine, and cortisol increased, tracking increases in their binding proteins. Within 6 months, plasma total cholesterol concentrations had increased by 12% (p < 0.001) with no effect on those of low density lipoproteins. Concentrations of triglycerides and high-density lipoprotein cholesterol increased by 79% and 14%, respectively (both p < 0.001). Monophasic ethinyl estradiol/desogestrel effectively suppressed the HPO axis. Other endocrine changes were typical of oral contraceptives containing ethinyl estradiol. The increase in triglyceride concentrations is not considered to increase cardiovascular risk, whereas the increase in high-density lipoproteins may be protective.

Migraine and oral contraceptives

Initiation of oral contraceptive (OC) therapy in migraine may worsen pre-existing migraine or change the pattern of the individual migraine attacks. Many women experience no change in their migraine and a few show improvement. Evidence is accumulating that migraine increases ischemic stroke risk and that this risk is higher in migraine with aura than in migraine without aura. OCs also increase stroke risk, and the increased stroke risk attributable to each of migraine and OC therapy may be additive. The risk of ischemic stroke in young women is very low and likely remains acceptably low in young women with migraine without aura and in those with a simple migraine aura when OCs are prescribed. However, the presence of a complex or prolonged migraine aura, or of additional stroke risk factors such as increased age, smoking, and hypertension likely increases the ischemic stroke risk further in patients with migraine when OCs are prescribed. Whether OCs can be prescribed safely for the patient with migraine depends upon many factors including patient age, type of migraine, and the presence or absence of other stroke risk factors.

Desogestrel, norgestimate, and gestodene: the newer progestins

OBJECTIVE

To review and compare the newer progestins desogestrel, norgestimate, and gestodene with regard to chemistry, pharmacokinetics, efficacy, and tolerability.

DATA SOURCES

Primary literature on desogestrel, norgestimate, and gestodene was identified from a comprehensive MEDLINE English-literature search from 1984 through 1994, with additional studies selected by review of the references. Indexing terms included progestins, desogestrel, gestodene, norgestimate, levonorgestrel, and norgestrel.

STUDY SELECTION

Only human clinical and pharmacokinetic trials performed in Europe, Canada, and the US were included.

DATA EXTRACTION

All available data from human studies were reviewed; both comparative and noncomparative studies were included because of the paucity of direct comparative information available.

DATA SYNTHESIS

The newer progestins were designed to minimize the adverse effects (e.g., acne, hirsuitism, nausea, carbohydrate and lipid metabolism changes) observed with older oral contraceptives (OCs) while maintaining efficacy and good menstrual cycle control. Desogestrel, norgestimate, and gestodene have minimal amounts of androgenicity and antiestrogenic potential. All of these agents are pharmacokinetically similar to older agents: they are highly bioavailable when administered orally, hepatically metabolized, and obtain steady-state concentrations after 8-10 days of continuous administration. The newer agents have similar Pearl Indexes and slightly better cycle control. Furthermore, the new progestins appear to cause fewer adverse effects, such as acne and hirsuitism, and similar rates of weight gain, blood pressure changes, and lipid and carbohydrate metabolism changes.

CONCLUSIONS

Desogestrel, norgestimate, and gestodene appear to offer clinical advantages because of their decreased androgenicity. Women whose cycles are currently well controlled with other OCs should not be switched to a newer progestin. However, any of the combination OC products that contain these progestins may be prescribed for women intolerant of older agents or to first-time users of OCs. The newer progestins appear to be efficacious and offer similar cycle control, improved safety and tolerability profiles, and comparable price with the older agents.

Influence of oral contraceptive use on lipoprotein (a) and other coronary heart disease risk factors

We have studied the influence of oral contraceptive use on lipoprotein (a) levels in a cohort of women aged 18, 21 and 24 years (n = 559). Data was available on oral contraceptive formulation and dosage, anthropometric variables, exercise, serum lipoprotein (a), insulin, lipid and apolipoprotein levels. Lipoprotein (a) was determined by radioimmunoassay. Differences were assessed with non-parametric statistical methods. Forty per cent of the study women used oral contraceptives. The use of desogestrel-containing monophasic preparations was associated with lower levels of lipoprotein (a) compared to triphasic/levonorgestrel formulations or to non-users (P = 0.005). This effect was seen only in non-smoking women. Oral contraceptive users had higher levels of serum apolipoprotein B, HDL3-cholesterol, apolipoprotein A-I, triglycerides and systolic blood pressure, and lower serum lecithin:cholesterol acyltransferase activity. Lifestyle factors (smoking, exercise) showed no significant influence on lipoprotein levels. In conclusion, the use of desogestrel-containing oral contraceptives has a marked lowering effect on lipoprotein levels. Prospective studies will be needed to assess the net influence of oral contraceptive use on cardiovascular health.

Androgenic effects of oral contraceptives: implications for patient compliance

Androgenic disorders have many negative physical effects. These effects may be caused by excess androgen (exogenous or endogenous) or by end-organ sensitivity to normal levels of androgens. Historically, androgenic progestins in oral contraceptives have also been associated with some of these negative effects. The most apparent signs of androgen excess are the external manifestations, including oily skin, acne, hirsutism, android obesity, and androgenic alopecia. Of equal concern are the potential metabolic disturbances associated with hyperandrogenicity. Unfavorable lipid profiles and increased incidence of diabetes and hypertension are very real threats to long-term health. In oral contraceptive users, external manifestations of androgenicity often lead to poor compliance, decreased efficacy, and discontinuation of oral contraceptive use, especially in the younger patient. With the introduction of the newer oral contraceptive formulations containing less androgenic progestins (norgestimate, desogestrel, gestodene), androgen-related effects have been reduced and better compliance is anticipated.

Clinical and metabolic features of desogestrel: a new oral contraceptive preparation

Desogestrel is a highly selective gonane progestin. A monophasic formulation containing 150 micrograms of desogestrel and 30 micrograms of ethinyl estradiol has recently been approved as an oral contraceptive (OC) in the United States. Although desogestrel-containing formulations are new to the United States, they have been the most widely prescribed OCs in Europe for almost 10 years. An extensive literature demonstrates that desogestrel-containing preparations are safe, effective, and well tolerated by most women. In light of desogestrel's high selectivity, low affinity for androgen receptors, and lack of interference with the increase in sex hormone-binding globulin, desogestrel-containing OCs may be particularly appropriate for women with androgen-induced skin disorders because of their high selectivity. Several European studies have found significant improvement or almost complete resolution of previously existing acne. Desogestrel provides excellent cycle control, no major impact on weight, minimal or no adverse effects on blood pressure, statistically significant increases in high-density lipoprotein cholesterol with low-density lipoprotein cholesterol usually unchanged or reduced, and little effect on glucose tolerance or insulin resistance.