Contraceptive effectiveness of Silastic implants containing the progestin R-2323

Clinical Approaches to Nestorone Subdermal Implant Therapy in Women's Health

Segesterone acetate (SA) or Nestorone, a fourth-generation progestogen, is a synthetic compound with high progestational activity and no androgenic, glucocorticoid, or anabolic effects. However, due to its oral inactivity, SA must be used by other routes, such as subcutaneous. Thus, considering its peculiar properties, the SA subdermal implant is successfully used in female contraception and postmenopausal hormone replacement therapy (HRT). In recent years, its potential uses in endometriosis, polycystic ovaries syndrome (PCOS), and a new therapeutic possibility for neuroprotection have made this treatment extremely interesting. However, the absence of a standardized dose and the long-term safety of SA implant therapy in women is still controversial. Here, we present the possible indications, doses, limitations, and side effects of SA implant therapy.

Gestrinone in the treatment of uterine leiomyomata: effects on uterine blood supply

Gestrinone has been shown to reduce uterine volume and stop bleeding in women with uterine leiomyomata. In the present study, we demonstrated a reduction in the volume of uterine myomas and in the uterine artery blood perfusion over a 6-month period of gestrinone administration in premenopausal women.

Regression of uterine leiomyomas after treatment with gestrinone, an antiestrogen, antiprogesterone

Ninety-seven women, aged 18 to 53 years, with uterine leiomyomas diagnosed by bimanual palpation and ultrasonography, were treated for 4 to 13 months with gestrinone, a potent steroidal, antiestrogen, antiprogesterone. Thirteen women were less than 30 years old and six 50 years old or older. Forty-six women were 30 to 40 years old and 32 others were 40 to 50 years old. Sixty-one women were nulliparous. Patients were divided in a random fashion into three groups according to treatment schedule. In group A, 34 patients received capsules containing 5 mg of gestrinone twice weekly. In group B, 36 patients received 2.5 mg capsules three times weekly. In group C, 27 patients were instructed to insert 2.5 mg tablets in the vagina three times weekly. Uterine volume was measured by ultrasonography before and at the end of treatment. At the end of 4 months, uterine volume fell from 303 to 251 cm3 in group A, from 361 to 266 cm3 in group B, but increased from 371 to 387 cm3 in group C. For those patients treated for 10 (+/- 1) months, mean uterine volume fell from 368 to 282 cm3 in group A and from 384 to 327 cm3 in group B, but increased from 262 to 290 cm3 in group C. Mean uterine volume of patients who were treated for 13 (+/- 1) months also fell from 325 to 259 cm3 in group A, from 416 to 268 cm3 in group B, and from 406 to 399 cm3 in group C. Changes in uterine volume measured at the time of discontinuation for the various groups revealed volume decrease in 71 and increase or no change in 26. Differences between groups A, B, and C were statistically significant when comparisons were made at 4 and 13 months. Uterine bleeding ceased by the second month of treatment in half the patients initially complaining of menometrorrhagias. After 4 months of treatment, 95% of the women were amenorrheic. Hemoglobin increased in 85 of 90 patients for whom values were available before treatment began. Both dyspareunia and chronic pain were significantly reduced by the gestrinone treatment. Androgenic side effects such as seborrhea, acne, and hirsutism, whenever they occurred, were benign and reverted soon after discontinuing the medication.

Contraception with subdermal ST-1435 capsules: side-effects, endocrine profiles and liver function related to different lengths of capsules

One Silastic capsule of 15 mm, 20 mm or 30 mm length was inserted subcutaneously into the ventral aspect of the left forearm or upper arm of 28 healthy women during menstrual bleeding or not later than on the seventh day of the menstrual cycle. A new capsule of the same length was inserted after six months and both capsules were removed twelve months after the first insertion. Side-effects, including changes in body weight, blood pressure, menstrual bleeding and liver function test results, were registered. Blood samples were taken from selected subjects twice a week during the 1st, 2nd, 3rd, 6th, 7th and 12th month of use. Plasma concentrations of ST-1435 were measured by radioimmunoassay and the effects of treatment on pituitary and ovarian function were determined by assaying plasma concentrations of LH, FSH, estradiol and progesterone. There were no differences in hormonal side-effects between subjects who had a 30 mm capsule or subjects who had 20 mm or 15 mm capsules, but subjects who had 20 or 15 mm capsules had significantly longer bleeding or spotting periods in comparison with subjects who had a 30 mm capsule. There were no changes in blood pressure, body weight or liver function test results in comparison with pre-insertion values. The plasma level of ST-1435 was not significantly higher during the use of 30 mm capsules than during the use of 20 or 15 mm capsules. During the use of the shorter ST-1435 capsules, plasma estradiol elevation and slightly suppressed FSH were seen, while the use of longer capsules resulted in a slight suppression of LH. Progesterone concentrations during monitored cycles indicated anovulation. No pregnancies occurred during the study period of one year. The continuation rate at one year was 71% in the 30 mm capsule group and 57% in the 20 and 15 mm capsule groups taken together.

Anovulation, inadequate luteal phase and poor sperm penetration in cervical mucus during prolonged use of Norplant implants

Blood samples for progesterone assay were collected for a total of 49 cycles, from 27 volunteers using the NORPLANT system. Levonorgestrel determinations were carried out in the same samples. A group of 12 women with normal cycles were studied in the same manner to serve as controls. Of the 49 cycles studied, 20 (41%) were ovulatory. The mean levonorgestrel level in ovulatory patients was 0.34 +/- 0.11 ng/ml (S.D.) compared to 0.42 +/- 0.14 ng/ml (S.D.) in anovulatory cycles. Compared to the control group, progesterone levels were significantly lower for users of NORPLANT implants during days -12 to -10 (p less than 0.025), -9 to -7 (p less than 0.05), -6 to -4 (p less than 0.0005) and days -3 to -1 (p less than 0.01). Cervical mucus evaluations and post-coital tests were done around mid-cycle in 29 of the cycles studied. All samples of cervical mucus were of poor quality, viscous and scarce, with a mean SPK of 4.1 +/- 2.3 cm. Most had absent or atypical ferning. Twenty-one subjects (73%) had a post-coital score of 1, and 4 (14%) of zero. Thus, anovulation, inadequate luteal phase and the direct effect of the continuous administration of levonorgestrel over cervical function, all seem to contribute to the effectiveness of NORPLANT implants.

Treatment of fibrocystic disease of the breast with gestrinone, a new trienic synthetic steroid with anti-estrogen, anti-progesterone properties

Twenty-eight patients with radiologically diagnosed fibrocystic disease were given twice weekly 5 mg tablets of Gestrinone, a synthetic contraceptive steroid with potent anti-estrogen, anti-progesterone properties, for periods ranging from 3 to 9 months. Treatment was discontinued when the nodularity disappeared and the patient became asymptomatic. Twelve patients had palpable nodules or masses in both breasts, while the remaining 16 had a single nodule or lump. In 12 patients, all with small nodules or lumps, complete elimination of nodularity occurred at the end of the first 3 months of treatment. In a further eight patients, five of whom had small nodules and three of whom had large ones, an additional 3 months of therapy were required to achieve complete elimination of nodularity. In two subjects, nodularity was eliminated at the end of 9 months of therapy, and in the remaining six subjects, although a reduction in nodularity greater than 50% occurred, masses remained palpable at the end of 9 months. Pain and tenderness were eliminated during the first 2 weeks of therapy in most cases. The most common complaints were acne and seborrhea (70% of patients) and a weight gain of between 2 and 5 kg in patients treated for 9 months. Main side effects encountered were acne and seborrhea.

Contraception with levonorgestrel-releasing subdermal capsules, Norplant, after pregnancy termination

Six Silastic levonorgestrel-releasing capsules, Norplant, were introduced subcutaneously into the ventral aspect of the left forearm or upper arm of thirty-eight patients immediately after first trimester pregnancy termination. In the control group, a Nova-T device was inserted immediately after pregnancy termination in thirty patients. Clinical examination was performed after three, six and twelve months of use. The continuation of the Norplant at one year was 91.7 per cent and that of the Nova-T 73.9 per cent. No pregnancies occurred during the study period of one year. Hemoglobin concentrations and the diastolic blood pressures of the Norplant users increased significantly. Dysmenorrhea and menstrual flow increased in the IUD group. Menstrual disturbances were the main side effects in the Norplant group during the first five months of use.

Treatment of endometriosis with gestrinone (R-2323), a synthetic antiestrogen, antiprogesterone

Twenty patients with endometriosis diagnosed by laparoscopy were treated with the antiestrogen, antiprogesterone gestrinone (R-2323) for 6 to 8 months. The drug was administered in a dose of 5 mg twice weekly. According to the American Fertility Society's classification of endometriosis, five patients were classified as having mild (Stage I), eight as having moderate (Stage II), and seven as having severe endometriosis (Stage III). All patients became amenorrheic at the end of the second month of treatment, and symptomless at the end of the third month. Of nine women who had the potential and the desire to conceive, three conceived within 3 months after termination of treatment. Two more became pregnant within 1 year, and another, 14 months after termination of treatment. Five pregnancies progressed to term. One patient aborted. Two of the three women who did not conceive had subfertile husbands. Major side effects recorded were seborrhea and acne, which subsided after discontinuation of therapy. Treatment of endometriosis with gestrinone offers the advantage of effective clearing of lesions with relatively low dosage and frees the patient from the daily administration of drugs required by similar conservative hormonal therapies.

Long-term contraception with a single implant of the progestin ST-1435

Silastic capsules containing the synthetic progestin ST-1435 was inserted in 282 women of reproductive age who desired long-term contraception. Each woman received a single implant for 6 months' use. After evaluating the experience of the first 45 subjects, replacement capsules were offered to women desirous of continuing the method after the initial 6 months of use. In the first 6-month segment one pregnancy and 1720 woman-months of use were recorded. The total experience, through as many as six segments of use was 3373 woman-months of use and one pregnancy. The Pearl Index is 0.36 per 100 woman-years. The single pregnancy, recorded in the 1st month of the first segment, may represent a conception prior to implant placement. Amenorrhea was the most common side effect reported, with 83% of the women having at least one nonbleeding interval longer than 60 days during the first segment of use.

Menstrual blood loss with contraceptive subdermal levonorgestrel implants

Six Silastic capsules each containing 30 mg of levonorgestrel were inserted subcutaneously in the left forearms of 13 volunteer women for contraceptive purposes. Quantitative determinations of menstrual blood loss were performed during a control cycle and during a 1-month period at the 1st, 6th, and 12th months of treatment. Days on which bleeding and spotting occurred were recorded and hemoglobin concentrations were determined. No changes were found in the amount of menstrual blood loss between the control cycles and the treatment cycles. The mean number of bleeding days during each of the three recorded treatment periods was significantly greater than that in the control cycles. No changes in hemoglobin concentration were found. None of the patients became pregnant during the study.

Contraception with subcutaneous capsules containing ST-1435. Pituitary and ovarian function and plasma levels of ST-1435

An RIA for a new progestin, ST-1435, was developed. Plasma concentrations of this steroid were measured in three women having three subcutaneous capsules, each containing 40 mg of ST-1435. Pituitary and ovarian functions were assessed by measuring plasma levels of LH, FSH, estradiol and progesterone. Plasma profiles of ST-1435 were characterized by high and irregular peaks all the way through the study period of 7-9 months. Concentrations below 100 pg/ml were not observed, whereas the highest peaks reached concentrations of 10.1 ng/ml. Plasma estradiol concentrations remained uniformly suppressed below 100 pg/ml, thus indicating a suppression in follicle development. As judged by constantly suppressed progesterone concentrations, no ovulations occurred during the treatment. Plasma FSH concentrations remained at the upper limit of the follicular phase, and those of LH at the lower limit of the luteal phase of the normal menstrual cycle. No midcycle gonadotropin peaks were observed.

Plasma levels of norethindrone and effect upon ovarian function during treatment with silastic implants containing norethindrone

The study was made to evaluate the effect upon the ovarian steroid pattern during treatment with subcutaneously implanted silastic rods containing norethindrone. Four rods, each containing 37 mg norethindrone (NET), were implanted subcutaneously in five women and left in place for 135--200 days. Plasma levels of NET, estradiol and progesterone were determined by radioimmunoassays. After an initial peak found in all subjects, the plasma level of NET declined. Great day-to-day variations of NET were found. Ovulations were suppressed during treatment in three subjects. One subject had regular ovulations throughout treatment and in one subject a single ovulation was recorded. Peaks of estradiol without subsequent ovulation were found in two subjects. The bleeding pattern was irregular; three subjects had varying degrees of spotting and bleeding, two subjects were amenorrheic. The average daily release rate was 300/micrograms, calculated from the amount of steroids lost from the removed rods. This study indicates that the release of steroid from four NET rods is high enough only initially to completely inhibit ovulation.

Contraceptive and sterilization practices and extrauterine pregnancy: a realistic perspective

Comparative data on the incidence of ectopic pregnancy among accidental pregnancies associated with failure of a contraceptive or sterilization procedure are shown in Table 16. The practical clinical significance of the data in this review is predicated upon a number of related factors. One of the most important of these is the realistic failure rate (or success rate) of each contraceptive or sterilization method. The reported efficacy of various contraceptive methods has such a wide range that we have not attempted to calculate the likelihood that a woman may experience an ectopic pregnancy within a particular time period while using a specific method. The success or failure rate of each method is influenced by such variables as (1) the conscientiousness and ability of the patient to follow instructions, (2) the true failure rate of the method itself, (3) the experience of the clinician prescribing a method or performing a surgical procedure, and (4) other factors less clearly defined. Because of these many variables, the data shown in Table 16 were calculated on the basis of the number of reported accidental pregnancies which occurred coincidentally with, or subsequent to, a specific contraceptive or sterilization modality. (formula: see text). These data do not reflect the actual rate of occurrence of ectopic pregnancy with respect to woman-months of experience. We recognize the significant influence that age, race, gravidity, and socioeconomic factors have upon the incidence of ectopic pregnancy, but were unable to control for these factors in the data presented in this review. These data reprresent only what has occurred under specific circumstances and cannot logically be extrapolated to any specific future case or study series. It is important to emphasize the necessity of constant awareness by the medical and paraprofessional personnel of the potentially increased risk to the patient of an extrauterine pregnancy should one or another of these contraceptive or sterilization procedures fail. Complacency or a false sense of security on the part of responsible medical personnel concerning women who are "protected against conception" can quickly lead to a life-threatening situation in case of an ectopic pregnancy. Prompt diagnosis and definitive treatment of the extrauterine pregnancy is vital for the successful management of this serious complication of conception.