Comparative effects of the oral contraceptive combinations 0.150 mg desogestrel + 0.030 mg ethinyloestradiol and 0.150 mg levonorgestrel + 0.030 mg ethinyloestradiol on lipid and lipoprotein metabolism in healthy female volunteers

Biology: risk factor modification by OCs and HRT lipids and lipoproteins

The many effects that the oestrogens and progestagens used in oral contraceptive (OC) and postmenopausal hormone replacement therapies (HRTs) have on lipoprotein metabolism are of importance because of the involvement of lipoproteins in endothelial damage and arterial occlusion. Lipoproteins promoting endothelial damage include: low density lipoprotein (LDL), particularly the small dense subfraction (sdLDL), remnants of very low density lipoprotein (VLDL) and chylomicron metabolism, and lipoprotein (a). High density lipoprotein (HDL) has pleiotropic effects that prevent or alleviate endothelial damage. Orally administered oestrogens increase hepatic triglyceride synthesis and VLDL secretion and increase the proportion of sdLDL. Oestrogens increase the rates of elimination of LDL, VLDL remnants and chylomicrons, suppress the synthesis of key enzymes of lipoprotein metabolism, hepatic and lipoprotein lipase, and increase synthesis of the principal apoprotein of HDL, apoAI. In general, progestagens oppose these effects according to type and dose. In OC and HRT users, this leads to a range of different lipoprotein profiles, which may differ from those evaluated with respect to vascular disease risk in population studies. Accumulating evidence suggests that the clinical implications of steroid induced changes in the lipoprotein profile will need to be evaluated independently of population-based evidence.

Effects of low-dose monophasic levonorgestrel with ethinyl estradiol preparation on serum lipid levels: A twenty-four month clinical trial

OBJECTIVE

The aim of this 24-cycle study was to evaluate the effects on serum lipid concentrations of an oral contraceptive preparation containing 100 microg levonorgestrel and 20 microg ethinyl estradiol.

STUDY DESIGN

Forty-two healthy women were enrolled in a study designed to evaluate the effects on serum lipid concentrations of an oral contraceptive containing 100 microg levonorgestrel and 20 microg ethinyl estradiol. Lipid data were evaluated for 28 women who completed 24 cycles of treatment with a preparation of 100 microg levonorgestrel with 20 microg ethinyl estradiol for 21 days followed by placebo for 7 days. Concentrations of triglycerides, total cholesterol, high-density lipoprotein cholesterol, high-density lipoprotein cholesterol subfractions 2 and 3, low-density lipoprotein cholesterol, and apolipoproteins A-I and B were analyzed. Mean percentage changes from baseline were tested for significance by means of paired Student t tests.

RESULTS

Total cholesterol, high-density lipoprotein cholesterol, high-density lipoprotein subfraction 2, and apolipoprotein A-I concentrations were not significantly changed from baseline. Neither was the ratio of high-density lipoprotein subfraction 2 to high-density lipoprotein subfraction 3. Mean percentage increases in concentrations of triglyceride, high-density lipoprotein subfraction 3, apolipoprotein B, and low-density lipoprotein cholesterol and increases in the ratios of total cholesterol to high-density lipoprotein cholesterol, low-density lipoprotein cholesterol to high-density lipoprotein cholesterol, and apolipoprotein B to apolipoprotein A-I were significant (P <.05) at >/=1 cycle. By cycle 24, however, only the concentration of high-density lipoprotein subfraction 3 remained significantly elevated.

CONCLUSION

Changes in the plasma lipid profiles among women receiving monophasic 100 microg levonorgestrel with 20 microg ethinyl estradiol were similar to those seen with other low-dose oral contraceptives, but by cycle 24 only 1 of 7 mean values remained significantly different from baseline.

Effects of oral contraceptives on coagulation factors in African women

Despite overwhelming evidence that the use of oral contraceptive pills (OCP) may lead to thrombotic episodes, no studies have been performed to investigate the effect of OCP on the coagulation profile in African women. We assessed the levels of fibrinogen, factors VIIc, and VIIIc as well as the fibrinolytic activity in 100 African women on OCP. Fibrinogen levels were significantly increased (p<0.001) and factors VIIc, VIIIc, and fibrinolytic activity significantly decreased (p<0.001) when compared with those of healthy women not on OCP. We conclude that the combination of hyperfibrinogenaemia and decreased fibrinolytic activity combined with a decrease in factor VIIc and VIIIc levels reflects a hemostatic imbalance in African women on OCP that needs to be investigated.

Twelve years of clinical experience with an oral contraceptive containing 30 micrograms ethinyloestradiol and 150 micrograms desogestrel

The clinical experience with a combined oral contraceptive (COC) containing 150 micrograms desogestrel and 30 micrograms ethinylestradiol is reviewed. Fourteen clinical trials have been reported involving over 44,000 women for more than 190,000 cycles. None of the 17 pregnancies which occurred (overall Pearl Index 0.12) were due to method failure. The incidences of breakthrough bleeding and spotting after 6 treatment cycles varied from 0.1-6.0% and 2.8-11% of subjects, respectively, and at this time they were not significantly different from pretreatment in most trials. About 90% of subjects maintained regular cycles. The incidence of subjective side effects (approximately 5% for headache, 4% for breast tenderness, 2% for nausea) was low. No significant changes occurred in body weight or blood pressure. In all trials, the COC was well accepted and the rates of discontinuation were similar to those in other COC trials. Pharmacodynamic effects have been widely investigated. There were no significant changes in glucose metabolism or in haematological factors except for possibly minor increases in factors VII and X, fibrinogen and plasminogen. Over thirty studies of the effect of the COC on lipid metabolism have been published; significant increases occur in serum triglycerides, HDL-C and apoprotein A1. SHBG concentrations increase 2-3 fold with a consequent decrease in the levels of free testosterone. This effect can be particularly important therapeutically in women with hyperandrogenic skin disorders and 14 trials in women with these disorders have demonstrated significant clinical improvement with the COC. The findings from the various trials show the COC to be effective and acceptable with no adverse metabolic effects.

Treatment of hirsutism with flutamide and a low-dosage oral contraceptive in polycystic ovarian disease patients

OBJECTIVE

To evaluate the clinical and hormonal response of the antiandrogen flutamide (Eulexin, Schering Plough, Milan, SA, Italy) associated with a low dosage oral contraceptive (OC) in a group of hirsute women who were unresponsive to OC treatment.

DESIGN

Twenty-two polycystic ovarian disease (PCOD) patients with hirsutism were treated with flutamide (250 mg twice/d) in association with ethinyl-E2 (0.030 mg/d) plus desogestrel (0.150 mg/d) (Practil 21; Organon, Rome, Italy) for 21 d/mo.

SETTING

Patients were recruited in the Institute of Obstetrical and Gynaecological Pathology, St. Bambino Hospital, University of Catania, Italy. Hormonal assays were performed in the Hormone Laboratories of St. Bambino Hospital, University of Catania, Catania, Italy.

MAIN OUTCOME MEASURE

Every 2 months the hirsutism score was evaluated using the Ferriman-Gallwey hair density index. Mean plasma concentrations of LH, FSH, E2, total T, dihydrotestosterone (DHT), androstenedione (A), sex hormone-binding globulin, DHEAS were determined.

RESULTS

After 8 months treatment with flutamide and low dosage OC, the Ferriman-Gallwey score improved in all patients, mean values decreasing from 25.4 +/- 3.96 to 14.6 +/- 1.92. Plasma levels of total T and E2 were unchanged, whereas LH, FSH, A, and DHT values decreased significantly. Sex hormone-binding globulin levels showed a marked increase.

CONCLUSION

Flutamide, associated with low dosage OC, favorably influence the hirsutism in PCOD women who are unresponsive to OC treatment alone.

Effect on lipid metabolism of a biphasic desogestrel-containing oral contraceptive: divergent changes in apolipoprotein B and E and transitory decrease in Lp(a) levels

The effect of a low dose biphasic oral contraceptive containing 40 micrograms ethinylestradiol + 25 micrograms desogestrel (7 tablets) and 30 micrograms ethinylestradiol + 125 micrograms desogestrel (15 tablets) on lipid metabolism was investigated in 19 women during 6 cycles of treatment and compared to the values of the pre- and post-treatment cycle. During treatment, all components of HDL increased reversibly by 10 to 30%. The levels of total cholesterol (CH), LDL-CH and IDL-CH rose only slightly, while those of total triglycerides (TG), VLDL-TG and LDL-TG rose continuously by more than 100% until the 6th cycle. At the same time, plasma levels of VLDL-CH increased by 60% and of apolipoprotein B by 20%. Contrary to this, apolipoprotein E decreased by 25% during treatment, and Lp(a) was transitorily reduced during the 3rd cycle. After termination of intake, total CH, LDL-CH, IDL-CH and apolipoprotein B remained elevated, while total TG, VLDL-TG, VLDL-CH and LDL-TG decreased significantly, but were still elevated during the post-treatment cycle. The levels of apolipoprotein E returned to pre-treatment values. The results indicate a marked preponderance of the effect of the estrogen component. The rise in TG and VLDL synthesis seems to be outweighed by an enhanced removal of apolipoprotein E-containing remnants which might offer protection from the development of atherosclerosis.

Effect of oral contraception on water-suppressed proton NMR spectra of plasma

Lipid linewidths were measured in the plasma proton spectra of young women. The individuals taking a contraceptive pill associating ethinyloestradiol and levonorgestrel or norethisterone were found with an average linewidth 2.5 Hz narrower than controls. As this drug regimen systematically induces an increase in plasma VLDL and a decrease in HDL/LDL ratio, our observation supports the theory that the Fossel test reflects plasma lipids abnormalities in cancer patients.

Effects of three combined oral contraceptive preparations containing desogestrel plus ethinyl estradiol on lipid metabolism in comparison with two levonorgestrel preparations

The effects of three different desogestrel-containing combined oral contraceptive preparations on lipid metabolism were compared with those of two levonorgestrel preparations. The following preparations were studied: (1) monophasic desogestrel (150/30), (2) monophasic desogestrel (150/20, containing 20 micrograms of ethinyl estradiol instead of 30 micrograms of ethinyl estradiol, (3) biphasic desogestrel, (4) monophasic levonorgestrel (150/30), and (5) triphasic levonorgestrel. The effects of these preparations were assessed on high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, apolipoprotein A-I, apolipoprotein B, the ratio of high-density lipoprotein cholesterol to low-density lipoprotein cholesterol, and the ratio of apolipoprotein A-I to apolipoprotein B after 3 months of treatment, and the percentage changes with regard to pretreatment were calculated. The monophasic desogestrel (150/30) and biphasic desogestrel preparations induced higher high-density lipoprotein cholesterol and apolipoprotein A-I levels than did their levonorgestrel-containing counterparts. Low-density lipoprotein cholesterol levels were increased in monophasic levonorgestrel and clearly decreased in the lowest ethinyl estradiol-containing monophasic desogestrel (150/20) and biphasic desogestrel preparations. Apolipoprotein B increased in all preparations. The antiatherogenic indexes (ratios of high-density lipoprotein cholesterol to low-density lipoprotein cholesterol and apolipoprotein A-I to apolipoprotein B were higher for monophasic desogestrel (150/30) and biphasic desogestrel than for comparable levonorgestrel-containing preparations. The differences seen between the desogestrel and levonorgestrel preparations can best be explained by the lower intrinsic androgenicity of 3-keto-desogestrel (active metabolite of desogestrel) than that of levonorgestrel.

Clinical evaluation of a new combined oral contraceptive desogestrel--ethinylestradiol

A clinical study was performed with a new progestogen, desogestrel, in a 0.15 mg dose associated with 0.03 mg of ethinylestradiol and was administered cyclically during 21 days; 632 cycles were evaluated in 56 women. Side-effects were scarce and generally of a mild nature. Monthly bleeding was normal and present in all cycles. Patients with irregular cycles were normalized to 28/29 days. The intermenstrual bleeding (spotting) was an isolated event in 16 cycles. Mastalgia, the most frequent symptom, disappeared spontaneously in the majority of patients. In only 2 cases was it necessary to stop medication because of side-effects. The contraceptive effect was excellent; no pregnancies occurred. A progestative effect was evident in the cervical mucus and the endometrium. The patients who started treatment with acne improved noticeably. In the mild cases, acne disappeared completely. A discrete improvement in hirsutism was reported. The body-weight variation was not significant. Biochemical studies revealed an increase in HDL-C and a decrease in the ratio LDL-C/HDL-C. Cholesterol and triglycerides did not show variations, which could indicate a lesser cardiovascular risk.

Effects of three types of combined O.C. pills on blood coagulation, fibrinolysis and platelet function

The results of a prospective longitudinal controlled study comparing the coagulation effects of a standard low-dose combined oral contraceptive (Microgynon 30), a desogestrel-containing pill (Marvelon) and a triphasic preparation (Triquilar) after one year's treatment in ethnic Chinese women is presented in this paper. In general the changes in coagulation parameters are similar to those seen in Caucasian women. The rise in Factor VII levels seen at 6 and 12 months in Marvelon users was not present to a significant degree in the other pill users. Antithrombin III levels remained unchanged in Microgynon and Marvelon users but with Triquilar there was a significant fall at 6 and 12 months of use. Whether these differences have any clinical relevance in the local Chinese population with low incidence of thromboembolism remains to be seen.

Changes in lipoprotein composition in women receiving two low-dose oral contraceptives containing ethinylestradiol and gonane progestins

In a prospective double-blind study of the effects of two low-dose oral contraceptives (OCs) on lipid and lipoprotein metabolism, two groups of eighteen young healthy women selected at random were submitted to a six months' use of either monophasic ethinylestradiol (EE) + desogestrel (DG) or triphasic EE + levonorgestrel (LNG). Total cholesterol (C), triglycerides (TG), phospholipids (PL), low density lipoprotein-cholesterol (LDL-C) and high density lipoprotein-cholesterol (HDL-C) together with apoproteins A-I, A-II, B and lecithin cholesterol acyltransferase activity (LCAT) were determined in serial plasma samples collected before, at three and six months during, and one month after OC use. Cholesterol and apoproteins (A-I, A-II, B) composition of lipoproteins (HDL-2, HDL-3, LDL) isolated by ultracentrifugation were additionally determined. On Mono-EE + DG, plasma TG (+39.3%, +45.6%), PL (+21.9%, +16.8%) and apo A-I (+35.5%, +23.3%) levels were significantly increased at 3 and 6 months of use; plasma HDL-C (+24%) and Apo A-II (+21.4%) were transiently increased at 3 months. Lipid and apoprotein composition of HDL-2, HDL-3 and LDL were unchanged. On Tri-EE + LNG, a slight but not significant decrease in HDL-C was observed throughout the study while other plasma lipids and apoproteins were unchanged. Ultracentrifugation revealed a lower content of C (-44.2%) and apo A-I (-44.6%) in HDL-2. LCAT activity expressed as molar esterification rate (MER) rose in a more sustained way during EE + DG use than during EE + LNG treatment. Covariance analysis shows a further significant difference between results of both treated groups for the Apo AI/Apo B ratio that was increased by Mono-EE + DG.

Metabolic effects of oral contraceptives

Combination oral contraceptives (OCs) are probably not an independent risk factor for cardiovascular disease but through their metabolic actions, may partly amplify the effects of known risk factors for cardiovascular disease. This review of the literature and our own data indicate that use of high-dose, progestogen-dominant OCs induces a potentially atherogenic lipoprotein profile (high low-density lipoprotein-cholesterol:high-density lipoprotein-cholesterol ratio), mostly attributable to the antiestrogenic action of the progestogen content of these OCs. In contrast, lower-dose combination OCs with reduced amounts of progestogens and slight estrogen dominance, either monophasic or multiphasic, produce strikingly fewer adverse effects on lipoproteins. Moreover, use of low-dose, as opposed to high-dose, OCs results in almost unchanged glucose tolerance, marginally increased or unchanged insulin and glucagon responses to glucose, and probably unchanged levels and activity of peripheral insulin receptors. Further in-depth studies of low-dose OC formulations are mandatory to ascertain reduced metabolic risk of these OCs.

Effects of combined desogestrel-ethinylestradiol treatment on lipid profiles in women with polycystic ovarian disease

A longitudinal study was conducted to determine the effect of combined desogestrel-ethinylestradiol treatment on lipid profiles in 28 women with polycystic ovarian disease. Mean patient age was 26.3 years (range, 16 to 36 years). Mean patient weight and height were 59.2 kg and 153.8 cm, respectively. After initial assessment, all patients were treated with a cyclical pill containing 150 micrograms desogestrel and 30 micrograms ethinylestradiol. Clinical, hormonal, and lipid determinations were evaluated after 3 and 6 cycles of treatment. The results revealed that, during the treatment course, serum luteinizing hormone, testosterone (T), free testosterone, and dehydroepiandrosterone sulfate decreased significantly, while serum follicle-stimulating hormone and prolactin levels did not change. Increased levels of total triglyceride, alpha, and prebeta lipoproteins, and decreased levels of beta lipoproteins, were observed. The ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol, although showing no significant change, had a tendency to decrease. This lipoprotein change seems to have a favorable rather than an adverse effect on the patients.

Effects of seven low dose combined oral contraceptives on high density lipoprotein subfractions

The effects on lipid metabolism of seven combined oral contraceptives were investigated, particularly the effects on high density lipoprotein (HDL) subfractions, which were separated by density gradient ultracentrifugation. There were no differences between the preparations in the effects on the LDL fraction, the so-called atherogenic particle, but there were marked differences in the effects on the anti-atherogenic HDL fraction, of which the effects on HDL-2 were most pronounced. After treatment with monophasic cyproterone acetate and biphasic desogestrel, the cholesterol and phospholipid contents of the HDL-2 fraction were significantly higher than those found after treatment with the other preparations. The lowest values were found after treatment with monophasic levonorgestrel, whereas monophasic desogestrel, triphasic levonorgestrel, monophasic norethisterone and triphasic gestoden induced intermediate values for these variables. The levels of HDL-2 reflect the intrinsic androgenicity of the various progestogens used in the preparations.

Comparative effects of monophasic desogestrel plus ethinyloestradiol and triphasic levonorgestrel plus ethinyloestradiol on lipid metabolism

The effects of the monophasic oral contraceptive preparation desogestrel plus ethinyloestradiol (EE) and triphasic levonorgestrel plus EE on lipid metabolism were compared. Sixteen young healthy female volunteers received monophasic desogestrel plus EE (21 X 150/30), whereas eighteen women received triphasic levonorgestrel plus EE (6 X 50/30 + 5 X 75/40 + 10 X 125/30) for six consecutive cycles. The lipid composition of the various lipoprotein fractions was estimated after separation in a density gradient by ultracentrifugation. In addition, the apolipoproteins A-I and B were assessed. HDL-cholesterol (precipitation method), HDL-2 cholesterol, HDL-2 phospholipids and the ratio apolipoprotein A-I to apolipoprotein B were significantly higher in the monophasic desogestrel group than in the triphasic levonorgestrel group after three and six treatment cycles. HDL-cholesterol (gradient), HDL-phospholipids (gradient), HDL-3 phospholipids and apolipoprotein A-I were only significantly higher after six treatment cycles. No differences between the groups were observed for the other lipid variables studied including triglycerides and VLDL-triglycerides.

The effects of two gonane progestins alone and in combination with ethinyl estradiol on serum lipoproteins

Twenty women, oophorectomized as part of the treatment for cervical carcinoma in an early stage but otherwise healthy, participated in the study. Ten of them were given desogestrel (DG) 150 micrograms/day for 3 wk followed by DG + 30 micrograms ethinyl estradiol (EE) for 6 wk, and finally EE alone for 3 wk. The other ten women were given 150 micrograms levonorgestrel (NORG) and EE in a similar way. Before treatment and after each period, total and free cholesterol (TC, FC) triglycerides (TG) and phospholipids (PL) were assayed in serum and in the ultracentrifugally isolated lipoprotein fractions very low, low and high density lipoproteins (VLDL, LDL and HDL). The results indicate that both progestins induced the same 'androgenic' pattern when given alone, i.e. a decrease in serum- and HDL-TC and a decrease in VLDL-lipids. In combination with EE, however, DG seems to counteract the effects of EE to a lesser extent than NORG, as judged particularly from the effects on TG and PL in serum and VLDL.

Oral contraceptives, lipids and cardiovascular disease

Evidence for the involvement of changes in lipid metabolism and oral contraceptive use in the development of cardiovascular disease is briefly reviewed with particular reference to the main object of the article, to assess the effect of different oral contraceptive formulations on serum lipid levels. The preferred formulations should contain a low dose of ethynyloestradiol and should not increase serum levels of cholesterol and LDL-C or reduce those of HDL-C. Such formulations appear to be the triphasic one containing ethynyloestradiol and levonorgestrel and the ethynyloestradiol-desogestrel combination, which appears to be unique in that it may actually increase HDL-C. However other determinants in addition to effects on lipid metabolism will be important in deciding the choice of an oral contraceptive. Any changes which do occur in serum lipid concentrations with OC use appear within the first three months and do not appear to be progressive with continued use after this time.

Serum lipid and lipoprotein changes induced by new oral contraceptives containing ethinylestradiol plus levonorgestrel or desogestrel

Changes in serum lipid and lipoprotein levels were evaluated in a randomized prospective study conducted in matched healthy young women before and after 6 months' use of three oral contraceptives (OCs): Trigynon (preparation A, n = 13), a triphasic OC containing low doses of ethinylestradiol (EE) and levonorgestrel (LNG); Marvelon (preparation B, n = 14), a monophasic OC containing low doses of EE + Desogestrel (DOG, a new progestogen derived from LNG); and Ovidol (preparation C, n = 11), a sequential OC containing higher doses (50 micrograms) of EE + DOG. After 6 months of use, total triglyceride levels were non-significantly increased by preparations A (+ 29% from basal values) and B (+21%), and very significantly increased by preparation C (+90%). Total cholesterol and phospholipids were unchanged by preparations A and B, whereas phospholipids were significantly increased by preparation C. However, HDL-cholesterol, LDL-cholesterol and their epidemiologically important ratios (HDL-chol:total-chol; LDL-chol:HDL-chol) were kept unchanged by all preparations tested. Apolipoprotein A-1 (Apo A-1) was slightly but significantly increased by all three preparations whereas apolipoprotein B (Apo B) was significantly decreased by preparation B. All ratios Apo A-1:Apo B were accordingly ("favorably") increased, especially during treatment with preparation B. In conclusion, the triphasic OC containing low doses of LNG does not induce obvious, clinically significant, alterations of lipid metabolism, and it is also the case for the low-dose monophasic combination of EE + DOG. The higher-dose sequential preparation of EE + DOG behaves as a more estrogenic compound, increasing total triglyceride concentrations above the normal range.

Effects of levonorgestrel and desogestrel in low-dose oral contraceptive combinations on serum lipids, apolipoproteins A-I and B and glycosylated proteins

Fasting serum lipids, apolipoproteins and glycosylated serum proteins were studied in 20 women before, after three months of treatment and two months after termination of treatment with oral contraceptives containing 30 micrograms ethinyloestradiol (EE) plus 150 micrograms levonorgestrel or desogestrel. Levonorgestrel + EE induced significant increases in total triglycerides (48%), apoB (19%) and the ratio apoB/apoA-I (18%) and no significant changes in HDL-cholesterol (8% decrease), apoA-I, % HDL-cholesterol, total cholesterol and serum glycosylated proteins. Desogestrel + EE induced significant increases in HDL-cholesterol (12%), % HDL-cholesterol (15%), triglycerides (35%) and apoA-I (20%), no changes in total cholesterol, apoB and glycosylated serum proteins and a significant decrease in the ratio apoB/apoA-I (17%). Two months after termination of treatment the values for all parameters for both preparations were similar to those observed before treatment. The differences between the effects of the two preparations on the parameters HDL-cholesterol, % HDL-cholesterol, apoA-I, apoB and the ratio apoB/apoA-I were statistically significant and can be explained by a difference in the intrinsic androgenicity of the two progestagens.