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Plagianos MG, Ramanadhan S, Merkatz RB, Brache V, Friedland BA, Haddad LB. Risk factors for and outcomes of ring expulsions with a 1-year contraceptive vaginal system. Am J Obstet Gynecol 2024; 230:548.e1-548.e8. [PMID: 38295968 DOI: 10.1016/j.ajog.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 01/03/2024] [Accepted: 01/19/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The US Food and Drug Administration-approved segesterone acetate and ethinyl estradiol ring-shaped contraceptive vaginal system, known as Annovera (Sever Pharma Solutions/QPharma, Malmö, Sweden), was inserted and removed under a woman's control for a 21 day in and 7 day out regimen for up to 13 cycles of use. OBJECTIVE We aimed to describe the patterns of ring expulsion over time, to identify potential predictors of expulsion, and to evaluate the impact of expulsions on method discontinuation and pregnancy risk. STUDY DESIGN Using data from 2064 participants who were enrolled in 2 multinational phase 3 clinical trials on the use of this contraceptive vaginal system, we examined data from participants' daily diaries for documentation of complete ring expulsion. We modeled the odds of reported expulsions over time with adjustment for background and demographic characteristics using mixed-effects logistic regression models with random intercepts. We compared the probability of continuation between those who did and those who did not report expulsions in the first cycle of use using survival analysis and hazards modeling. To determine if expulsions during the first cycle of use affected the risk for pregnancy, we calculated Pearl Indices. RESULTS Most participants (75%) never experienced any expulsions during any cycle of use, and 91% to 97% did not experience an expulsion during any 1 cycle. The incidence of expulsion was highest in cycle 1 (9%). The odds of experiencing expulsions decreased by half in cycles 2 to 8 when compared with cycle 1 (0.48; 95% confidence interval, 0.40-0.58), and in cycles 9 to 13, expulsions were about a third of that in cycle 1 (0.32; 95% confidence interval, 0.26-0.41). Of those who did experience expulsions, most (62%-84%) experienced ≤2 expulsions per cycle. Participants from study sites in Latin America vs those in the United States had higher odds of not experiencing an expulsion (odds ratio, 1.95; 95% confidence interval, 1.45-2.63). Women with a higher education level had higher odds of experiencing an expulsion. Notably, parity, age, and body mass index were not associated with expulsion. Participants who experienced any expulsions in cycle 1 were more likely to discontinue use early (hazard ratio, 1.28; 95% confidence interval, 1.14-1.43) than participants who did not have an expulsion. The Pearl Index for participants who had expulsions during cycle 1 was 3.99 (95% confidence interval, 1.29-9.31), which was higher than that among participants who reported no expulsions (Pearl Index, 2.39; 95% confidence interval, 1.61-3.41), but the overlapping confidence intervals indicate that there is not sufficient evidence to demonstrate an association between expulsions and pregnancy risk. CONCLUSION Expulsions were infrequent overall, decreased with subsequent cycles of use, and were not associated with body mass index or parity. Early discontinuation of product use was higher among participants who experienced an expulsion during cycle 1. Although it is unclear whether pregnancy risk was associated with expulsions, early recognition of expulsions among users may identify those at higher risk for discontinuation and may highlight when enhanced anticipatory counselling and guidance may be advantageous.
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Bernaud VE, Koebele SV, Northup-Smith SN, Willeman MN, Barker C, Schatzki-Lumpkin A, Sanchez MV, Bimonte-Nelson HA. Evaluations of memory, anxiety, and the growth factor IGF-1R after post-surgical menopause treatment with a highly selective progestin. Behav Brain Res 2023; 448:114442. [PMID: 37085118 PMCID: PMC11105077 DOI: 10.1016/j.bbr.2023.114442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
Progestogens are a key component of menopausal hormone therapies. While some progestogens can be detrimental to cognition, there is preclinical evidence that progestogens with a strong progesterone-receptor affinity benefit some molecular mechanisms believed to underlie cognitive function. Thus, a progestin that maximizes progesterone-receptor affinity and minimizes affinities to other receptors may be cognitively beneficial. We evaluated segesterone-acetate (SGA), a 19-norprogesterone derivative with a strong progesterone-receptor affinity and no androgenic or estrogenic-receptor activity, hypothesizing that it would enhance cognition. Middle-aged rats underwent Sham or Ovariectomy (Ovx) surgery followed by administration of medroxyprogesterone-acetate (MPA; used as a positive control as we have previously shown MPA-induced cognitive deficits), SGA (low or high dose), or vehicle (one Sham and one Ovx group). Spatial working and reference memory, delayed retention, and anxiety-like behavior were assessed, as were memory- and hormone- related protein assays within the frontal cortex, dorsal hippocampus, and entorhinal cortex. Low-dose SGA impaired spatial working memory, while high-dose SGA had a more extensive detrimental impact, negatively affecting spatial reference memory and delayed retention. Replicating previous findings, MPA impaired spatial reference memory and delayed retention. SGA, but not MPA, alleviated Ovx-induced anxiety-like behaviors. On two working memory measures, IGF-1R expression correlated with better working memory only in rats without hormone manipulation; any hormone manipulation or combination of hormone manipulations used herein altered this relationship. These findings suggest that SGA impairs spatial cognition after surgical menopause, and that surgical menopause with or without progestin administration disrupts relationships between a growth factor critical to neuroplasticity.
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Affiliation(s)
- Victoria E Bernaud
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Stephanie V Koebele
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Steven N Northup-Smith
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Mari N Willeman
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA; TGen Institute, 445 N 5th St, Phoenix, AZ 85004, USA
| | - Charlotte Barker
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Alex Schatzki-Lumpkin
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Maria Valenzuela Sanchez
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Heather A Bimonte-Nelson
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA.
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Ridgeway K, Montgomery ET, Smith K, Torjesen K, van der Straten A, Achilles SL, Griffin JB. Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world. Contraception 2022; 106:16-33. [PMID: 34644609 PMCID: PMC9128798 DOI: 10.1016/j.contraception.2021.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out. STUDY DESIGN This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression. RESULTS Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability. CONCLUSIONS Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development. IMPLICATIONS This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.
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Affiliation(s)
- Kathleen Ridgeway
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Elizabeth T. Montgomery
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Kevin Smith
- Centre for Global Health, RTI International, Durham, NC, United States
| | - Kristine Torjesen
- FHI 360, Global Health Population Nutrition, Durham, NC, United States
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States,Center for AIDS Pervention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Sharon L. Achilles
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Jennifer B. Griffin
- Centre for Global Health, RTI International, Durham, NC, United States,Corresponding author. J. B. Griffin, (J.B. Griffin)
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4
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Delvaux T, Jespers V, Benova L, van de Wijgert J. Acceptability and Satisfaction of Contraceptive Vaginal Rings in Clinical Studies: A Systematic Review and Narrative Synthesis. Front Glob Womens Health 2022; 2:799963. [PMID: 34970653 PMCID: PMC8712726 DOI: 10.3389/fgwh.2021.799963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Acceptability of and satisfaction with contraceptive methods are paramount for uptake and continuation. In the current context of multipurpose prevention of pregnancy and sexually transmitted diseases/HIV development, it is critical to have a better understanding of acceptability of and satisfaction with the contraceptive vaginal ring (CVR) including sexual satisfaction. The objective of this study was to review the evidence about acceptability of CVRs and general and sexual satisfaction of users. Methods: We searched PubMed, CINAHL, and Web of Science (until December 31, 2020) and selected original studies documenting actual use of hormonal CVR and explicitly addressing any of the 3 outcomes. Results: Of a total of 1,129 records screened, 46 studies were included. Most studies (n = 43, 93%) were prospective, conducted in high-income settings (n = 35), and reported on NuvaRing® use (n = 31). Overall, 27 (59%) studies included a comparison group, 38 (82%) studies used exclusively quantitative questionnaires, with qualitative only (n = 4, 9%), or mixed methods (n = 4, 9%) studies being less common. Ease of CVR insertion/removal/reinsertion was high in all the settings and improved with time of use, with qualitative studies supporting these findings. When mentioned, ring-related events were associated with discontinuation, and results on continuation of use were mixed. Among NuvaRing® studies, general satisfaction (being satisfied or very satisfied) was between 80 and 90% and tended to mirror continuation. Sexual satisfaction was less commonly reported and results were mixed. Overall, limited information was provided on actual CVR experiences of women (and men) and cultural norms that may affect sexuality and CVR use. Conclusion: Positive aspects of acceptability of and satisfaction with CVRs were reported, but ring-related events and factors, which may affect long-term CVR use, deserve further study. More information is needed on actual experiences of women using CVRs, relationship aspects, male partner opinions, and contextual norms to better understand the acceptability of and satisfaction with CVRs.
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Affiliation(s)
| | - Vicky Jespers
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | - Lenka Benova
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Janneke van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Begg L, Sailer J, Hazra A, Roy M, Merkatz R, Haddad L, Brodsky R, Bongaarts J. Measuring potential interest in a postpartum contraceptive vaginal ring among breastfeeding women in India. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000804. [PMID: 36962466 PMCID: PMC10021958 DOI: 10.1371/journal.pgph.0000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022]
Abstract
Access to safe and effective contraception for postpartum women is an important priority in India, where the unmet need for postpartum contraception is high. In this paper, we estimate the potential market size in India for the progesterone vaginal ring (PVR), a novel user-controlled contraceptive method that offers additional contraceptive choice for lactating women. We integrated results of a one-year phase-3 multicenter clinical trial for the PVR conducted in India with an analysis of the National Family Health Survey (2015-16) and 2019 United Nations Population Division data to generate three estimates of potential market size for the PVR among postpartum breastfeeding women in India. We estimate the potential market size for the PVR ranges from a low estimate of 543,262 women to a high estimate of 1.3 million women, with a separate intermediate estimate of 737,460 women. Our analysis indicates the PVR could play an important role in decreasing unmet need among postpartum women in India, thereby reducing risks to mothers and children associated with short birth intervals, helping to prevent unintended pregnancies, and helping to address access-related issues heightened by the COVID-19 pandemic.
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Affiliation(s)
- Lorna Begg
- Population Council, New York, NY, United States of America
| | - Jim Sailer
- Population Council, New York, NY, United States of America
| | | | - Malabika Roy
- Indian Council of Medical Research, New Delhi, India
| | - Ruth Merkatz
- Population Council, New York, NY, United States of America
| | - Lisa Haddad
- Population Council, New York, NY, United States of America
| | | | - John Bongaarts
- Population Council, New York, NY, United States of America
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Altuntaş E, Tekko IA, Vora LK, Kumar N, Brodsky R, Chevallier O, McAlister E, Kurnia Anjani Q, McCarthy HO, Donnelly RF. Nestorone nanosuspension-loaded dissolving microneedles array patch: A promising novel approach for "on-demand" hormonal female-controlled peritcoital contraception. Int J Pharm 2021; 614:121422. [PMID: 34958899 DOI: 10.1016/j.ijpharm.2021.121422] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/17/2022]
Abstract
"On demand" hormonal female-controlled pericoital contraception is one strategy which could be used to minimize the impact of unintended pregnancy. Nestorone (NES) is a potent contraceptive, with relatively few side effects in comparison with other contraceptives. NES presents an attractive option for "on demand" pericoital contraceptive. Unfortunately, the drug is inactive if taken orally, but it has high progestational activity and antiovulatory potency if administered parenterally. Current drug delivery systems, such as a transdermal hydrogel are not so satisfactory. Dissolving microneedles array (DMNs) are an attractive alternative, minimally-invasive, delivery system. In this study, we report, for the first time, development of tip-loaded NES-nanosuspension (NES-NS)-loaded bilayer DMNs to deliver NES intradermally for subsequent release. NES-NS was prepared and optimised, freeze-dried and then used to fabricate DMNs using a blend of two biocompatible polymers, namely poly(vinyl alcohol) and poly(vinyl pyrrolidone). Both NES-NS and the NES-NS-loaded DMNs were fully characterised and the performance of the DMNs was evaluated in vivo using Sprague Dawley rats. Results showed that the finalised NES-NS had particle size and PDI values of 666.06 ± 1.86 nm and 0.183 ± 0.01, respectively. The NES-NS-DMNs had relatively high tips-localised drug loading (approximately 2.26 ± 1.98 mg/array) and exhibited satisfactory mechanical and insertion properties. In Sprague Dawley rats, DMNs delivered NES into the skin, with the drug then appearing in blood and rapidly reaching its maximum concentration (Cmax of 32.68 ± 14.06 ng/mL) within 1h post-DMNs application. Plasma levels above 3.4 ng/mL were maintained for 2 days. This suggests that DMNs are a promising drug delivery system that could be used to deliver NES as an "On demand" hormonal female-controlled pericoital contraceptive.
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Affiliation(s)
- Ebru Altuntaş
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK; Department of Pharmaceutical Technology, Faculty of Pharmacy, Istanbul University, 34416, Fatih, Istanbul, Turkey
| | - Ismaiel A Tekko
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK; Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Aleppo University, Aleppo, Syria
| | - Lalitkumar K Vora
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Narender Kumar
- Center for Biomedical Research, The Population Council, New York, NY, USA
| | - Rebecca Brodsky
- Center for Biomedical Research, The Population Council, New York, NY, USA
| | - Olivier Chevallier
- Avignon Université, Campus Jean-Henri Fabre, 301 rue Baruch de Spinoza BP 21239, 84911 Avignon cedex 9, France; Institute for Global Food Security, School of Biological Science, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, Northern Ireland, UK
| | - Emma McAlister
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Qonita Kurnia Anjani
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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7
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Rafiei F, Tabesh H, Farzad S, Farzaneh F, Rezaei M, Hosseinzade F, Mottaghy K. Development of Hormonal Intravaginal Rings: Technology and Challenges. Geburtshilfe Frauenheilkd 2021; 81:789-806. [PMID: 34276064 PMCID: PMC8277443 DOI: 10.1055/a-1369-9395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/20/2021] [Indexed: 12/24/2022] Open
Abstract
Intravaginal rings (IVRs) are minimally invasive polymeric devices specifically designed to be used for the sustained and prolonged release of various type of drugs such as hormones. One of the benefits of using topical drug delivery systems (e.g., IVRs) is the fact that systemic drug delivery may cause drug resistance due to elevated drug levels. Topical drug delivery also provides higher concentrations of the drug to the target site and has fewer side effects. In addition, when a drug is administered vaginally, the hepatic first-pass effect is avoided, resulting in higher absorption. Contraception and treatments for specific diseases such as endometriosis and hormone deficiencies can be improved by the administration of hormones via an IVR. This article aims to classify and compare various designs of commercially available and non-commercial hormonal IVRs and to analyze their performance. Current challenges affecting the development of IVRs are investigated, and
proposed solutions are discussed. A comprehensive search of publications in MEDLINE/PubMed and of commercial product data of IVRs was performed, and the materials, designs, performance, and applications (e.g., contraception, endometriosis, estrogen deficiency and urogenital atrophy) of hormonal IVRs were thoroughly evaluated. Most hormonal IVRs administer female sex hormones, i.e., estrogen and progestogens. In terms of material, IVRs are divided into 3 main groups: silicone, polyurethane, and polyethylene-co-vinyl acetate IVRs. As regards their design, there are 4 major designs for IVRs which strongly affect their performance and the timing and rate of hormone release. Important challenges include reducing the burst release and maintaining the bioavailability of hormones at their site of action over a prolonged period of administration as well as lowering production costs. Hormonal IVRs are a promising method which could be used to facilitate combination therapies by
administering multiple drugs in a single IVR while eliminating the side effects of conventional drug administration methods. IVRs could considerably improve womenʼs quality of life all over the world within a short period of time.
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Affiliation(s)
- Fojan Rafiei
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Hadi Tabesh
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Shayan Farzad
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California, United States
| | - Farah Farzaneh
- Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Rezaei
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Fateme Hosseinzade
- Department of Life Science Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Khosrow Mottaghy
- Institute of Physiology, RWTH Aachen University, Aachen, Germany
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8
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Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther 2021; 222:107789. [PMID: 33316287 PMCID: PMC8122039 DOI: 10.1016/j.pharmthera.2020.107789] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Many different forms of hormonal contraception are used by millions of women worldwide. These contraceptives differ in the dose and type of synthetic progestogenic compound (progestin) used, as well as the route of administration and whether or not they contain estrogenic compounds. There is an increasing awareness that different forms of contraception and different progestins have different side-effect profiles, in particular their cardiovascular effects, effects on reproductive cancers and susceptibility to infectious diseases. There is a need to develop new methods to suit different needs and with minimal risks, especially in under-resourced areas. This requires a better understanding of the pharmacokinetics, metabolism, serum and tissue concentrations of progestins used in contraception as well as the biological activities of progestins and their metabolites via steroid receptors. Here we review the current knowledge on these topics and identify the research gaps. We show that there is a paucity of research on most of these topics for most progestins. We find that major impediments to clear conclusions on these topics include a lack of standardized methodologies, comparisons between non-parallel clinical studies and variability of data on serum concentrations between and within studies. The latter is most likely due, at least in part, to differences in intrinsic characteristics of participants. The review highlights the importance of insight on these topics in order to provide the best contraceptive options to women with minimal risks.
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Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Renate Louw-du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Boyd P, Merkatz R, Variano B, Malcolm RK. The ins and outs of drug-releasing vaginal rings: a literature review of expulsions and removals. Expert Opin Drug Deliv 2020; 17:1519-1540. [DOI: 10.1080/17425247.2020.1798927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
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17β-estradiol/progesterone in a single, oral, softgel capsule (TX-001HR) significantly increased the number of vasomotor symptom-free days in the REPLENISH trial. ACTA ACUST UNITED AC 2020; 27:1382-1387. [PMID: 32740481 PMCID: PMC7709918 DOI: 10.1097/gme.0000000000001615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To examine responder rates and vasomotor symptom-free days with oral 17β-estradiol/progesterone (E2/P4; TX-001HR) versus placebo in the REPLENISH trial. Methods: REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, evaluating single, oral, softgel E2/P4 capsules in postmenopausal women (40-65 y) with a uterus and vasomotor symptoms (VMS). Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were randomized (VMS substudy) to daily E2/P4 (mg/mg) of 1/100, 0.5/100, 0.5/50, 0.25/50, or placebo. Proportions of women with ≥50% or ≥75% reductions in moderate to severe VMS (responders), and those with no severe VMS as well as the weekly number of days without moderate to severe VMS with TX-001HR versus placebo were determined. Mixed model repeated measures was used to analyze data and Fisher exact test was employed to compare E2/P4 versus placebo. Results: Seven hundred twenty-six women were eligible for the VMS efficacy analysis (E2/P4 1/100 [n = 141], 0.5/100 [n = 149], 0.5/50 [n = 147], 0.25/50 [n = 154], or placebo [n = 135]). Significantly more women treated with all E2/P4 doses versus placebo were ≥50% responders and ≥75% responders at weeks 4 and 12 (P < 0.05) and also had significantly more days per week without moderate to severe VMS at week 12 (1.9-3.0 d for E2/P4 versus 1.3 d for placebo; P < 0.05). The proportion of women without severe hot flushes at week 12 was 43% to 56% for all E2/P4 doses versus 26% for placebo (P ≤ 0.01). Conclusions: Women treated with E2/P4 had a greater response to treatment with more VMS-free days than with placebo. The E2/P4 1/100 dose (Bijuva [E2 and P4] capsules) represents an oral treatment option for postmenopausal women with moderate to severe VMS and a uterus.
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11
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Micks EA, Jensen JT. A technology evaluation of Annovera: a segesterone acetate and ethinyl estradiol vaginal ring used to prevent pregnancy for up to one year. Expert Opin Drug Deliv 2020; 17:743-752. [PMID: 32410464 DOI: 10.1080/17425247.2020.1764529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles). AREAS COVERED This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety. EXPERT OPINION The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington , Seattle, WA, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, OR, USA
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12
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Controlled-Release from High-Loaded Reservoir-Type Systems-A Case Study of Ethylene-Vinyl Acetate and Progesterone. Pharmaceutics 2020; 12:pharmaceutics12020103. [PMID: 32013050 PMCID: PMC7076478 DOI: 10.3390/pharmaceutics12020103] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/14/2020] [Accepted: 01/26/2020] [Indexed: 12/13/2022] Open
Abstract
Reservoir systems (drug-loaded core surrounded by drug-free membrane) provide long-term controlled drug release. This is especially beneficial for drug delivery to specific body regions including the vagina. In this study, we investigated the potential of reservoir systems to provide high drug release rates over several weeks. The considered model system was an intra-vaginal ring (IVR) delivering progesterone (P4) in the mg/day range using ethylene-vinyl acetate (EVA) as release rate-controlling polymers. To circumvent the high material needs associated with IVR manufacturing, we implemented a small-scale screening procedure that predicts the drug release from IVRs. Formulations were designed based on the solubility and diffusivity of P4 in EVAs with varying vinyl acetate content. High in-vitro P4 release was achieved by i) high P4 solubility in the core polymer; ii) high P4 partition coefficient between the membrane and the core; and/or iii) low membrane thicknesses. It was challenging for systems designed to release comparatively high fractions of P4 at early times to retain a constant drug release over a long time. P4 crystal dissolution in the core could not counterbalance drug diffusion through the membrane and drug crystal dissolution was found to be the rate-limiting step. Overall, high P4 release rates can be achieved from EVA-based reservoir systems.
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13
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Dlamini S, Kuipa M, Enfield K, Skosana S, Woodland JG, Moliki JM, Bick AJ, van der Spuy Z, Maritz MF, Avenant C, Hapgood JP. Reciprocal Modulation of Antiretroviral Drug and Steroid Receptor Function In Vitro. Antimicrob Agents Chemother 2019; 64:e01890-19. [PMID: 31658973 PMCID: PMC7187592 DOI: 10.1128/aac.01890-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/23/2019] [Indexed: 11/20/2022] Open
Abstract
Millions of women are exposed simultaneously to antiretroviral drugs (ARVs) and progestin-based hormonal contraceptives. Yet the reciprocal modulation by ARVs and progestins of their intracellular functions is relatively unexplored. We investigated the effects of tenofovir disoproxil fumarate (TDF) and dapivirine (DPV), alone and in the presence of select steroids and progestins, on cell viability, steroid-regulated immunomodulatory gene expression, activation of steroid receptors, and anti-HIV-1 activity in vitro Both TDF and DPV modulated the transcriptional efficacy of a glucocorticoid agonist via the glucocorticoid receptor (GR) in the U2OS cell line. In TZM-bl cells, DPV induced the expression of the proinflammatory interleukin 8 (IL-8) gene while TDF significantly increased medroxyprogesterone acetate (MPA)-induced expression of the anti-inflammatory glucocorticoid-induced leucine zipper (GILZ) gene. However, peripheral blood mononuclear cell (PBMC) and ectocervical explant tissue viability and gene expression results, along with TZM-bl HIV-1 infection data, are reassuring and suggest that TDF and DPV, in combination with dexamethasone (DEX) or MPA, do not reciprocally modulate key biological effects in primary cells and tissue. We show for the first time that TDF induces progestogen-independent activation of the progesterone receptor (PR) in a cell line. The ability of TDF and DPV to influence GR and PR activity suggests that their use may be associated with steroid receptor-mediated off-target effects. This, together with cell line and individual donor gene expression responses in the primary models, raises concerns that reciprocal modulation may cause side effects in a cell- and donor-specific manner in vivo.
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Affiliation(s)
- Sigcinile Dlamini
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Michael Kuipa
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Kim Enfield
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Salndave Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - John G Woodland
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Johnson Mosoko Moliki
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Zephne van der Spuy
- Department of Obstetrics and Gynaecology, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Michelle F Maritz
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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14
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Tietz K, Klein S. In Vitro Methods for Evaluating Drug Release of Vaginal Ring Formulations-A Critical Review. Pharmaceutics 2019; 11:pharmaceutics11100538. [PMID: 31623277 PMCID: PMC6836189 DOI: 10.3390/pharmaceutics11100538] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 12/28/2022] Open
Abstract
The vagina is a promising site for both local and systemic drug delivery and represents an interesting administration route for compounds with poor oral bioavailability. Whereas most of the currently marketed dosage forms were designed as immediate release formulations, intravaginal rings (IVRs) offer the possibility of a controlled vaginal drug delivery over several weeks or months. For a long time, the development of IVRs was limited to steroid-releasing formulations. Recently, IVRs have witnessed a surge of new interest as promising delivery systems for microbicides. Therefore, various novel IVR designs have been introduced. To ensure that only safe and effective IVRs will be administered to patients, it is important to properly distinguish between IVRs with desired and undesired release performance. In vitro methods for evaluating drug release of IVRs that present with sufficient predictive capacity for in vivo drug release, and discriminatory power with regard to IVRs quality, are an essential tool for this purpose. The objective of the present review article is to present the current status of in vitro drug release testing of IVRs and to critically discuss current compendial and non-official in vitro drug release methods with regard to their discriminatory power and in vivo predictivity.
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Affiliation(s)
- Katharina Tietz
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany
| | - Sandra Klein
- Center of Drug Absorption and Transport, Institute of Biopharmaceutics and Pharmaceutical Technology, Department of Pharmacy, Felix-Hausdorff-Str. 3, University of Greifswald, Greifswald 17489, Germany.
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15
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Nelson AL. Comprehensive overview of the recently FDA-approved contraceptive vaginal ring releasing segesterone acetate and ethinylestradiol: A new year-long, patient controlled, reversible birth control method. Expert Rev Clin Pharmacol 2019; 12:953-963. [DOI: 10.1080/17512433.2019.1669448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anita L. Nelson
- Obstetrics & Gynecology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
- Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Obstetrics & Gynecology, University Southern California, Los Angeles, CA, USA
- Research Division, Essential Access Health, Los Angeles, CA, USA
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16
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Dallal Bashi YH, McCoy CF, Murphy DJ, Boyd P, Spence P, Kleinbeck K, Devlin B, Malcolm RK. Towards a dapivirine and levonorgestrel multipurpose vaginal ring: Investigations into the reaction between levonorgestrel and addition-cure silicone elastomers. Int J Pharm 2019; 569:118574. [PMID: 31352053 DOI: 10.1016/j.ijpharm.2019.118574] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023]
Abstract
With a dapivirine-releasing vaginal ring having successfully completed late-stage clinical testing for HIV prevention and currently undergoing regulatory review, there is now growing interest in next-generation multipurpose prevention technologies that seek to combine antiretroviral and contraceptive drugs within a single product. Here, we focus on ongoing efforts to develop a silicone elastomer vaginal ring releasing both dapivirine and levonorgestrel. Specifically, we evaluate various strategies aimed at both better understanding and reducing the tendency of levonorgestrel to bind with the elastomer, including: (i) formulation and post-manufacturing strategies aimed at reducing the extent of levonorgestrel reaction with addition-cure silicone elastomers; (ii) evaluation of a simple silicone system to model the complex elastomer; (iii) use of model compounds representing the enone and ethinyl moieties of levonorgestrel to probe the mode of addition of levonorgestrel to addition-cure silicone elastomers; and (iv) solution and solid-state 13C NMR analysis to probe the structural features of the levonorgestrel-silicone system. The results demonstrate that both the enone and ethinyl groups within levonorgestrel undergo hydrosilylation reactions with the hydrosiloxane groups in the silicone elastomer leading to covalent binding. The results also highlight potential strategies for further optimising the dapivirine + levonorgestrel silicone vaginal ring formulation to ensure that the levonorgestrel is available for release.
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Affiliation(s)
| | - Clare F McCoy
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | | | - Peter Boyd
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Patrick Spence
- International Partnership for Microbicides, Silver Spring, MD 20910, USA
| | - Kyle Kleinbeck
- International Partnership for Microbicides, Silver Spring, MD 20910, USA
| | - Bríd Devlin
- International Partnership for Microbicides, Silver Spring, MD 20910, USA
| | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK.
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Gemzell-Danielsson K, Sitruk-Ware R, Creinin MD, Thomas M, Barnhart KT, Creasy G, Sussman H, Alami M, Burke AE, Weisberg E, Fraser I, Miranda MJ, Gilliam M, Liu J, Carr BR, Plagianos M, Roberts K, Blithe D. Segesterone acetate/ethinyl estradiol 12-month contraceptive vaginal system safety evaluation. Contraception 2019; 99:323-328. [PMID: 30831102 DOI: 10.1016/j.contraception.2019.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate safety outcomes from clinical studies of a 12-month contraceptive vaginal system (CVS) releasing an average of segesterone acetate (SA) 150 mcg and ethinyl estradiol (EE) 13 mcg daily. STUDY DESIGN We integrated clinical safety data from nine studies in which women used the CVS for 21 consecutive days and removed it for 7 days of each 28-day cycle. Four studies used the final manufactured CVS, including a 1-year pharmacokinetic study, two 1-year phase 3 trials and a second-year treatment extension study. We assessed safety by evaluating adverse events women reported in a daily diary. We also included data from focused safety studies evaluating endometrial biopsies, vaginal microbiology and liver proteins from one of the phase 3 studies. RESULTS The combined studies included 3052 women; 2308 women [mean age 26.7±5.1 years; mean body mass index (BMI) 24.1±3.7 kg/m2] received the final manufactured CVS, of whom 999 (43.3%) completed 13 cycles of use. Women using the final CVS most commonly reported adverse events of headache (n=601, 26%), nausea (n=420, 18%), vaginal discharge/vulvovaginal mycotic infection (n=242, 10%) and abdominal pain (n=225, 10%). Few (<1.5%) women discontinued for these complaints. Four (0.2%) women experienced venous thromboembolism (VTE), three of whom had risk factors for thrombosis [Factor V Leiden mutation (n=1); BMI>29 kg/m2 (n=2)]. During 21,482 treatment cycles in the phase 3 studies evaluable for expulsion, women reported partial expulsions in 4259 (19.5%) cycles and complete expulsions in 1509 (7%) cycles, most frequently in the initial cycle [499/2050 (24.3%) and 190/2050 (9.3%), respectively]. Safety-focused studies revealed no safety concerns. CONCLUSION The 1-year SA/EE CVS has an acceptable safety profile. Additional studies are warranted in obese women at higher risk of VTE. IMPLICATIONS This 1-year contraceptive vaginal system represents a new long-term, user-controlled and procedure-free option with a safety profile similar to other combination hormonal contraceptives. The same precautions currently used for combination hormonal contraceptive prescriptions apply to this new contraceptive vaginal system.
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Affiliation(s)
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Michael Thomas
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, USA
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Creasy
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Heather Sussman
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Mohcine Alami
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD, USA
| | - Edith Weisberg
- Family Planning NSW, and University of Sydney, Sydney, Australia
| | - Ian Fraser
- University of New South Wales; Family Planning NSW, and University of Sydney, Sydney, Australia
| | | | - Melissa Gilliam
- Department of Obstetrics, Gynecology and Pediatrics, University of Chicago, Chicago, IL, USA
| | - James Liu
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH, USA
| | | | - Marlena Plagianos
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kevin Roberts
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Diana Blithe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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18
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Monteiro I, Guazzelli CF, Bahamondes L. Advances in contraceptive vaginal rings: what does the future hold? Expert Opin Pharmacother 2018; 19:1685-1691. [PMID: 30286682 DOI: 10.1080/14656566.2018.1519549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Contraceptive vaginal rings (CVRs) are good contraceptive options because they do not require skilled providers, are self-administered, and show a higher stability of drug diffusion. AREAS COVERED This article provides a review of the developments made with CVRs over the past number of years, while giving focus to the latest CVRs that have gone through clinical development. The author of the article also provides an expert perspective on the future of these useful therapeutic options. EXPERT OPINION Pharmacokinetic studies have shown that segesterone, an absorbable progestin that is used alone or in combination with ethinyl estradiol (EE) or E2, is the CVR of choice at this present time. Indeed, segesterone has demonstrated safety and efficacy as a CVR and is also an appropriate option for lactating women, as they are not absorbed orally. However, good cycle control is important for improved CVR adherence. CVRs that allow the combination of more than one drug may unravel another multi-purpose use when combined with microbicides and could provide combined protection to women who wish to protect themselves from pregnancy and sexually transmitted infection.
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Affiliation(s)
- Ilza Monteiro
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
| | - Cristina Falbo Guazzelli
- b Family Planning clinic, Department of Obstetrics and Gynecology , University of Campinas Medical School , São Paulo , Brazil
| | - Luis Bahamondes
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
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McCoy CF, Apperley DC, Variano B, Sussman H, Loeven D, Boyd P, Malcolm RK. Solid state 13C NMR spectroscopy provides direct evidence for reaction between ethinyl estradiol and a silicone elastomer vaginal ring drug delivery system. Int J Pharm 2018; 548:689-697. [PMID: 30016672 DOI: 10.1016/j.ijpharm.2018.07.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/25/2018] [Accepted: 07/14/2018] [Indexed: 02/02/2023]
Abstract
Steroid molecules have a long history of incorporation into silicone elastomer materials for controlled release drug delivery applications. Previously, based on in vitro release testing and drug content analysis, we demonstrated indirectly that the contraceptive progestin levonorgestrel (LNG) chemically and irreversibly binds to addition cure silicone elastomers, presumably via a hydrosilylation reaction between the levonorgestrel ethynyl group and the hydrosilane groups in the poly(dimethylsiloxane-co-methylhydrosiloxane) crosslinker of the silicone elastomer. Here, for the first time, we report that solid state 13C nuclear magnetic resonance (NMR) spectroscopy provides direct evidence for the irreversible binding of ethinyl estradiol (EE) - an estrogenic steroid molecule also containing an ethynyl functional group - to an addition cure silicone elastomer. By preparing silicone elastomer samples containing 13C-labelled EE, signals in the NMR spectra could readily be assigned to both the free and bound EE. Additional depolymerisation studies, performed on an addition cure silicone elastomer system from which the unbound EE fraction was completely extracted, further confirmed the presence of bound EE through the formation of coloured reaction mixtures resulting from the reaction of bound EE and trifluoroacetic acid (TFA). These methods will be particularly useful in the ongoing development of new steroid-releasing silicone drug delivery devices, including various vaginal ring devices for contraception, HIV prevention and multipurpose prevention technology applications.
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Affiliation(s)
- Clare F McCoy
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - David C Apperley
- EPSRC National Solid-State NMR Service, Durham University, Durham DH1 3LE, UK
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
| | - Heather Sussman
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
| | - Daniel Loeven
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
| | - Peter Boyd
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK.
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20
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Jensen JT, Edelman AB, Chen BA, Archer DF, Barnhart KT, Thomas MA, Burke AE, Westhoff CL, Wan LS, Sitruk-Ware R, Kumar N, Variano B, Blithe DL. Continuous dosing of a novel contraceptive vaginal ring releasing Nestorone® and estradiol: pharmacokinetics from a dose-finding study. Contraception 2018; 97:422-427. [PMID: 29409834 PMCID: PMC5948142 DOI: 10.1016/j.contraception.2018.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/08/2018] [Accepted: 01/23/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND As part of a program to develop a novel estradiol-releasing contraceptive vaginal ring (CVR), we evaluated the pharmacokinetic (PK) profile of CVRs releasing segesterone acetate (Nestorone® (NES)) combined with one of three different estradiol (E2) doses. STUDY DESIGN A prospective, double-blind, randomized, multi-centered study to evaluate a 90-day CVR releasing NES [200mcg/day] plus E2, either 10mcg/day, 20mcg/day, or 40mcg/day in healthy reproductive-age women with regular cycles. Participants provided blood samples twice weekly for NES and E2 levels during the first 60 days (ring 1) and the last 30 days (ring 2) of use. A subset underwent formal PK assessments at ring initiation, ring exchange (limited PK), and study completion. RESULTS The main study enrolled 197 women; 22 participated in the PK substudy. Baseline characteristics between the main and PK participants were comparable, with an average BMI of 25.8 kg/m2 (SD 4.3). In the PK substudy, all three rings showed similar NES PK: mean area under the curve (AUC(0-72)) 34,181 pg*day/mL; concentration maximum (Cmax) 918 pg/mL; time to maximum concentration (Tmax) 3.5 h. For E2, the Cmax occurred at 2 h, and was significantly higher with the 20 mcg/day ring (mean 390 pg/mL); 10 mcg/day, 189 pg/mL, p=.003; 40 mcg/day, 189 pg/mL, p<.001), and declined rapidly to≤50 pg/mL for all doses by 24 h. For all subjects, the median E2 levels remained under 35 pg/mL during treatment. CONCLUSION PK parameters of NES were not affected when paired with different doses of E2, but E2 levels from all three doses were lower than anticipated and no dose response was observed. IMPLICATIONS While these novel estradiol-releasing combination contraceptive vaginal rings provided sustained release of contraceptive levels of Nestorone over 90 days, the E2 levels achieved were not consistent with bone protection, and a dose-response was not observed.
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Affiliation(s)
- J T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR.
| | - A B Edelman
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - B A Chen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - D F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - K T Barnhart
- Pennsylvania Clinical Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - M A Thomas
- Reproductive Medicine Research, Department of Obstetrics & Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - A E Burke
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - C L Westhoff
- Department of Obstetrics & Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - L S Wan
- Department of Obstetrics & Gynecology, New York University School of Medicine, New York, NY
| | - R Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY
| | - N Kumar
- Center for Biomedical Research, Population Council, New York, NY
| | - B Variano
- Center for Biomedical Research, Population Council, New York, NY
| | - D L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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21
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Effects of concurrent vaginal miconazole treatment on the absorption and exposure of Nestorone® (segesterone acetate) and ethinyl estradiol delivered from a contraceptive vaginal ring: a randomized, crossover drug–drug interaction study. Contraception 2018; 97:270-276. [DOI: 10.1016/j.contraception.2017.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/17/2017] [Accepted: 10/22/2017] [Indexed: 11/17/2022]
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Kumar N, Fagart J, Liere P, Mitchell SJ, Knibb AR, Petit-Topin I, Rame M, El-Etr M, Schumacher M, Lambert JJ, Rafestin-Oblin ME, Sitruk-Ware R. Nestorone® as a Novel Progestin for Nonoral Contraception: Structure-Activity Relationships and Brain Metabolism Studies. Endocrinology 2017; 158:170-182. [PMID: 27824503 PMCID: PMC5412978 DOI: 10.1210/en.2016-1426] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022]
Abstract
Nestorone® (NES) is a potent nonandrogenic progestin being developed for contraception. NES is a synthetic progestin that may possess neuroprotective and myelin regenerative potential as added health benefits. In receptor transactivation experiments, NES displayed greater potency than progesterone to transactivate the human progesterone receptor (PR). This was confirmed by docking experiments where NES adopts the same docking position within the PR ligand-binding domain (LBD) as progesterone and forms additional stabilizing contacts between 17α-acetoxy and 16-methylene groups and PR LBD, supporting its higher potency than progesterone. The analog 13-ethyl NES also establishes similar contacts as NES with Met909, leading to comparable potency as NES. In contrast, NES is not stabilized within the human androgen receptor LBD, leading to negligible androgen receptor transactivation. Because progesterone acts in the brain by both PR binding and indirectly via binding of the metabolite allopregnanolone to γ-aminobutyric acid type A receptor (GABAAR), we investigated if NES is metabolized to 3α, 5α-tetrahydronestorone (3α, 5α-THNES) in the brain and if this metabolite could interact with GABAAR. In female mice, low concentrations of reduced NES metabolites were identified by gas chromatography/mass spectrometry in both plasma and brain. Electrophysiological studies showed that 3α, 5α-THNES exhibited only limited activity to enhance GABAAR-evoked responses with WSS-1 cells and did not modulate synaptic GABAARs of mouse cortical neurons. Thus, the inability of reduced metabolite of NES (3α, 5α-THNES) to activate GABAAR suggests that the neuroprotective and myelin regenerative effects of NES are mediated via PR binding and not via its interaction with the GABAAR.
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Affiliation(s)
- Narender Kumar
- Population Council, Center for Biomedical Research, New York, New York 10065
| | | | - Philippe Liere
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Scott J. Mitchell
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | - Alanah R. Knibb
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | | | - Marion Rame
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Martine El-Etr
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Michael Schumacher
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Jeremy J. Lambert
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | | | - Regine Sitruk-Ware
- Population Council, Center for Biomedical Research, New York, New York 10065
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Development of controlled release systems over the past 50 years in the area of contraception. J Control Release 2016; 240:235-241. [DOI: 10.1016/j.jconrel.2015.12.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/22/2015] [Accepted: 12/23/2015] [Indexed: 11/23/2022]
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Malcolm RK, Boyd PJ, McCoy CF, Murphy DJ. Microbicide vaginal rings: Technological challenges and clinical development. Adv Drug Deliv Rev 2016; 103:33-56. [PMID: 26829289 DOI: 10.1016/j.addr.2016.01.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/13/2016] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
Abstract
Vaginal rings (VRs) are flexible, torus-shaped, polymeric devices designed to sustain delivery of pharmaceutical drugs to the vagina for clinical benefit. Following first report in a 1970 patent application, several steroid-releasing VR products have since been marketed for use in hormone replacement therapy and contraception. Since 2002, there has been growing interest in the use of VR technology for delivery of drugs that can reduce the risk of sexual acquisition of human immunodeficiency virus type 1 (HIV-1), the causative agent of acquired immunodeficiency syndrome (AIDS). Although no vaginally-administered product has yet been approved for HIV reduction/prevention, extensive research efforts are continuing and a number of VR devices offering sustained release of so-called 'HIV microbicide' compounds are currently being evaluated in late-stage clinical studies. This review article provides an overview of the published scientific literature within this important field of research, focusing primarily on articles published within peer-reviewed journal publications. Many important aspects of microbicide-releasing VR technology are discussed, with a particular emphasis on the technological, manufacturing and clinical challenges that have emerged in recent years.
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Nanda K, Callahan R, Dorflinger L. Addressing gaps in the contraceptive method mix: methods in development. ACTA ACUST UNITED AC 2015; 11:729-35. [PMID: 26674125 DOI: 10.2217/whe.15.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite the availability of a variety of contraceptive methods, millions of women still have an unmet need for contraceptive choices. Short-acting methods are plagued by issues with adherence, leading to imperfect or inconsistent use and subsequent unintended pregnancy. Long-acting contraceptive methods such as intrauterine devices and contraceptive implants, while providing highly effective and safe contraception, do not meet the needs of all women, often due to cost, access or acceptability issues. Several new methods are in various stages of development and are designed to address the shortcomings of current methods. Providers should be aware of these future options and how they might better meet women's needs.
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Affiliation(s)
- Kavita Nanda
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
| | - Rebecca Callahan
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
| | - Laneta Dorflinger
- Contraceptive Technology Innovation Department, Global Health, Population & Nutrition, FHI 360, Durham, NC, USA
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Huang Y, Merkatz RB, Hillier SL, Roberts K, Blithe DL, Sitruk-Ware R, Creinin MD. Effects of a One Year Reusable Contraceptive Vaginal Ring on Vaginal Microflora and the Risk of Vaginal Infection: An Open-Label Prospective Evaluation. PLoS One 2015; 10:e0134460. [PMID: 26267119 PMCID: PMC4534458 DOI: 10.1371/journal.pone.0134460] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/07/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A contraceptive vaginal ring (CVR) containing Nestorone® (NES) and ethinyl estradiol (EE) that is reusable for 1- year (13 cycles) is under development. This study assessed effects of this investigational CVR on the incidence of vaginal infections and change in vaginal microflora. METHODS There were 120 women enrolled into a NES/EE CVR Phase III trial and a microbiology sub-study for up to 1- year of cyclic product use. Gynecological examinations were conducted at baseline, the first week of cycle 6 and last week of cycle 13 (or during early discontinuation visits). Vaginal swabs were obtained for wet mount microscopy, Gram stain and culture. The CVR was removed from the vagina at the last study visit and cultured. Semi-quantitative cultures for Lactobacillus, Gardnerella vaginalis, Enterococcus faecalis, Staphylococcus aureus, Escherichia coli, anaerobic gram negative rods (GNRs), Candida albicans and other yeasts were performed on vaginal and CVR samples. Vaginal infections were documented throughout the study. RESULTS Over 1- year of use, 3.3% of subjects were clinically diagnosed with bacterial vaginosis, 15.0% with vulvovaginal candidiasis, and 0.8% with trichomoniasis. The detection rate of these three infections did not change significantly from baseline to either Cycle 6 or 13. Nugent scores remained stable. H2O2-positive Lactobacillus dominated vaginal flora with a non-significant prevalence increase from 76.7% at baseline to 82.7% at cycle 6 and 90.2% at cycle 13, and a median concentration of 107 colony forming units (cfu) per gram. Although anaerobic GNRs prevalence increased significantly, the median concentration decreased slightly (104 to 103cfu per gram). There were no significant changes in frequency or concentrations of other pathogens. High levels of agreement between vaginal and ring surface microbiota were observed. CONCLUSION Sustained use of the NES/EE CVR did not increase the risk of vaginal infection and was not disruptive to the vaginal ecosystem. TRIAL REGISTRATION ClinicalTrials.gov NCT00263341, NCT00455156.
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Affiliation(s)
- Yongmei Huang
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Ruth B. Merkatz
- Population Council, Center for Biomedical Research, New York, United States of America
- * E-mail:
| | - Sharon L. Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh and the Magee-Womens Research Institute, Pittsburgh, United States of America
| | - Kevin Roberts
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Diana L. Blithe
- Contraceptive Discovery and Development Branch, National Institute of Child Health and Human Development, Bethesda, United States of America
| | - Régine Sitruk-Ware
- Population Council, Center for Biomedical Research, New York, United States of America
| | - Mitchell D. Creinin
- Department of Obstetrics and Gynecology, University of California Davis, Sacramento, United States of America
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Lack of in vitro–in vivo correlation for a UC781-releasing vaginal ring in macaques. Drug Deliv Transl Res 2015; 5:27-37. [DOI: 10.1007/s13346-015-0216-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Merkatz RB, Plagianos M, Hoskin E, Cooney M, Hewett PC, Mensch BS. Acceptability of the Nestorone®/ethinyl estradiol contraceptive vaginal ring: development of a model; implications for introduction. Contraception 2014; 90:514-21. [PMID: 24993487 DOI: 10.1016/j.contraception.2014.05.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 05/07/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Develop and test a theoretical acceptability model for the Nestorone®/ethinyl estradiol contraceptive vaginal ring (CVR); explore whether domains of use within the model predict satisfaction, method adherence and CVR continuation. STUDY DESIGN Four domains of use were considered relative to outcome markers of acceptability, that is, method satisfaction, adherence and continuation. A questionnaire to evaluate subjects' experiences relative to the domains, their satisfaction (Likert scale) and adherence to instructions for use was developed and administered to 1036 women enrolled in a 13-cycle Phase 3 trial. Method continuation was documented from the trial database. Stepwise logistic regression (LR) analysis was conducted and odds ratios (ORs) calculated to assess associations of satisfaction with questions from the four domains. Fisher's Exact Test was used to determine the association of satisfaction with outcome measures. RESULTS A final acceptability model was developed based on the following determinants of CVR satisfaction: ease of use, side effects, expulsions/feeling the CVR and sexual activity including physical effects during intercourse. Satisfaction was high (89%) and related to higher method adherence [OR, 2.6 (1.3, 5.2)] and continuation [OR, 5.5 (3.5, 8.4)]. According to the LR analysis, attributes of CVR use representing items from the four domains - finding it easy to remove, not complaining of side effects, not feeling the CVR while wearing it and experiencing no change or an increase in sexual pleasure and/or frequency - were associated with higher odds of satisfaction. CONCLUSION Hypothesized domains of CVR use were related to satisfaction, which was associated with adherence and continuation. Results provide a scientific basis for introduction and future research. IMPLICATIONS STATEMENT Acceptability research is important when introducing a new method of contraception and determining whether it can be a successful option in meeting the reproductive health needs of women and men. This study was designed to test a conceptual model of acceptability and identify factors associated with successful use of a new contraceptive delivery modality. Original research was conducted for this publication.
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Guazzelli CAF, Barbieri M, Vieira CS, Torloni MR. New Developments in Vaginal Rings for Contraception. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014. [DOI: 10.1007/s13669-014-0080-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bahamondes L, Bahamondes MV. New and emerging contraceptives: a state-of-the-art review. Int J Womens Health 2014; 6:221-34. [PMID: 24570597 PMCID: PMC3933723 DOI: 10.2147/ijwh.s46811] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The first hormonal contraceptive was introduced onto the market in several countries 50 years ago; however, the portfolio of contraceptive methods remains restricted with regards to their steroid composition, their cost, and their ability to satisfy the requirements of millions of women/couples in accordance with their different reproductive intentions, behaviors, cultures, and settings. Methods A literature review was conducted using Medline, Embase, and Current Contents databases, up to September 1, 2013 to identify publications reporting new contraceptives in development using combinations of the search terms: contraception, contraceptives, oral contraceptives, patch, vaginal ring, implants, intrauterine contraceptives, and emergency contraception (EC). Also, several experts in the field were also consulted to document ongoing projects on contraception development. Additionally, the Clinicaltrial.gov website was searched for ongoing studies on existing contraceptive methods and new and emerging female contraceptives developed over the past 5 years. Information was also obtained from the pharmaceutical industry. Results Early sexual debut and late menopause means that women may require contraception for up to 30 years. Although oral, injectable, vaginal, transdermal, subdermal, and intrauterine contraceptives are already available, new contraceptives have been developed in an attempt to reduce side effects and avoid early discontinuation, and to fulfill women’s different requirements. Research efforts are focused on replacing ethinyl-estradiol with natural estradiol to reduce thrombotic events. In addition, new, less androgenic progestins are being introduced and selective progesterone receptor modulators and new delivery systems are being used. In addition, research is being conducted into methods that offer dual protection (contraception and protection against human immunodeficiency virus transmission), and contraceptives for use “on demand.” Studies are also investigating non-hormonal contraceptive methods that have additional, non-contraceptive benefits. Conclusion The most pressing need worldwide is, first, that the highly effective contraceptive methods already available should be affordable to most of the population and also that these methods should fulfill the needs of women of different ages and with different reproductive requirements. The development of new contraceptive methods should also take advantage of the knowledge obtained over the past 30 years on gamete physiology and gamete interaction to avoid the use of steroid compounds.
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Affiliation(s)
- Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas and National Institute of Hormones and Women's Health, Campinas, SP, Brazil
| | - M Valeria Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas and National Institute of Hormones and Women's Health, Campinas, SP, Brazil
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Benagiano G, Gabelnick H, Farris M. Contraceptive devices: intravaginal and intrauterine delivery systems. Expert Rev Med Devices 2014; 5:639-54. [DOI: 10.1586/17434440.5.5.639] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Thurman AR, Clark MR, Hurlburt JA, Doncel GF. Intravaginal rings as delivery systems for microbicides and multipurpose prevention technologies. Int J Womens Health 2013; 5:695-708. [PMID: 24174884 PMCID: PMC3808127 DOI: 10.2147/ijwh.s34030] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There is a renewed interest in delivering pharmaceutical products via intravaginal rings (IVRs). IVRs are flexible torus-shaped drug delivery systems that can be easily inserted and removed by the woman and that provide both sustained and controlled drug release, lasting for several weeks to several months. In terms of women's health care products, it has been established that IVRs effectively deliver contraceptive steroids and steroids for the treatment of postmenopausal vaginal atrophy. A novel application for IVRs is the delivery of antiretroviral drugs for the prevention of human immunodeficiency virus (HIV) genital infection. Microbicides are antiviral drugs delivered topically for HIV prevention. Recent reviews of microbicide IVRs have focused on technologies in development and optimizing ring design. IVRs have several advantages, including the ability to deliver sustained drug doses for long periods of time while bypassing first pass metabolism in the gut. IVRs are discreet, woman-controlled, and do not require a trained provider for placement or fitting. Previous data support that women and their male sexual partners find IVRs highly acceptable. Multipurpose prevention technology (MPT) products provide protection against unintended/mistimed pregnancy and reproductive tract infections, including HIV. Several MPT IVRs are currently in development. Early clinical testing of new microbicide and MPT IVRs will require a focus on safety, pharmacokinetics and pharmacodynamics. Specifically, IVRs will have to deliver tissue concentrations of drugs that are pharmacodynamically active, do not cause mucosal alterations or inflammation, and do not change the resident microbiota. The emergence of resistance to antiretrovirals will need to be investigated. IVRs should not disrupt intercourse or have high rates of expulsion. Herein, we reviewed the microbicide and MPT IVRs currently in development, with a focus on the clinical aspects of IVR assessment and the challenges facing microbicide and MPT IVR product development, clinical testing, and implementation. The information in this review was drawn from PubMed searches and a recent microbicide/MPT product development workshop organized by CONRAD.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Meredith R Clark
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jennifer A Hurlburt
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Gustavo F Doncel
- CONRAD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Malcolm RK, Fetherston SM, McCoy CF, Boyd P, Major I. Vaginal rings for delivery of HIV microbicides. Int J Womens Health 2012. [PMID: 23204872 PMCID: PMC3508658 DOI: 10.2147/ijwh.s36282] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Following the successful development of long-acting steroid-releasing vaginal ring devices for the treatment of menopausal symptoms and contraception, there is now considerable interest in applying similar devices to the controlled release of microbicides against HIV. In this review article, the vaginal ring concept is first considered within the wider context of the early advances in controlled-release technology, before describing the various types of ring device available today. The remainder of the article highlights the key developments in HIV microbicide-releasing vaginal rings, with a particular focus on the dapivirine ring that is presently in late-stage clinical testing.
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Affiliation(s)
- R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Roumen FJME, Mishell DR. The contraceptive vaginal ring, NuvaRing®, a decade after its introduction. EUR J CONTRACEP REPR 2012; 17:415-27. [DOI: 10.3109/13625187.2012.713535] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Brache V, Payán LJ, Faundes A. Current status of contraceptive vaginal rings. Contraception 2012; 87:264-72. [PMID: 23040125 DOI: 10.1016/j.contraception.2012.08.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/26/2012] [Indexed: 11/18/2022]
Abstract
Contraceptive vaginal rings (CVR) offer a new, effective contraceptive option, expanding the available choices of hormonal contraception. Various ring prototypes have been evaluated: progestin-only rings and combined progestin-estrogen rings, as well as different combination of progestins and estrogens. The progestin-only ring is intended for continuous use, whereas the combined ring has been designed for cyclic 3-week in/1-week out use, although several studies have explored alternative schemes of extended use. However, only two ring designs have reached the market: NuvaRing, a 1-month combined ring that releases etonogestrel and ethinylestradiol, and Progering, a 3-month progesterone-releasing ring for use in lactating women. A one year Nestorone/ethinyl estradiol CVR is approaching the final stages of development, as the Population Council is preparing to submit a new drug application to the Food and Drug Administration. The main advantages of CVRs are their effectiveness (similar or slightly better than the pill), ease of use without the need of remembering a daily routine, user ability to control initiation and discontinuation, nearly constant release rate allowing for lower doses, greater bioavailability and good cycle control with the combined ring, in comparison with oral contraceptives. Current prototypes in development include rings releasing progesterone receptor modulators, which would provide estrogen-free contraception, as well as combined rings releasing estradiol, instead of ethinyl-estradiol, providing a safer profile. Furthermore, intensive efforts towards developing dual protection rings, providing both contraception and protection against reproductive tract infections, offer hope that this greatly needed technology will soon undergo clinical testing and will be in the hands of women worldwide in the near future.
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Affiliation(s)
- Vivian Brache
- PROFAMILIA, P.O. Box 1053, Santo Domingo, Dominican Republic 10401.
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Abstract
INTRODUCTION Progesterone receptor (PR) agonists (progestins) and antagonists are developed for female contraceptives. However, non-contraceptive applications of newer progestins and PR modulators are being given more attention. AREAS COVERED The newer PR agonists including drospirenone, nomegestrol, trimegestone, dienogest and nestorone are being evaluated as contraceptives with health benefits because of their unique pharmacological properties. The selective PR modulators (SPRM; PR antagonists with PR agonistic properties) are under development not only for emergency contraception but also for other health benefits such as the treatment of endometritis and leiomyoma. After searching the literature from PubMed, clinicaltrials.gov and patent database, this review focuses on the effects and mechanisms of these progestins, and SPRMs as contraceptives with other health benefits. EXPERT OPINION PR agonists and antagonists that have novel properties may generate better contraceptive effects with other health benefits.
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Affiliation(s)
- Ying Su
- The 2nd Affiliated Hospital, Wenzhou Medical College, 109 Xueyuan Road, Wenzhou, Zhejiang 325000, China
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Bahamondes L, Bahamondes MV, Fernandes AMDS, Monteiro I. Emerging female contraceptives. Expert Opin Emerg Drugs 2011; 16:373-87. [DOI: 10.1517/14728214.2011.536761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Helbling IM, Luna JA, Cabrera MI. Mathematical modeling of drug delivery from torus-shaped single-layer devices. J Control Release 2010; 149:258-63. [PMID: 20971140 DOI: 10.1016/j.jconrel.2010.10.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/03/2010] [Accepted: 10/14/2010] [Indexed: 01/27/2023]
Abstract
A mathematical modeling of controlled release of drug from torus-shaped single-layer devices is presented. Analytical solutions based on the pseudo-steady state approximation are derived. The reliability and usefulness of the model are ascertained by comparison of the simulation results with matrix-type vaginal ring experimental release data reported in the literature. A good agreement between the model prediction and the experimental data is observed. An analysis of the effect of the variation in torus design parameters on the solute release is also presented. The model is applicable only to torus-shaped single-layer systems wherein the initial load of drug is higher than its solubility in the polymer.
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Affiliation(s)
- Ignacio M Helbling
- Laboratorio de Química Fina, Instituto de Desarrollo Tecnológico para la Industria Química (INTEC), Universidad Nacional del Litoral and Consejo Nacional de Investigaciones Científicas y Técnicas (UNL-CONICET), CCT CONICET-SANTA FE, Ruta Nacional 168, Paraje El Pozo, 3000, Santa Fe, Argentina.
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Abstract
The contraceptive vaginal ring is a relatively new combined hormonal contraceptive method. Ethinyl estradiol and etonogestrel are rapidly absorbed through the vaginal epithelium and result in a steady serum concentration. Studies have demonstrated that the efficacy and safety of the ring are equivalent to oral contraceptives (OCs). Patients report being highly satisfied with the vaginal ring and report fewer systemic side effects than do OC users. The ring provides effective cycle control as well as symptom relief for women with menorrhagia, dysmenorrhea and polycystic ovarian syndrome. A new combined contraceptive ring containing Nestorone and ethinyl estradiol is currently being investigated in a Phase 3 trial. A progesterone-releasing vaginal ring appropriate for lactating women is available in Chile and Peru. Recent studies have demonstrated that vaginal rings can also be effective means of delivering antiretroviral drugs that provide protection from HIV.
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Hugon-Rodin J, Chabbert-Buffet N, Bouchard P. The future of women's contraception: stakes and modalities. Ann N Y Acad Sci 2010; 1205:230-9. [DOI: 10.1111/j.1749-6632.2010.05688.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Prasad PV, Bashir M, Sitruk-Ware R, Kumar N. Single-dose pharmacokinetics of Nestorone, a potential female-contraceptive. Steroids 2010; 75:252-64. [PMID: 20064539 DOI: 10.1016/j.steroids.2009.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 12/26/2009] [Accepted: 12/29/2009] [Indexed: 11/25/2022]
Abstract
A synthetic progestin Nestorone is being developed for female-contraception. This study was conducted to determine the distribution, metabolism, and excretion of tritium-labeled Nestorone ((3)H Nestorone) in adult female rats. Rats were injected subcutaneously (S.C.) with a single dose of 400 microCi (3)H Nestorone/kg BW. Its distribution and concentrations in blood, plasma and other tissues were determined at defined times. The excreta were examined for elimination of (3)H Nestorone. Radioactivity in all samples was analyzed by liquid scintillation counter. Metabolite profiling was performed by HPLC and LC/MS analysis of the plasma, urine, and feces samples. Following subcutaneous injection of (3)H Nestorone, the mean peak concentrations of radioactivity (C(max)) in the blood and plasma were 58.1 and 95.5 ng equiv. (3)H Nestorone/g, respectively, at 2-h postdose (T(max)). Thereafter, the concentration of drug steadily declined through 96-h postdose with a terminal elimination half-life (t(1/2)) of 15.6 h. (3)H Nestorone-derived radioactivity was widely distributed in most tissues by 0.5 h and attained a mean maximal concentration by 2-h postdose. Approximately, 81.4% and 7.62% of the administered dose was excreted via feces and urine, respectively. In vivo metabolism of (3)H Nestorone resulted into a total of 19 metabolites. Among them, two metabolites viz., 17alpha-deacetyl-Nestorone (M9) and 4,5-dihydro-17alpha-deacetyl-Nestorone (M19) were identified by HPLC and LC/MS analysis. Metabolite profiling of plasma samples showed that most of the circulating radioactivity was associated with unchanged parent drug, and M19. The M19 was a major metabolite in the profiled urine and feces samples. Presence of large proportion of drug/drug-related material in feces suggested that the biliary excretion is a main elimination route of (3)H Nestorone. The distribution, metabolism, and excretion profiles of (3)H Nestorone obtained in this study provide a fairly good insight about its fate in women.
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Affiliation(s)
- Pramod Vishwanath Prasad
- Center for Biomedical Research, The Population Council, The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA.
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Mahabadi V, Amory JK, Swerdloff RS, Bremner WJ, Page ST, Sitruk-Ware R, Christensen PD, Kumar N, Tsong YY, Blithe D, Wang C. Combined transdermal testosterone gel and the progestin nestorone suppresses serum gonadotropins in men. J Clin Endocrinol Metab 2009; 94:2313-20. [PMID: 19366848 PMCID: PMC2708961 DOI: 10.1210/jc.2008-2604] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT Testosterone (T) plus progestin combinations are the most promising hormonal male contraceptives. Nestorone (NES), a progestin without estrogenic or androgenic activity, when combined with T may be an excellent candidate for male contraception. OBJECTIVE Our objective was to determine the effect of transdermal NES gel alone or with T gel on gonadotropin suppression. DESIGN AND SETTING The randomized, unblinded clinical trial was conducted at two academic medical centers. PARTICIPANTS A total of 140 healthy male volunteers participated. INTERVENTIONS One hundred subjects were randomized initially (20 per group) to apply NES gel 2 or 4 mg, T gel 10 g, or T gel 10 g plus NES gel 2 or 4 mg daily for 20 d. Because only about half of the subjects in T plus NES 4 mg group suppressed serum gonadotropins to 0.5 IU/liter or less (suboptimal suppression), two additional groups of 20 men were randomized to apply daily T gel 10 g plus NES gel 6 or 8 mg. MAIN OUTCOME VARIABLE Suppression of serum LH and FSH concentrations to 0.5 IU/liter or less after treatment was the main outcome variable. RESULTS A total of 119 subjects were compliant with gel applications with few study-related adverse events. NES alone reduced gonadotropins significantly but less than T gel alone. Combined T gel 10g plus NES gel 6 or 8 mg suppressed both serum gonadotropins to 0.5 IU/liter or less in significantly more men than either gel alone. CONCLUSION Transdermal NES gel alone had gonadotropin suppression activity. Combined transdermal NES (6 or 8 mg) plus T gel demonstrated safe and effective suppression of gonadotropins, justifying a longer-term study of this combination for suppression of spermatogenesis.
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Affiliation(s)
- Vahid Mahabadi
- Department of Medicine, Division of Endocrinology, Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, California 90509, USA
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Methods for Female Contraception: A Model for Innovation in Drug Delivery Systems. Clin Pharmacol Ther 2009; 85:553-7. [DOI: 10.1038/clpt.2009.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sitruk-Ware R, Plu-Bureau G, Menard J, Conard J, Kumar S, Thalabard JC, Tokay B, Bouchard P. Effects of oral and transvaginal ethinyl estradiol on hemostatic factors and hepatic proteins in a randomized, crossover study. J Clin Endocrinol Metab 2007; 92:2074-9. [PMID: 17374706 DOI: 10.1210/jc.2007-0026] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The use of combined hormonal contraceptives with ethinyl estradiol (EE) and a progestin results in alterations in potential biomarkers of venous thromboembolism risk. Evaluation of the impact of delivery route on these changes is difficult due to an interaction between EE and the progestin component. OBJECTIVE The aim of the study was to compare the impact of oral and vaginal administration of EE alone on hemostatic variables and estrogen-sensitive liver proteins. DESIGN This was a single-center, randomized, crossover study with two treatment cycles separated by a washout cycle. SETTING The study was conducted in an academic outpatient center. PARTICIPANTS Fourteen healthy postmenopausal women were enrolled; 13 completed the study and were included in the analyses. INTERVENTION Participants were randomized to receive EE (15 microg/d) delivered by oral tablet or vaginal ring for 21 d in one of two treatment sequences. MAIN OUTCOME MEASURES Changes in plasma concentration or activity of 10 hemostatic variables and six estrogen-sensitive liver proteins between baseline and d 21 of treatment were the primary outcomes. RESULTS Prothrombin fragment 1 + 2 plasma level was unaffected by treatment or delivery route. Angiotensinogen (expressed as plasma level of angiotensin I) increased similarly with oral and vaginal delivery; mean (sd) increases were 2757 (1033) and 2864 (893) ng /ml, respectively (P = 0.0002). Alterations in other study variables, except total cholesterol, were similar with oral and vaginal administration. CONCLUSION Our results provide evidence that the customary effects of combined hormonal contraceptives on hemostatic variables and estrogen-sensitive liver proteins are largely related to EE and independent of delivery route during short-term treatment.
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Affiliation(s)
- Régine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY 10021, USA.
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Sitruk-Ware RL, Menard J, Rad M, Burggraaf J, de Kam ML, Tokay BA, Sivin I, Kluft C. Comparison of the impact of vaginal and oral administration of combined hormonal contraceptives on hepatic proteins sensitive to estrogen. Contraception 2007; 75:430-7. [PMID: 17519148 DOI: 10.1016/j.contraception.2007.01.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 11/23/2006] [Accepted: 01/23/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We evaluated the effects of a new combined hormonal contraceptive vaginal ring (CVR) delivering the nonandrogenic progestin Nestorone (NES) and ethinyl estradiol (EE) on several key estrogen-sensitive hepatic proteins that may be markers for the risk of arterial or venous disease events and on blood pressure (BP). Because the pharmacologic androgenicity of the progestin in these formulations influences the hepatic impact of EE, we selected an oral contraceptive (OC) delivering the androgenic progestin levonorgestrel (LNG) and EE as the comparator. We also investigated the effect of delivery route, which is known to modify the hepatic effects of estradiol, but has not been widely studied with EE. STUDY METHODS Women, aged 18-34 years, with no contraindications to the use of combined OCs, were randomized to three cycles of treatment with a CVR delivering NES/EE (150/15 microg/day) or a combined OC providing LNG and EE (150/30 microg per tablet). Each cycle consisted of 21 days of active treatment, followed by 7 days without treatment. During the last weeks of the pretreatment and third treatment cycles, blood samples were obtained for determinations of plasma concentrations of angiotensinogen, an estrogen-sensitive hepatic protein, and serum concentrations of sex hormone-binding globulin (SHBG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and estrogen- and androgen-sensitive proteins. BP was also measured. RESULTS Of 47 women randomized, 45 completed the study (CVR: 23; OC: 22). Within-group comparisons over time by repeated-measure analysis of variance demonstrated statistically significant changes over time with both treatments for all hepatic proteins (p < .02) but not for TC. The within-group effects, presented as relative percent difference [95% confidence interval (CI)], were greatest for angiotensinogen [CVR: 227% (195-262%); OC: 251.3% (218-288%)] and SHBG [CVR: 306% (237-389%); OC: 55% (30-86)]. Both treatments were associated with small changes in systolic BP and diastolic BP (DBP), but only the within-group change in DBP for the OC group was statistically significant (p = .04). Between-treatment comparisons of third treatment cycle mean values were performed by analysis of covariance (baseline values as covariate). No statistically significant between-treatment differences were found for angiotensinogen, sensitive only to estrogen, or BP. Statistically significant treatment differences were found for all estrogen- and androgen-sensitive proteins (p < or = .002) but not for TC. When presented as relative percent difference between the effects of treatment (CVR-OC/OC; 95% CI of percent difference), the difference was largest for SHBG (159% [117-210%]); smaller relative percent differences were found for HDL-C [31.9% (18.5-46.8%)], LDL-C [23.6% (33.4% to -2.4%)] and TG [39.0% (14.0-69.4%)], but not TC. CONCLUSION Vaginal delivery of a combined hormonal contraceptive did not reduce the EE-associated changes in estrogen-sensitive hepatic proteins observed after use of a combined OC. Significant treatment differences between the NES/EE CVR and the LNG/EE OC were found for SHBG, HDL-C, LDL-C, and TG, proteins sensitive to androgen as well as estrogen. No treatment difference was observed for angiotensinogen, which is sensitive only to estrogen. The observed treatment differences were therefore most likely due to the difference in androgenicity between NES and LNG.
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MESH Headings
- Adolescent
- Adult
- Blood Proteins/drug effects
- Cholesterol/blood
- Cholesterol, HDL/blood
- Cholesterol, HDL/drug effects
- Cholesterol, LDL/blood
- Cholesterol, LDL/drug effects
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/pharmacology
- Contraceptive Devices, Female
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/pharmacology
- Ethinyl Estradiol/administration & dosage
- Ethinyl Estradiol/pharmacology
- Female
- Humans
- Levonorgestrel/administration & dosage
- Levonorgestrel/pharmacology
- Menstrual Cycle
- Norprogesterones/administration & dosage
- Norprogesterones/pharmacology
- Sex Hormone-Binding Globulin/drug effects
- Triglycerides/blood
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Rad M, Kluft C, Ménard J, Burggraaf J, de Kam ML, Meijer P, Sivin I, Sitruk-Ware RL. Comparative effects of a contraceptive vaginal ring delivering a nonandrogenic progestin and continuous ethinyl estradiol and a combined oral contraceptive containing levonorgestrel on hemostasis variables. Am J Obstet Gynecol 2006; 195:72-7. [PMID: 16545330 DOI: 10.1016/j.ajog.2005.12.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 11/04/2005] [Accepted: 12/05/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to compare the effects on hemostasis variables of a contraceptive vaginal ring with those of an oral contraceptive. STUDY DESIGN Twenty-three and 22 healthy premenopausal women were randomized to the contraceptive vaginal ring (150 microg Nestorone and 15 microg ethinyl estradiol) or Stediril 30 during 3 cycles. Analysis of covariance was performed with baseline values as covariate. RESULTS The contraceptive vaginal ring changed most hemostasis variables similarly but raised (95% confidence intervals of percent treatment differences) Factor VIIt (28% to 49%), extrinsic activated protein C resistance (14% to 65%), and sex hormone-binding globulin (117% to 210%) and lowered Protein S (-32% to -16%) and the global activated partial thromboplastin time-based activated protein C resistance (-12% to -2%) more than the oral contraceptive. CONCLUSION The contraceptive vaginal ring affected some measured hemostasis variables and sex hormone-binding globulin differently from the oral contraceptive, most likely because of difference in androgenicity of the progestins. The results suggest that the contraindications for oral contraceptive use would also apply to the tested contraceptive vaginal ring.
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Affiliation(s)
- Mandana Rad
- Centre for Human Drug Research, Leiden, The Netherlands.
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