1
|
Gassen J, Mengelkoch S, Shanmugam D, Pearson JT, van Lamsweerde A, Benhar E, Hill SE. Longitudinal changes in sexual desire and attraction among women who started using the Natural Cycles app. Horm Behav 2024; 162:105546. [PMID: 38640590 DOI: 10.1016/j.yhbeh.2024.105546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024]
Abstract
Many women experience sexual side effects, such as decreased libido, when taking hormonal contraceptives (HCs). However, little is known about the extent to which libido recovers after discontinuing HCs, nor about the timeframe in which recovery is expected to occur. Given that HCs suppress the activities of multiple endogenous hormones that regulate both the ovulatory cycle and women's sexual function, resumption of cycles should predict libido recovery. Here, using a combination of repeated and retrospective measures, we examined changes in sexual desire and partner attraction (among partnered women) across a three-month period in a sample of Natural Cycles users (Survey 1: n = 1596; Survey 2: n = 550) who recently discontinued HCs. We also tested whether changes in these outcomes coincided with resumption of the ovulatory cycle and whether they were associated with additional factors related to HC use (e.g., duration of HC use) or relationship characteristics (e.g., relationship length). Results revealed that both sexual desire and partner attraction, on average, increased across three months after beginning to use Natural Cycles. While the prediction that changes in sexual desire would co-occur with cycle resumption was supported, there was also evidence that libido continued to increase even after cycles resumed. Together, these results offer new insights into relationships between HC discontinuation and women's sexual psychology and lay the groundwork for future research exploring the mechanisms underlying these effects.
Collapse
Affiliation(s)
- Jeffrey Gassen
- Texas Christian University, Department of Psychology, 2955 S. University Dr., Fort Worth, TX 76129, United States of America; University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences, UCLA Medical Plaza 300, Los Angeles, CA 90095-7076, United States of America.
| | - Summer Mengelkoch
- Texas Christian University, Department of Psychology, 2955 S. University Dr., Fort Worth, TX 76129, United States of America; University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences, UCLA Medical Plaza 300, Los Angeles, CA 90095-7076, United States of America
| | - Divya Shanmugam
- Massachusetts Institute of Technology, Department of Electrical Engineering and Computer Science, Cambridge, MA 02139, United States of America
| | - Jack T Pearson
- Natural Cycles Nordic AB, Sankt Eriksgatan 63 B, 112 34 Stockholm, Sweden
| | | | - Eleonora Benhar
- Natural Cycles Nordic AB, Sankt Eriksgatan 63 B, 112 34 Stockholm, Sweden
| | - Sarah E Hill
- Texas Christian University, Department of Psychology, 2955 S. University Dr., Fort Worth, TX 76129, United States of America
| |
Collapse
|
2
|
Donangelo CM, Cornes R, Sintes C, Bezerra FF. Combined Oral Contraceptives: Association with Serum 25-Hydroxyvitamin D and Calcium and Bone Homeostasis. J Womens Health (Larchmt) 2024; 33:805-815. [PMID: 38417038 DOI: 10.1089/jwh.2023.0657] [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] [Indexed: 03/01/2024] Open
Abstract
Background: Use of combined oral contraceptives (COCs) has been found to increase serum 25-hydroxyvitamin D [25(OH)D] but effects on calcium and bone homeostasis are unclear. Materials and Methods: Serum 25(OH)D, parathyroid hormone (PTH), alkaline phosphatase (ALK) and estradiol, dietary intake of bone-related nutrients and foods, bone mineral density (BMD), and body fat were compared in adult women (20-35 years; body mass index 21.5 ± 2.3 kg/m2) users (+COC, n = 32) and nonusers (-COC, n = 20) of COC. Biochemical markers were measured by automated assays. BMD at total body (TB), lumbar spine (LS), femoral neck (FN) and trochanter (TR), and body fat, were measured by dual-energy X-ray absorptiometry. Dietary intake was assessed by a food frequency questionnaire. Results: Intake of calcium, dairy foods, and fruits and vegetables, were adequate and did not differ by COC. Mean 25(OH)D was 35% higher in +COC (110.4 ± 27.3 nmol/L, 44.2 ± 1.8 ng/mL) compared with -COC (81.7 ± 22.8 nmol/L, 32.7 ± 2.3 ng/mL; p < 0.001). Mean PTH, ALK, and estradiol were 28%, 12%, and 62% lower, respectively, in +COC compared with -COC (p ≤ 0.05). Mean BMD z-scores (all sites) were adequate and did not differ by COC. There were no correlations between 25(OH)D and dietary, biochemical, and body composition variables. PTH was inversely correlated with TR-BMD z-score in -COC (r = -0.47; p = 0.04), and ALK was inversely correlated with TB-, TR-, and LS-BMD z-scores in -COC (r ≤ -0.43; p ≤ 0.04), but not in +COC. Conclusions: Increased serum 25(OH)D with COC use was paralleled by expected physiologic adjustments in calcium and bone homeostasis, and adequate bone mass status, in nonobese young adult women consuming bone-healthy diets.
Collapse
Affiliation(s)
| | - Rafael Cornes
- Escuela de Nutrición, Universidad de la República, Montevideo, Uruguay
| | - Celia Sintes
- Escuela de Nutrición, Universidad de la República, Montevideo, Uruguay
| | - Flavia F Bezerra
- Instituto de Nutrição, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brasil
| |
Collapse
|
3
|
Badenhorst CE, Goto K, O'Brien WJ, Sims S. Iron status in athletic females, a shift in perspective on an old paradigm. J Sports Sci 2021; 39:1565-1575. [PMID: 33583330 DOI: 10.1080/02640414.2021.1885782] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Iron deficiency is a common nutrient deficiency within athletes, with sport scientists and medical professionals recognizing that athletes require regular monitoring of their iron status during intense training periods. Revised considerations for athlete iron screening and monitoring have suggested that males get screened biannually during heavy training periods and females require screening biannually or quarterly, depending on their previous history of iron deficiency. The prevalence of iron deficiency in female athletes is higher than their male counterparts and is often cited as being a result of the presence of a menstrual cycle in the premenopausal years. This review has sought to revise our current understanding of female physiology and the interaction between primary reproductive hormones (oestrogen and progesterone) and iron homoeostasis in females. The review highlights an apparent symbiotic relationship between iron metabolism and the menstrual cycle that requires additional research as well as identifying areas of the menstrual cycle that may be primed for nutritional iron supplementation.
Collapse
Affiliation(s)
- Claire E Badenhorst
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Kazushige Goto
- Graduate School of Sport and Health Science, Ritsumeikan University, Kusatsu, Japan
| | - Wendy J O'Brien
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Stacy Sims
- Te Huataki Waiora - School of Health, the University of Waikato, Hamilton, New Zealand
| |
Collapse
|
4
|
Asprodini E, Tsiokou V, Begas E, Kilindris T, Kouvaras E, Samara M, Messinis I. Alterations in Xenobiotic-Metabolizing Enzyme Activities across Menstrual Cycle in Healthy Volunteers. J Pharmacol Exp Ther 2018; 368:262-271. [PMID: 30591530 DOI: 10.1124/jpet.118.254284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/06/2018] [Indexed: 11/22/2022] Open
Abstract
The purpose of the study was to determine whether the in vivo activities of drug-metabolizing enzymes CYP1A2 and CYP2A6, xanthine oxidase (XO), and N-acetyltransferase-2 (NAT2) vary across the menstrual cycle. Forty-two healthy women were studied at early follicular phase (EFP: 2nd to 4th days), late follicular phase (LFP: 10th to 12th days), and luteal phase (LP: 19th to 25th days) of a single menstrual cycle, and blood and urine samples were collected at each phase. Spot urine samples obtained 6 hours following 200-mg caffeine administration were used to determine caffeine metabolite ratios (CMRs); blood samples were used to determine CYP1A2*1F (rs762551) and CYP1A2*1C (rs2069514) polymorphisms and the hormonal profile (estradiol, progesterone, and luteinizing and follicle-stimulating hormones) at EFP, LFP, and LP. CMR and hormone variations were analyzed at three levels (EFP, LFP, LP) using one-way repeated-measures analysis of variance. CYP1A2 activity was lower and that of CYP2A6 and NAT2 were higher at LFP compared with EFP and LP. Enzyme alterations were significant in volunteers (n = 21) whose hormonal profiles at EFP, LFP, and LP corresponded to expected levels, but not in volunteers (n = 15) with presumed early or late sampling around LFP. No significant difference was detected in any enzyme activity in presumed anovulatory volunteers (n = 6). The reduction of CYP1A2 activity at LFP was not associated with smoking or CYP1A2*1F polymorphism. XO and NAT2 (fast acetylators) activities remained unaltered. It is suggested that drug-metabolizing enzyme activities are altered across the menstrual cycle. Selection of appropriate sampling periods verified by hormonal assessment and identification of anovulatory cycles are decisive factors in disclosing altered enzyme activity across the menstrual cycle.
Collapse
Affiliation(s)
- E Asprodini
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - V Tsiokou
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - E Begas
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - T Kilindris
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - E Kouvaras
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - M Samara
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - I Messinis
- Laboratory of Pharmacology (E.A., V.T., E.B., E.K.), Medical Informatics (T.K.), Pathology (M.S.), and Department of Obstetrics and Gynecology (I.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
5
|
Gersten J, Hsieh J, Weiss H, Ricciotti NA. Effect of Extended 30 μg Ethinyl Estradiol with Continuous Low-Dose Ethinyl Estradiol and Cyclic 20 μg Ethinyl Estradiol Oral Contraception on Adolescent Bone Density: A Randomized Trial. J Pediatr Adolesc Gynecol 2016; 29:635-642. [PMID: 27287084 DOI: 10.1016/j.jpag.2016.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 05/04/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To compare changes in lumbar spine bone mineral density after 12 months of a 91-day extended regimen or 28-day combined oral contraceptive with those in a healthy reference group not using hormonal contraceptives. DESIGN Phase 2, multicenter, open-label, randomized, controlled study. SETTING Forty-five academic centers, clinical research centers, and community practices in the United States. PARTICIPANTS Eight hundred twenty-nine postmenarcheal adolescent girls aged 12-18 years. INTERVENTIONS Adolescents were randomly assigned to 91-day levonorgestrel (LNG)/ethinyl estradiol (EE) extended regimen (84 days of LNG 150 μg/EE 30 μg with 7 days of EE 10 μg [LNG/EE extended regimen]) or 28 days of LNG/EE (21 days of LNG 100 μg/EE 20 μg with 7 days of placebo [LNG/EE 21/7]) for 12 months. A reference group not seeking hormonal contraception was also evaluated. MAIN OUTCOME MEASURES The primary end point was mean percent change in lumbar spine bone mineral density measured using dual-energy x-ray absorptiometry. RESULTS Of 1361 adolescents randomized/enrolled, 829 were included in the primary analysis. Mean changes in lumbar spine bone mineral density were +2.26% with LNG/EE extended regimen, +1.45% with LNG/EE 21/7, and +2.50% in the reference group. Noninferiority of the LNG/EE extended regimen compared with the reference group was shown. A statistically significant treatment difference was found between LNG/EE 21/7 and the reference group (1.05%; 95% confidence interval, 0.61%-1.49%) but not between LNG/EE extended regimen and the reference group (0.23%; 95% confidence interval, -0.20% to 0.67%). No new safety signals were noted. CONCLUSION Compared with the reference group, bone accrual was statistically significantly lower among LNG/EE 21/7 users but not among LNG/EE 30-μg extended regimen users. Additional research is needed to clarify the clinical relevance of these findings.
Collapse
Affiliation(s)
- Janet Gersten
- New Age Medical Research Corporation, Miami, Florida.
| | - Jennifer Hsieh
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pennsylvania
| | - Herman Weiss
- Teva Global Medical Affairs, Petach Tikva, Israel
| | | |
Collapse
|
6
|
Rationale for eliminating the hormone-free interval in modern oral contraceptives. Int J Gynaecol Obstet 2016; 134:8-12. [DOI: 10.1016/j.ijgo.2015.10.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/23/2015] [Accepted: 03/07/2016] [Indexed: 11/21/2022]
|
7
|
Nappi RE, Kaunitz AM, Bitzer J. Extended regimen combined oral contraception: A review of evolving concepts and acceptance by women and clinicians. EUR J CONTRACEP REPR 2015; 21:106-15. [PMID: 26572318 PMCID: PMC4841029 DOI: 10.3109/13625187.2015.1107894] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: The clinical utility of extended regimen combined oral contraceptives (COCs) is increasingly being recognised. Our objective was to understand the attitudes of women and clinicians about the use of these regimens. We present the rationale for extended regimen COCs from a historical perspective, and trace their evolution and growing popularity in light of their clinical benefits. We conclude by offering potential strategies for counselling women about extended regimen COC options. Methods: We conducted a MEDLINE search to identify and summarise studies of extended regimen COCs, focusing on attitudes of women and clinicians regarding efficacy, safety/tolerability and fewer scheduled bleeding episodes and other potential benefits. Results: The body of contemporary literature on extended regimen COCs suggests that their contraceptive efficacy is comparable to that of conventional 28-day (i.e., 21/7) regimens. For women seeking contraception that allows infrequent scheduled bleeding episodes, particularly those who suffer from hormone withdrawal symptoms and cyclical symptoms (e.g., headache, mood changes, dysmenorrhoea, heavy menstrual bleeding), extended regimen COCs are an effective and safe option. Although satisfaction with extended regimen COCs in clinical trials is high, misperceptions about continuous hormone use may still limit the widespread acceptance of this approach. Conclusions: Despite the widespread acceptance among clinicians of extended regimen COCs as an effective and safe contraceptive option, these regimens are underused, likely due to a lack of awareness about their availability and utility among women. Improved patient education and counselling regarding the safety and benefits of extended regimen COCs may help women make more informed contraceptive choices.
Collapse
Affiliation(s)
- Rossella E Nappi
- a Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, Department of Obstetrics and Gynaecology , IRCCS San Matteo Foundation, University of Pavia , Pavia , Italy
| | - Andrew M Kaunitz
- b Department of Obstetrics and Gynecology , University of Florida College of Medicine-Jacksonville , Jacksonville , FL , USA
| | - Johannes Bitzer
- c Department of Obstetrics and Gynaecology , Basel University Hospital , Basel , Switzerland
| |
Collapse
|
8
|
Abstract
INTRODUCTION The focus in contraception is shifting from oral contraceptives to more effective methods, such as implants and intrauterine devices. Generics are favored by third-party payors. As a result, potentially exciting developments in branded pills to increase safety or to reduce side effects may have gone unnoticed. AREAS COVERED This article reviews the features of each of the four new oral contraceptives that have been introduced in the United States and/or Europe in the last few years. The motivation for the development of each product is outlined as is its efficacy, safety, tolerability and the noncontraceptive applications that have been explored are described. EXPERT OPINION The hypothesis that using estradiol in place of ethinyl estradiol would reduce the risk of venous thromboembolism is still to be proven. However, the stronger progestogens used in these formulations may offer other tangible benefits for selected women. The new products for extended cycle pill use may have less impact. The flexible regimen can be adopted using any pill, but the approved product does provide convenience to patients. Cost will continue to be the determining factor in the acceptance of these new products, unless substantial health benefits can be conclusively proven.
Collapse
Affiliation(s)
- Anita L Nelson
- a Obstetrics and Gynecology , David Geffen School of Medicine at UCLA , Manhattan Beach , CA , USA
| |
Collapse
|
9
|
Efficacy and safety of a 21/7-active combined oral contraceptive with continuous low-dose ethinyl estradiol. Contraception 2015; 93:249-56. [PMID: 26499407 DOI: 10.1016/j.contraception.2015.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Substituting low-dose ethinyl estradiol (EE) for the hormone-free interval in combined oral contraceptives (COCs) may enhance ovarian suppression and improve tolerability. This noncomparative phase 3 study evaluated the efficacy and safety of a 21/7-active COC regimen including 21days of desogestrel (DSG)/EE followed by 7days of EE. STUDY DESIGN This multicenter, open-label, phase 3, single-arm study enrolled sexually active women aged 18-40years at risk for pregnancy. Women received up to 1year, or 13 consecutive 28-day cycles, of DSG 150mcg/EE 20mcg for 21days and EE 10mcg alone for 7days. Participants kept diaries to record compliance, bleeding/spotting and other contraceptive use. Efficacy was measured using the Pearl Index (PI) and life-table approach. Safety and tolerability were assessed primarily through reported adverse events (AEs). RESULTS A total of 2858 women enrolled and 1680 completed the study. Forty-six pregnancies in 2401 women aged 18-35years occurred after COC initiation and up to 7days after last DSG/EE or EE-only tablet was taken. When cycles in which another contraceptive method was used were excluded, the PI was 2.68 [95% confidence interval (CI), 1.96-3.57]. The cumulative pregnancy rate after 1year of treatment was 2.47% (95% CI, 1.85-3.29) for all users aged 18-35years. When only cycles during which women considered compliant were included, the PI was 2.00 (95% CI, 1.39-2.80). AEs were similar to those seen with other oral contraceptives. CONCLUSIONS This 21/7-active DSG/EE COC with 7days of low-dose EE was efficacious and well tolerated for pregnancy prevention. IMPLICATIONS STATEMENT This phase 3 open-label study demonstrated that a 21/7-active COC regimen including 21days of DSG 150mcg/EE 20mcg and 7days of EE 10mcg was efficacious and well tolerated for pregnancy prevention.
Collapse
|
10
|
Seidman L, Kroll R, Howard B, Ricciotti N, Hsieh J, Weiss H. Ovulatory effects of three oral contraceptive regimens: a randomized, open-label, descriptive trial. Contraception 2015; 91:495-502. [DOI: 10.1016/j.contraception.2015.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 02/26/2015] [Accepted: 03/01/2015] [Indexed: 10/23/2022]
|
11
|
Burness CB. Extended-Cycle Levonorgestrel/Ethinylestradiol and Low-Dose Ethinylestradiol (Seasonique(®)): A Review of Its Use as an Oral Contraceptive. Drugs 2015; 75:1019-26. [PMID: 26017303 DOI: 10.1007/s40265-015-0407-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 91-day extended-cycle oral contraceptive (OC) consisting of levonorgestrel/ethinylestradiol 150/30 µg for 84 days and ethinylestradiol 10 µg for 7 days (Seasonique(®)) has recently been approved for the prevention of pregnancy in adult women in the EU. This regimen allows for a reduction in the number of withdrawal bleeding episodes to four per year, compared with 13 episodes per year with conventional 28-day regimens. Seasonique(®) was effective in preventing pregnancy in a large (n = 1006), noncomparative trial of healthy, sexually active women. In this trial, the overall Pearl index (pregnancies per 100 woman-years of use) in women aged 18-35 years (n = 621) was 0.76 and the Pearl index for method-failure (compliant use) was 0.26. Scheduled (withdrawal) bleeding and/or spotting remained fairly constant over time, with a mean of 2 days of bleeding and 1 day of spotting per each 91-day cycle. Unscheduled bleeding and unscheduled spotting was highest during the first few cycles of use and decreased thereafter. Seasonique(®) was generally well tolerated, with a tolerability profile in line with that expected for OCs. Seasonique(®) extends the contraceptive options currently available to women, particularly in those who desire fewer withdrawal bleeding episodes.
Collapse
Affiliation(s)
- Celeste B Burness
- Springer, Private Bag 65901, Mairangi Bay, 0754, Auckland, New Zealand,
| |
Collapse
|
12
|
Abstract
BACKGROUND The dosing, schedules, and other aspects of combined oral contraceptive (COC) design have evolved in recent years to address a variety of issues including short- and long-term safety, bleeding profiles, and contraceptive efficacy. In particular, several newer formulations have altered the length of the hormone-free interval (HFI), in order to minimize two key undesired effects that occur during this time: hormone-withdrawal-associated symptoms (HWaS) and follicular development. OBJECTIVE This primer reviews our current understanding of the key biological processes that occur during the HFI and how this understanding has led to changes in the dosing and schedule of newer COC formulations. MAIN MESSAGE In brief, HWaS are common, underappreciated, and a likely contributor to COC discontinuation; because of this, shortening the HFI and/or supplementing with estrogen during the progestin-free interval may provide relief from these symptoms and improve adherence. A short HFI (with or without estrogen supplementation) may also help maintain effective follicular suppression and contraceptive efficacy, even when the overall dose of estrogen throughout the cycle is low. CONCLUSIONS Taken together, the available data about HWaS and follicular activity during the HFI support the rationale for recent COC designs that use a low estrogen dose and a short HFI. The availability of a variety of COC regimens gives physicians a range of choices when selecting the most appropriate COC for each woman's particular priorities and needs.
Collapse
Affiliation(s)
- Brian A Hauck
- a a Department of Obstetrics and Gynecology , Foothills Hospital, University of Calgary , Calgary , Alberta , Canada
| | - Vivien Brown
- b b Department of Family and Community Medicine , University of Toronto , Toronto , Ontario , Canada
| |
Collapse
|
13
|
Kroll R, Seidman L, Ricciotti N, Howard B, Weiss H. A phase 1, multicentre, open-label study to evaluate ovarian follicular activity and hormone levels with an extended-regimen combined oral contraceptive with low-dose ethinyl estradiol supplementation. EUR J CONTRACEP REPR 2014; 20:249-58. [PMID: 25522805 DOI: 10.3109/13625187.2014.979282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the effect on ovarian follicular activity of the 91-day extended-regimen combined oral contraceptive (COC), consisting of 84 days of levonorgestrel (LNG)/ethinylestradiol (EE) 150 μg/30 μg tablets plus seven days of EE 10 μg tablets in place of placebo. METHODS This was a phase 1, open-label study. Ovarian follicular activity was classified via the Hoogland and Skouby method. Safety and tolerability as well as return to ovulation were assessed. RESULTS Of the 35 subjects included in the efficacy analysis, luteinized, unruptured follicles, or ovulation were detected in 0 of 35 cycles during the first 28-day interval; 1 of 35 cycles (2.9%) in the second 28-day interval; and 2 of 35 cycles (5.7%) in the final 35-day interval. The ovarian activity rate over the entire 91-day treatment period was 2.9%. There was a low incidence of treatment-emergent adverse events. Ovulation returned in most subjects (77.1%, 27/35) within 32 days following the last dose of COC. CONCLUSIONS The 91-day extended-regimen COC with low-dose EE supplementation was found to be effective in suppressing ovarian activity and inhibiting ovulation and was well tolerated. Return to ovulation was rapid, occurring within approximately one month after discontinuation of COC.
Collapse
Affiliation(s)
- Robin Kroll
- * Women's Clinical Research Center , Seattle, WA , USA
| | | | | | | | | |
Collapse
|
14
|
Panicker S, Mann S, Shawe J, Stephenson J. Evolution of extended use of the combined oral contraceptive pill. ACTA ACUST UNITED AC 2014; 40:133-41. [PMID: 24648529 DOI: 10.1136/jfprhc-2013-100600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Extended use of the combined oral contraceptive pill (COC), defined as taking active pills for at least 28 days, has been used in order to avoid bleeding at important times and to treat gynaecological conditions such as endometriosis. We examined the main issues involved in extended use of the COC and how it has evolved from being one of medicine's best-kept secrets to becoming more widely accepted by women and the medical community. STUDY DESIGN Literature review, using Medline, Embase, Pubmed, CINHAL Plus, the Cochrane Database of Systematic Reviews and the Ovid database for all relevant clinical trials, systematic reviews, meta-analyses, literature reviews, scientific papers and individual opinions between 1950 and October 2013. RESULTS Accumulating evidence supports various forms of extended pill use as suitable alternatives to the standard (21/7) regimen. In terms of user preference, much hinges on whether women wish to reduce the frequency or duration of scheduled bleeding on the combined pill. Available data on the safety of extended pill regimens do not give cause for concern, but longer term data should be collected. CONCLUSIONS Information for women considering extended COC regimens should keep pace with research findings to ensure that women and clinicians are better informed about the choices available.
Collapse
Affiliation(s)
- Sabeena Panicker
- Specialist Registrar in Obstetrics & Gynaecology, Sexual and Reproductive Health Research Group, Institute for Women's Health, University College London, London, UK
| | | | | | | |
Collapse
|
15
|
Darwish M, Bond M, Ricciotti N, Hsieh J, Fiedler-Kelly J, Grasela T. A comparison of the pharmacokinetic profile of an ascending-dose, extended-regimen combined oral contraceptive to those of other extended regimens. Reprod Sci 2014; 21:1401-10. [PMID: 24647707 DOI: 10.1177/1933719114526472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Quartette (levonorgestrel [LNG]/ethinyl estradiol [EE] and EE) is an ascending-dose, extended-regimen combined oral contraceptive (COC) that consists of a constant dose of LNG 150 µg on days 1 to 84 with EE 20 µg on days 1 to 42, 25 µg on days 43 to 63, 30 µg on days 64 to 84, and 10 µg of EE monotherapy on days 85 to 91. A population pharmacokinetic (PK) model for EE was developed using nonlinear mixed-effects modeling to characterize the PK profile of EE administered in Quartette and other extended-regimen LNG/EE COCs. Model-predicted plasma concentration-time profiles demonstrated a stepwise increase in systemic exposure to EE during the first 84 days of the cycle following each EE dose change. Lower concentrations of EE were noted during the final 7-day period of EE 10 µg. Gradual increases in EE seen with Quartette may decrease the incidence of unscheduled bleeding frequently observed during early cycles of extended-regimen COCs.
Collapse
Affiliation(s)
- Mona Darwish
- Clinical Pharmacology, SCI-MED BRIDGE, Malvern, PA, USA
| | - Mary Bond
- Phase 1 & Clinical Pharmacology, Teva Branded Pharmaceutical Products, R&D, Inc., Frazer, PA, USA
| | - Nancy Ricciotti
- Teva Women's Health, Teva Branded Pharmaceutical Products, R&D, Inc., Frazer, PA, USA
| | - Jennifer Hsieh
- Global Biostatistics, Teva Branded Pharmaceutical Products, R&D, Inc., West Chester, PA, USA
| | | | | |
Collapse
|
16
|
Portman DJ, Kaunitz AM, Howard B, Weiss H, Hsieh J, Ricciotti N. Efficacy and safety of an ascending-dose, extended-regimen levonorgestrel/ethinyl estradiol combined oral contraceptive. Contraception 2014; 89:299-306. [PMID: 24576794 DOI: 10.1016/j.contraception.2014.01.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 01/15/2014] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of an ascending-dose, extended-regimen (ADER) combined oral contraceptive consisting of levonorgestrel (LNG) 150 mcg/ethinyl estradiol (EE) 20 mcg for 42 days, LNG 150 mcg/EE 25 mcg for 21 days, LNG 150 mcg/EE 30 mcg for 21 days and EE 10 mcg for 7 days. STUDY DESIGN This was a multicenter, open-label, phase 3, single-arm study. Sexually active women aged 18-40 years were enrolled and received ADER for up to 1 year (4 consecutive 91-day cycles). Participants kept diaries to record adherence, bleeding/spotting and other contraceptive use. Efficacy was measured using the Pearl Index and the life-table method; safety and tolerability were assessed through reported adverse events (AEs). RESULTS A total of 3701 women were enrolled and 2144 completed the study. The Pearl Index was 3.19 [95% confidence interval (CI), 2.49-4.03], based on 70 pregnancies that occurred after ADER initiation and ≤ 7 days after the last LNG/EE or EE-only pill in women aged 18-35 years, excluding cycles in which another contraceptive method was used. Life-table pregnancy rate was 2.82% (95% CI, 2.23%-3.57%) for all users aged 18-35 years. Unscheduled bleeding/spotting decreased with increasing EE doses within each cycle and decreased after cycle 1. No unexpected AEs or changes in laboratory parameters were reported. CONCLUSION This study demonstrated that ADER effectively prevented pregnancy with a favorable safety and tolerability profile.
Collapse
Affiliation(s)
- David J Portman
- Columbus Center for Women's Health Research, Columbus, OH, USA.
| | - Andrew M Kaunitz
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | | | - Herman Weiss
- Teva Global Medical Affairs, Petach Tikva, Israel
| | - Jennifer Hsieh
- Teva Branded Pharmaceutical Products, R&D, Inc., West Chester, PA, USA
| | - Nancy Ricciotti
- Teva Branded Pharmaceutical Products, R&D, Inc., Frazer, PA, USA
| |
Collapse
|
17
|
Howard B, Trussell J, Grubb E, Lage MJ. Comparison of pregnancy rates in users of extended and cyclic combined oral contraceptive (COC) regimens in the United States: a brief report. Contraception 2013; 89:25-7. [PMID: 24161474 DOI: 10.1016/j.contraception.2013.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/06/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate pregnancy rates with 84/7, 21/7, and 24/4 combined oral contraceptives (COCs). STUDY DESIGN Data were obtained from the i3Invision Data Mart(TM) retrospective claims database. Subjects were 15 to 40 years; first prescribed COCs between January 1, 2006 and April 1, 2011; and continuously insured for ≥1 year. Eighty four over seven users (84/7) were matched 1:1 to 21/7 and 24/4 users. RESULTS One-year pregnancy rates were significantly lower with 84/7 than with 21/7 (4.4% vs. 7.3%; p<.0001) and 24/4 (4.4% vs. 6.9%, p<.0001) regimens. CONCLUSION Preliminary results suggest fewer pregnancies with 84/7 versus 21/7 or 24/4 regimens. IMPLICATIONS While newer COCs, including 84/7 and 24/4 regimens, potentially improve efficacy and alter bleeding profiles compared to 21/7 regimens, few data on comparative pregnancy rates with these regimens are available. In this retrospective claims analysis, real-world pregnancy rates were lower with 84/7 regimens versus 21/7 and 24/4 regimens.
Collapse
Affiliation(s)
- Brandon Howard
- Teva Global Medical Affairs, 41 Moores Road, Frazer, PA 19355
| | | | | | | |
Collapse
|
18
|
The creeping Pearl: Why has the rate of contraceptive failure increased in clinical trials of combined hormonal contraceptive pills? Contraception 2013; 88:604-10. [PMID: 23683581 DOI: 10.1016/j.contraception.2013.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/04/2013] [Accepted: 04/07/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite several drawbacks, the Pearl Index continues to be the most widely used statistical measure of contraceptive failure. However, Pearl indices reported in studies of newer hormonal contraceptives appear to be increasing. STUDY DESIGN We searched PubMed and Medical Intelligence Solutions databases for prospective trials evaluating oral contraceptive (OC) efficacy to examine potential factors that could contribute to increasing Pearl indices. RESULTS Numerous potential factors were identified, including an increased rate of failures of newer OCs, deficiencies in methods of calculating contraceptive failure rates, differences in study design and changes in patient populations resulting in increased rates of contraceptive failures due to the inappropriate or inconsistent use of the method. CONCLUSIONS The two most likely important contributors to the increase in Pearl indices are more frequent pregnancy testing with more sensitive tests and less adherent study populations. Because study populations appear to be increasingly representative of the likely actual users once the product is marketed, we can expect to see even higher failure rates in ongoing and future studies. This result poses challenges for companies and regulatory agencies.
Collapse
|
19
|
Kallio S, Puurunen J, Ruokonen A, Vaskivuo T, Piltonen T, Tapanainen JS. Antimüllerian hormone levels decrease in women using combined contraception independently of administration route. Fertil Steril 2013; 99:1305-10. [DOI: 10.1016/j.fertnstert.2012.11.034] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 11/02/2012] [Accepted: 11/20/2012] [Indexed: 02/08/2023]
|
20
|
Wilton JM. Oral contraception: new options. Nurs Womens Health 2012; 15:431-4. [PMID: 22900657 DOI: 10.1111/j.1751-486x.2011.01668.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jeanne M Wilton
- Wheaton Franciscan Healthcare Medical Group-All Saints, Racine, WI, USA.
| |
Collapse
|
21
|
Ziglar S, Hunter TS. The effect of hormonal oral contraception on acquisition of peak bone mineral density of adolescents and young women. J Pharm Pract 2012; 25:331-40. [PMID: 22572223 DOI: 10.1177/0897190012442066] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Maximizing bone mass in youth is touted as the best strategy to offset the natural losses of aging and the menopausal transition. Not achieving maximum peak bone mineral density (BMD) is an independent risk factor for osteoporosis and thus a public health concern. Adolescence is a critical time of bone mineralization mediated by endogenous estradiol. Research has shown that the highest velocity of bone mass accrual occurs 1 year before menarche and after the first 3 years. Low-peak attainment of BMD in young women is associated with contributing factors such as diets low in calcium, eating disorders, lack of exercise, smoking, and low estrogen states. Oral contraceptives (OCs) suppress endogenous estradiol production by suppressing the hypothalamic-pituitary-ovarian axis. Thus, OCs, by replacing endogenous estradiol with ethinyl estradiol (EE), establish and maintain new hormone levels. The early initiation and the use of very low dose of EE raises the possibility that bone mass accrual at a critical time of bone mineralization in young women or adolescents may be jeopardized. This review examines the studies of BMD in adolescents and young women that use combination hormonal contraception. Some studies had inherent limitations, such as small trial, poor control of confounders, failure to exclude women with prior use of hormonal contraceptives, or prior pregnancy from control groups. The vast majority of reviewed studies showed OCs containing 20 to 30 µg of EE interfere with acquisition of peak BMD. Limited numbers of studies examine the effects of OCs containing 35 µg on adolescents and young adults. Additionally, studies are needed evaluating the progestin component of OCs as their differing androgenic properties may affect bone mineralization as well.
Collapse
Affiliation(s)
- Susan Ziglar
- Wingate University School of Pharmacy, Wingate, NC 28174, USA.
| | | |
Collapse
|
22
|
Tran DQ. TGF-β: the sword, the wand, and the shield of FOXP3(+) regulatory T cells. J Mol Cell Biol 2011; 4:29-37. [PMID: 22158907 DOI: 10.1093/jmcb/mjr033] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Since its rediscovery in the mid-1990s, FOXP3(+) regulatory T cells (Tregs) have climbed the rank to become commander-in-chief of the immune system. They possess diverse power and ability to orchestrate the immune system in time of inflammation and infection as well as in time of harmony and homeostasis. To be the commander-in-chief, they must be equipped with both offensive and defensive weaponry. This review will focus on the function of transforming growth factor-β (TGF-β) as the sword, the wand, and the shield of Tregs. Functioning as a sword, this review will begin with a discussion of the evidence that supports how Tregs utilize TGF-β to paralyze cell activation and differentiation to suppress immune response. It will next provide evidence on how TGF-β from Tregs acts as a wand to convert naïve T cells into iTregs and Th17 to aid in their combat against inflammation and infection. Lastly, the review will present evidence on the role of TGF-β produced by Tregs in providing a shield to protect and maintain Tregs against apoptosis and destabilization when surrounded by inflammation and constant stimulation. This triadic function of TGF-β empowers Tregs with the responsibility and burden to maintain homeostasis, promote immune tolerance, and regulate host defense against foreign pathogens.
Collapse
Affiliation(s)
- Dat Q Tran
- Division of Pediatric Research Center, Department of Pediatrics, The University of Texas Medical School at Houston, Houston, TX 77030, USA.
| |
Collapse
|
23
|
Nelson A. New low-dose, extended-cycle pills with levonorgestrel and ethinyl estradiol: an evolutionary step in birth control. Int J Womens Health 2010; 2:99-106. [PMID: 21072303 PMCID: PMC2971737 DOI: 10.2147/ijwh.s4886] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Indexed: 11/23/2022] Open
Abstract
Aim: To review milestones in development of oral contraceptive pills since their introduction in the US 50 years ago in order to better understand how a new formulation with low-dose estrogen in an extended-cycle pattern fits into the evolution of birth control pills. Methods: This is a review of trends in the development of various birth controls pills and includes data from phase III clinical trials for this new formulation. Results: The first birth control pill was a very high-dose monophasic formulation with the prodrug estrogen mestranol and a first-generation progestin. Over the decades, the doses of hormones have been markedly reduced, and a new estrogen and several different progestins were developed and used in different dosing patterns. The final element to undergo change was the 7-day pill-free interval. Many of these same changes have been made in the development of extended-cycle pill formulation. Conclusion: The newest extended-cycle oral contraceptive formulation with 84 active pills, each containing 20 μg ethinyl estradiol and 100 μg levonorgestrel, represents an important evolution in birth control that incorporates lower doses of estrogen (to reduce side effects and possibly reduce risk of thrombosis), fewer scheduled bleeding episodes (to meet women’s desires for fewer and shorter menses) and the use of low-dose estrogen in place of placebo pills (to reduce the number of days of unscheduled spotting and bleeding). Hopefully, this unique formation will motivate women to be more successful contraceptors.
Collapse
Affiliation(s)
- Anita Nelson
- Harbor-UCLA Hospital, Los Angeles Biomedical Research Institute, Los Angeles, CA, USA
| |
Collapse
|
24
|
The efficacy and safety of a low-dose, 91-day, extended-regimen oral contraceptive with continuous ethinyl estradiol. Contraception 2010; 81:41-8. [DOI: 10.1016/j.contraception.2009.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 07/07/2009] [Accepted: 07/09/2009] [Indexed: 11/20/2022]
|
25
|
Kaunitz AM, Portman DJ, Hait H, Reape KZ. Adding low-dose estrogen to the hormone-free interval: impact on bleeding patterns in users of a 91-day extended regimen oral contraceptive. Contraception 2009; 79:350-5. [PMID: 19341846 DOI: 10.1016/j.contraception.2008.11.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/29/2008] [Accepted: 11/18/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND A cross-study analysis of contraceptive clinical trials for two different 91-day oral contraceptive (OC) regimens was performed to examine the impact on bleeding patterns when supplementing the 7-day hormone-free interval with 10 mcg ethinyl estradiol (EE) daily. STUDY DESIGN Two separate 1-year Phase 3 clinical programs were conducted using similar study designs. The percentages of subjects reporting bleeding and spotting using electronic diaries for each 91-day cycle were compared. RESULTS Scheduled bleeding with the EE regimen was less than that reported with the regimen utilizing placebo during Days 85-91, with significant differences noted for all four 91-day cycles. Unscheduled bleeding decreased more quickly with the 91-day regimen containing low-dose EE in place of placebo, with significant differences noted during the third cycle. CONCLUSIONS This cross-study comparison suggests that the administration of low-dose estrogen in place of placebo in a 91-day extended regimen OC improves the bleeding profile.
Collapse
Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA
| | | | | | | |
Collapse
|
26
|
Poindexter A, Reape KZ, Hait H. Efficacy and safety of a 28-day oral contraceptive with 7 days of low-dose estrogen in place of placebo. Contraception 2008; 78:113-9. [DOI: 10.1016/j.contraception.2008.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2008] [Revised: 04/02/2008] [Accepted: 04/02/2008] [Indexed: 11/25/2022]
|