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Adamyan L, Pivazyan L, Isaeva S, Shapovalenko R, Zakaryan A. Metformin and progestins in women with atypical hyperplasia or endometrial cancer: systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:2289-2305. [PMID: 38503850 DOI: 10.1007/s00404-024-07416-2] [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: 10/19/2023] [Accepted: 02/04/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE To assess metformin's effectiveness in adding it to progestin-based hormone therapy for treating atypical endometrial hyperplasia (AEH) and early endometrial cancer (EEC). METHODS We conducted a systematic review and meta-analysis following PRISMA guidelines (registration number CRD42023399094). We searched databases for studies up to March 2023, including randomized and non-randomized clinical trials in English. RESULTS Out of 280 studies, 9 studies (1104 patients) were eligible. A total of 408 patients were allocated to receive metformin, and 696 patients entered the control group. Primary analysis focused on evaluating the CR showed a significant difference in patients with AEH treated with metformin (RR = 1.10, 95% CI 1.02-1.20, p = 0.02). Relapse rate (RR = 0.62, 95% CI 0.33-1.17, p = 0.14) was also evaluated. Secondary analysis indicated higher pregnancy rates (RR = 1.28, 95% CI 1.04-1.57, p = 0.02) with no significant difference in live birth rates (RR = 0.56, 95% CI 0.29-1.10, p = 0.09). CONCLUSION Combined therapy is effective. Metformin shows superiority to the standard regimen in achieving better CR rate in patients with AEH and benefits pregnancy rates but not recurrence or live birth rates. Therefore, the ideal fertility-sparing treatment for EC has not yet been determined and further clinical trials are needed.
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Affiliation(s)
- Leila Adamyan
- Moscow State University of Medicine and Dentistry Named After A.I. Evdokimov, 127473, Moscow, Russia
- FSBI «National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After Academician V.I. Kulakov» Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Laura Pivazyan
- FSBI «National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After Academician V.I. Kulakov» Ministry of Healthcare of the Russian Federation, Moscow, Russia.
| | - Sapiyat Isaeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119048, Moscow, Russia
| | - Roman Shapovalenko
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119048, Moscow, Russia
| | - Araksya Zakaryan
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119048, Moscow, Russia
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2
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Belail Hammad WA, Gupta N, Konje JC. An overview of contraception in women with obesity. Best Pract Res Clin Obstet Gynaecol 2023; 91:102408. [PMID: 37683520 DOI: 10.1016/j.bpobgyn.2023.102408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/08/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023]
Abstract
The use of safe and effective contraception is essential for preventing unplanned pregnancy in women of all body sizes. When counseling women with obesity about contraception, it is important to consider the pharmacokinetic alterations of obesity on various modern contraceptive methods. However, evidence is reassuring that most contraceptive methods are safe and effective in women with obesity. Individual countries and the World Health Organization have published Medical Eligibility Criteria to guide contraceptive selection in women with medical issues including obesity. When choosing contraception, specific risks of the method relative to any underlying medical disorders must also be balanced against the risks of unintended pregnancy in this group.
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Affiliation(s)
- Wafaa Ali Belail Hammad
- Specialist Registrar, Department of Obstetrics & Gynaecology, Basildon and Thurrock University Hospitals NHS Foundation Trust, UK.
| | - Neerja Gupta
- Consultant Obstetrician and Gynaecologist, Basildon and Thurrock University Hospitals NHS Foundation Trust, UK
| | - Justin C Konje
- Senior Consultant Obstetrician and Gynaecologist, Feto Maternal Centre, Professor of Obstetrics and Gynecology, Weill Cornell Medicine, Qatar and Emeritus Professor of Obstetrics and Gynaecology, Department of Health Sciences, University of Leicester, UK
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3
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Langevin B, Gobburu JVS, Gopalakrishnan M. Is There a Need for a Dedicated Pharmacokinetic Trial for a Drug in Obese Populations? A Drug Prioritization Decision Tree Framework. J Clin Pharmacol 2023; 63 Suppl 2:S48-S64. [PMID: 37942905 DOI: 10.1002/jcph.2304] [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: 03/17/2023] [Accepted: 06/22/2023] [Indexed: 11/10/2023]
Abstract
Obesity is a growing global health concern associated with high comorbidity rates, leading to an increasing number of patients who are obese requiring medication. However, clinical trials often exclude or under-represent individuals who are obese, creating the need for a methodology to adjust labeling to ensure safe and effective dosing for all patients. To address this, we developed a 2-part decision tree framework to prioritize drugs for dedicated pharmacokinetic studies in obese subjects. Leveraging current drug knowledge and modeling techniques, the decision tree system predicts expected exposure changes and recommends labeling strategies, allowing stakeholders to prioritize resources toward the drugs most in need. In a case study evaluating 30 drugs from literature across different therapeutic areas, our first decision tree predicted the expected direction of exposure change accurately in 73% of cases. We conclude that this decision tree system offers a valuable tool to advance research in obesity pharmacology and personalize drug development for patients who are obese, ensuring safe and effective medication.
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Affiliation(s)
- Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Kofole Z, Haile D, Solomon Y. Fasting blood glucose, blood pressure and body mass index among combined oral contraceptive users in Chencha town Southern Ethiopia, 2019. Front Glob Womens Health 2023; 4:992750. [PMID: 37187593 PMCID: PMC10175825 DOI: 10.3389/fgwh.2023.992750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Background The use of contraceptives has become prevalent among women in Ethiopia. Oral contraceptive use has been suggested to trigger changes in glucose metabolism, energy expenditure, blood pressure, and body weight, among various populations and ethnic groups. Objective To elucidate the pattern of fasting blood glucose, blood pressure, and body mass index among combined oral contraceptive pills users compared to controls. Methods An institution-based cross-sectional study design was employed. A total of 110 healthy women using combined oral contraceptive pills were recruited as cases. Another 110 healthy age and sex-matched women not using any hormonal contraceptives were recruited as controls. A study was conducted between October 2018 and January 2019. Data obtained was entered and analyzed using IBM SPSS version 23 software packages. One-way ANOVA was used to identify the variation of variables in relation to the duration of use of the drug. The P-value of < 0.05 at the 95% confidence level was statistically significant. Results Fasting blood glucose level among oral contraceptive users (88.55 ± 7.89 mg/dl) was higher than fasting blood glucose level among oral contraceptive non-users (86.00 ± 9.85 mg/dl) with a p-value of 0.025. The mean arterial pressure of oral contraceptive users (88.2 ± 8.48 mmHg) was relatively higher than their counterparts (86.0 ± 6.74 mmHg), with a p-value of 0.04. Comparatively the body weight and body mass index among oral contraceptive users were 2.5% and 3.9% higher than non-users with a p-value of 0.03 and 0.003, respectively(5). Utilization of oral contraceptive pills for prolonged period of time seemed to be a significant predictive factor for higher mean arterial pressure and body mass index with p < 0.001and p < 0.05 respectively. Conclusions Use of combined oral contraceptives was associated with higher fasting blood glucose (+2.9%), mean arterial pressure (+2.5%), and body mass index (3.9%) compared to controls.
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Affiliation(s)
- Zelalem Kofole
- Department of Biomedical Sciences, School of Medicine, College of Health Science, Arba Minch University, Arba Minch, Ethiopia
- Correspondence: Zelalem Kofole Yerukneh Solomon
| | - Diresbachew Haile
- Department of Physiology, School of Medicine, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopian
| | - Yerukneh Solomon
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
- Correspondence: Zelalem Kofole Yerukneh Solomon
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Jensen JT, Kaunitz AM, Achilles SL, Zatik J, Weyers S, Piltonen T, Suturina L, Apolikhina I, Bouchard C, Chen MJ, Apter D, Jost M, Foidart JM, Creinin MD. Pooled efficacy results of estetrol/drospirenone combined oral contraception phase 3 trials. Contraception 2022; 116:37-43. [PMID: 35921870 DOI: 10.1016/j.contraception.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate overall and subgroup efficacy of an estetrol (E4) 15 mg drospirenone (DRSP) 3 mg oral contraceptive in a 24/4-day regimen. STUDY DESIGN We pooled efficacy outcomes from 2 pivotal phase 3 contraceptive trials with E4/DRSP conducted in the United States/Canada and Europe/Russia. We assessed Pearl Index (PI; pregnancies per 100 participant-years) and 13-cycle life-table pregnancy rates in at-risk cycles (confirmed intercourse and no other contraceptive use) among participants 16 to 35 years. We calculated PI by age and further subcategorization (contraceptive history and body mass index [BMI]). We performed multivariable analysis using Cox regression to assess impact of potential confounding factors. RESULTS Analyses included 3027 participants, of whom 451 (14.9%) had a BMI ≥30 kg/m2. The pooled PI was 1.52 (95% confidence interval 1.04-2.16) and the 13-cycle life-table pregnancy rate was 1.28% (0.83%-1.73%). We calculated unadjusted pooled PI in participants 16 to 25 years and 26 to 35 years of 1.61 (0.94-2.57) and 1.43 (0.78-2.40), respectively; in new starters and switchers of 1.88 (1.09-3.00) and 1.24 (0.68-2.08), respectively; and by BMI <25 kg/m2, 25 to 29.9 kg/m2, and ≥30 kg/m2 of 1.14 (0.64-1.88), 2.19 (1.05-4.03), and 2.27 (0.83-4.94), respectively. In multivariable analysis, we found associations of prior pregnancy (hazard ratio [HR] 3.61[1.56-8.38]), Black race (HR 4.61[1.97-10.80]), age 16 to 25 years (HR 2.37[1.09-5.15]) and compliance <99% of expected pills (HR 4.21[2.04-8.66]) with conception. CONCLUSION E4/DRSP is an effective oral contraceptive overall and across subgroups stratified by age, contraceptive history, and BMI. Other than compliance, predictors of contraceptive failure are nonmodifiable. IMPLICATIONS STATEMENT Pooled results from two phase 3 trials demonstrate high contraceptive efficacy of the novel estetrol-drospirenone oral contraceptive. Several non-modifiable risk factors, including prior pregnancy, race, and age, are associated with higher pregnancy risk. Additional research is needed to better understand predictors of combined oral contraceptive failure.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - János Zatik
- Szent Anna Szuleszeti, Nogyogyaszati es Ultrahang Maganrendelo, Debrecen, Hungary
| | - Steven Weyers
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - Terhi Piltonen
- Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, Oulu, Finland
| | - Larisa Suturina
- Department of Reproductive Health Protection, Scientific Center for Family Health and Human Reproduction, Irkutsk, Russia
| | - Inna Apolikhina
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - Céline Bouchard
- Clinique de Recherche en Santé de la femme (RSF) Inc., Québec City, Québec, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Dan Apter
- VL-Medi Clinical Research Center, Helsinki, Finland
| | - Maud Jost
- Estetra SRL, an affiliated company of Mithra Pharmaceuticals, Liège, Belgium.
| | - Jean-Michel Foidart
- Estetra SRL, an affiliated company of Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
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McNamee K, Edelman A, Li RHW, Kaur S, Bateson D. Best Practice Contraception Care for Women with Obesity: A Review of Current Evidence. Semin Reprod Med 2022; 40:246-257. [PMID: 36746158 DOI: 10.1055/s-0042-1760214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of obesity among females of reproductive age is increasing globally. Access to the complete range of appropriate contraceptive options is essential for upholding the reproductive rights of this population group. People with obesity can experience stigma and discrimination when seeking healthcare, and despite limited evidence for provider bias in the context of contraception, awareness for its potential at an individual provider and health systems level is essential. While use of some hormonal contraceptives may be restricted due to increased health risks in people with obesity, some methods provide noncontraceptive benefits including a reduced risk of endometrial cancer and a reduction in heavy menstrual bleeding which are more prevalent among individuals with obesity. In addition to examining systems-based approaches which facilitate the provision of inclusive contraceptive care, including long-acting reversible contraceptives which require procedural considerations, this article reviews current evidence on method-specific advantages and disadvantages for people with obesity to guide practice and policy.
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Affiliation(s)
| | - Alison Edelman
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Simranvir Kaur
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Deborah Bateson
- Faculty of Medicine and Health, Daffodil Centre, University of Sydney, Sydney, Australia
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7
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Casto KV, Jordan T, Petersen N. Hormone-based models for comparing menstrual cycle and hormonal contraceptive effects on human resting-state functional connectivity. Front Neuroendocrinol 2022; 67:101036. [PMID: 36126748 PMCID: PMC9649880 DOI: 10.1016/j.yfrne.2022.101036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022]
Abstract
Oral contraceptives (OCs) are widely used yet understudied given their potential for public health consequences. Emerging investigations scaling from single-subject, dense-sampling neuroimaging studies to population-level metrics have linked OCs to altered brain structure and function. Modeling the hypogonadal, hypergonadal, or mixed state effects of OCs in terms of their impact on hormone action in the brain is a valuable approach to synthesizing results across neuroimaging studies and comparing OC effects to companion findings from research on menstrual cycle phase effects on brain anatomy and function. Resting-state functional connectivity studies provide a powerful tool to evaluate the role of OCs on the intrinsic network connectivity that underlies multiple behavioral domains. The preponderance (but not consensus) of the current literature indicates that (1) as the menstrual cycle proceeds from a low to high progesterone state, prefrontal connectivity increases and parietal connectivity decreases; (2) OCs tend to mimic this connectivity pattern; therefore (3) OCs may produce a hyperprogestogenic state in the brain, in spite of overall reductions in endogenous steroid hormone levels. Alternative models are also considered.
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Affiliation(s)
- Kathleen V Casto
- Social Sciences Division, New College of Florida, 5800 Bay Shore Road, Sarasota, FL 34243, USA
| | - Timothy Jordan
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Nicole Petersen
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90095, USA.
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8
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Westhoff CL, Archer DF, Barnhart K, Darney P, Gilliam M, Jensen J, Nelson A, Teal S, Thomas M, Hu J, Brown J, Blithe DL. Evaluation of ovulation and safety outcomes in a multi-center randomized trial of three 84-day ulipristal acetate regimens. Contraception 2022; 112:54-60. [DOI: 10.1016/j.contraception.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
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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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Creinin MD, Westhoff CL, Bouchard C, Chen MJ, Jensen JT, Kaunitz AM, Achilles SL, Foidart JM, Archer DF. Estetrol-drospirenone combination oral contraceptive: North American phase 3 efficacy and safety results. Contraception 2021; 104:222-228. [PMID: 34000251 DOI: 10.1016/j.contraception.2021.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess efficacy, cycle control, and safety of an oral contraceptive containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg. STUDY DESIGN Women aged 16 to 50 years with a body mass index ≤35 kg/m2 enrolled in this multicenter, open-label, 13-cycle, phase 3 trial evaluating E4/DRSP in a 24-active/4-placebo regimen. Follow-up was scheduled at Cycles 2, 4, 7, and 10 and within 3 weeks of completing Cycle 13. Participants used daily diaries to record pill use and vaginal bleeding. We evaluated efficacy outcomes in women 16 to 35 years and bleeding patterns and safety (adverse events [AEs]) in all participants. We assessed overall and method-failure pregnancy rates using the Pearl index (PI) and life-table analysis. Scheduled bleeding included spotting or bleeding starting during the 4-day placebo period or first 3 days of the next cycle. RESULTS We enrolled 1864 women of whom 1674 were 16 to 35 years. Women 16 to 35 years had a PI of 2.65 (95% CI 1.73-3.88), method-failure PI of 1.43 (95% CI 0.7-2.39) and 13-cycle life-table pregnancy rate of 2.1%. Scheduled bleeding occurred in 82.9% to 87.0% of women per cycle; median duration was 4.5 days. Unscheduled bleeding decreased from 30.3% in Cycle 1 to 21.3% to 22.1% during Cycles 2 to 4 and remained stable (15.5% to 19.2%) thereafter. The most frequently reported AEs were headache (5.0%) and metrorrhagia (4.6%). One-hundred thirty-two (7.1%) women discontinued the study early for an AE, most commonly for metrorrhagia (0.9%) and menorrhagia (0.8%). No thromboembolic events occurred. CONCLUSION E4/DRSP is an effective oral contraceptive with a predictable bleeding pattern for most women and low AE rates. IMPLICATIONS STATEMENT A new oral contraceptive with a novel estrogen, estetrol, combined with drospirenone has efficacy and safety within the range of other available oral contraceptives. Large phase 4 studies will be needed to confirm if this combination is associated with an improved adverse event profile or lower thrombosis risk.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - Céline Bouchard
- Clinique de Recherche en Santé des Femmes, Quebec City, QC, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida Jacksonville, Jacksonville, FL, United States
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh/Magee-Womens Hospital, Pittsburgh, PA, United States
| | - Jean-Michel Foidart
- Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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11
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Endalifer ML, Diress G, Addisu A, Linger B. The association between combined oral contraceptive use and overweight/obesity: a secondary data analysis of the 2016 Ethiopia Demographic and Health Survey. BMJ Open 2020; 10:e039229. [PMID: 33361073 PMCID: PMC7768964 DOI: 10.1136/bmjopen-2020-039229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES In this study, we aimed to assess the association between combined oral contraceptive (OC) use and overweight/obesity among Ethiopian adult women of reproductive age. DESIGN, SETTING AND PARTICIPANTS The data were extracted from the 2016 Ethiopia Demographic and Health Survey; these data were collected from nine regions and two city administrations. We analysed the data from a total of 11 018 women aged 18-49 years who met eligibility criteria. MAIN OUTCOME MEASURES We employed WHO criteria to classify the body mass index of women. Specifically we tested the association between combined OC utilisation with overweight/obesity after controlling for confounding variables. RESULT The prevalence of combined OC utilisation was 1.7% and the prevalence of overweight/obesity was 8.6% among adult women of reproductive age. Use of combined OC increases the odds of overweight/obesity by two times among adult women of reproductive age after controlling for potential confounders (adjusted OR=1.902 (1.064-3.399)). CONCLUSION In conclusion there is significant association between combined OC use and overweight/obesity. The findings have important implications for policymakers to design evidence based policy approachs to obesity prevention for women and at large for government to recognise the negative consequences of combined OC on women health.
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Affiliation(s)
| | - Gedefaw Diress
- Department of Public Health, College Of Health Science, Woldia University, Woldia, Ethiopia
| | - Amanuel Addisu
- Department of Public Health, College Of Health Science, Woldia University, Woldia, Ethiopia
| | - Bedilu Linger
- Department of Pharmacy, College Of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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12
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Moreira de Brito C, de Melo ME, Mancini MC, Santo MA, Cercato C. Pharmacokinetics of oral levonorgestrel and ethinylestradiol in women after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2020; 17:673-681. [PMID: 33547015 DOI: 10.1016/j.soard.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/23/2020] [Accepted: 12/06/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Most patients undergoing Roux-en-Y gastric bypass (RYGB) are women in reproductive age. It is not known if bariatric surgery affects the pharmacokinetics of oral contraceptives. OBJECTIVES The primary objective was to evaluate ethinylestradiol (EE) and levonorgestrel (LNG) absorption in women undergoing RYGB, compared with nonoperated controls matched by age and body mass index (BMI). A secondary objective was to assess whether the time since surgery and BMI in the postoperative period influenced the absorption parameters. SETTING University hospital, Brazil. METHODS This study was designed to compare the maximum plasma concentration (Cmax), the time to the peak plasma level (Tmax), the area under the curve (AUC0-8 and AUC0-∞) after a single dose of a combined oral contraceptive with 0.03 mg EE and 0.15 mg LNG among 20 women after RYGB and 20 controls. Blood samples were obtained for 8 hours. RESULTS The mean LNG AUC0-8 and LNG AUC0-∞ were higher in RYGB group (P = .048 and P = .004, respectively). We found a positive correlation for LNG AUC0-8 (P = .045) and AUC0-∞ (P = .004) and the time since surgery, and we found a negative correlation for LNG Cmax (P = .018), AUC0-8 (P = .003), and AUC0-∞ (P = .001) and BMI. CONCLUSION No significant differences were found in oral EE pharmacokinetics. The operated group showed higher mean LNG AUC0-8 and AUC0-∞ but it was not considered clinically significant. The present study suggests that RYGB may not affect EE and LNG absorption.
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Affiliation(s)
- Claudia Moreira de Brito
- Grupo de Obesidade e Síndrome Metabólica, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
| | - Maria Edna de Melo
- Grupo de Obesidade e Síndrome Metabólica, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil; Laboratory of Carbohydrates and Raioimmunoassay, ICHC, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcio C Mancini
- Grupo de Obesidade e Síndrome Metabólica, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil; Laboratory of Carbohydrates and Raioimmunoassay, ICHC, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marco Aurelio Santo
- Unidade de Cirurgia Bariátrica e Metabólica, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Cintia Cercato
- Grupo de Obesidade e Síndrome Metabólica, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil; Laboratory of Lipids, Universidade de São Paulo, São Paulo, Brazil
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Ramanadhan S, Jusko WJ, Edelman A. Pharmacokinetics of Hormonal Contraception in Individuals with Obesity: a Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020; 9:72-78. [PMID: 33117601 DOI: 10.1007/s13669-020-00284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose of Review Obesity continues to affect many women globally. In the USA, almost 40% of all women are obese and many of these women use hormonal contraception for pregnancy prevention. How well hormonal contraceptive works for these individuals has been an area of ongoing research. Pharmacokinetics (PK), the study of drug passage through the body, can shed light on how differences in physiology between obese and non-obese populations can impact drug disposition and subsequent efficacy. This review aims to reflect on these types of studies and empower clinicians with information to help tackle the challenges of the obesity epidemic and help them provide the best contraceptive options to their patients. Here, we present the basics of the mechanisms of action of hormonal contraception, fundamental pharmacokinetic principles, and the latest research into pharmacokinetics, obesity, and hormonal contraception. Recent Findings New studies focused on the PK of hormonal contraception in women with obesity have shown that while there are distinct differences in how steroid hormones are processed in women with different body mass indices, contraceptive efficacy is likely the same. This is replicated in studies involving a variety of hormonal contraceptive methods. Summary PK studies allow for a detailed analysis of steroid hormone processing in individuals with obesity. Observing PK parameters at each stage of the passage of these hormones through the body, researchers have drilled down on physiologic differences that accompany obesity. In reviewing these PK parameter differences, however, it appears that while processes are different, the end result of pregnancy prevention is likely not compromised in the setting of obesity. Emergency contraception, which functions by a different mechanism from that of continuous hormonal contraception, is the one area in which obesity has been demonstrated to impact efficacy.
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Affiliation(s)
| | - William J Jusko
- WJJ Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Alison Edelman
- Oregon Health & Science University, Portland, OR 97239, USA
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Obesity and hormonal contraception: an overview and a clinician's practical guide. Eat Weight Disord 2020; 25:1129-1140. [PMID: 31515745 DOI: 10.1007/s40519-019-00774-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/31/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The growing prevalence of obesity among the fertile female population poses a considerable problem to contraceptive providers. Obese women, who are more at risk for venous thromboembolism and cardiovascular events due to their condition, might be at an even higher risk of developing thromboembolic events when on medical contraception. Combined hormonal contraceptives might be less effective in obese women and may lead to unacceptable metabolic side effects for this population. In addition, the lack of safety data for weight loss drugs and the higher risk for complications during and after pregnancy require a close surveillance of the fertility status of obese patients. OBJECTIVE The aim of this narrative review is to summarize the available medical contraceptive options and to give the readers a practical guidance for a wise contraceptive choice with regards to obesity. METHODS A general literature review of peer-reviewed publications on the topic "obesity and contraception" was performed using the PubMed database. RESULTS Nowadays, there are many useful tools that help clinicians in choosing among the wide range of therapeutic possibilities, such as the World Health Organization (WHO) Medical Eligibility Criteria for contraceptive use. Furthermore, the great diversity of hormonal contraceptive formulations (combined hormonal formulations; progestin-only methods) and active substances (different estrogens and progestins) allow physicians to tailor therapies to patients' clinical peculiarities. CONCLUSION Long-acting reversible contraceptives [progestin-only implants, levonorgestrel-intra-uterine devices (IUDs) and copper IUDs] and progestin-only methods in general are excellent options for many categories of patients, including obese ones. LEVEL OF EVIDENCE V, narrative review.
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Maxwell C, Gaudet L, Cassir G, Nowik C, McLeod NL, Jacob CÉ, Walker M. Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 41:1660-1675. [PMID: 31640866 DOI: 10.1016/j.jogc.2019.03.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care. INTENDED USERS All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity. TARGET POPULATION Women with obesity who are pregnant or planning pregnancies. EVIDENCE Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALIDATION METHODS The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity. GUIDELINE UPDATE SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. SPONSORS This guideline was developed with resources funded by the SOGC. SUMMARY STATEMENTS RECOMMENDATIONS.
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The Impact of Bariatric Surgery on Menstrual Abnormalities-a Cross-Sectional Study. Obes Surg 2020; 30:4505-4509. [PMID: 32661954 PMCID: PMC7524851 DOI: 10.1007/s11695-020-04840-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Obesity is associated with hyperestrogenism along with other hormonal abnormalities affecting the menstrual cycle. The most effective and decisive method of obesity treatment is bariatric surgery. The aim of this study was to analyze the impact of bariatric surgery on menstrual cycle, the incidence of menstrual abnormalities, hyperandrogenism manifestation, and contraception use. MATERIALS AND METHODS It was a cross-sectional study of 515 pre-menopausal women who had undergone bariatric surgery between 1999 and 2017 in a bariatric center. Data was collected via anonymous questionnaire, and the questions covered a 1-year period before the surgery and the last year before questionnaire completion. RESULTS Before the surgery, 38.6% of the patients reported irregular menstruations in comparison with 25.0% after bariatric surgery (RR = 0.65; 95%CI 0.53-0.79). The mean number of menstruations per year did not differ before and after surgery (10.2 ± 3.9 vs 10.4 ± 3.3; p < .45). There were no statistically significant differences in terms of prolonged menstruations, acne, and hirsutism prevalence. A total of 14.4% of patients before surgery reported estrogen-based contraception use in comparison with 15.0% after the surgery (p < .95). There were no significant differences in the frequency of OC use (11.0% before surgery vs 13.6% 12 months after the surgery vs 11.5% at the moment of survey administration; p < 0.46). CONCLUSION Bariatric surgery improves the regularity of the menstrual cycle in obese women in reproductive age. The lack of any changes in the combined hormonal contraception (CHC) use, especially OC, before and after bariatric surgery may be a result of a possibly low level of contraception counseling.
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Mandelbaum RS, Ciccone MA, Nusbaum DJ, Khoshchehreh M, Purswani H, Morocco EB, Smith MB, Matsuzaki S, Dancz CE, Ozel B, Roman LD, Paulson RJ, Matsuo K. Progestin therapy for obese women with complex atypical hyperplasia: levonorgestrel-releasing intrauterine device vs systemic therapy. Am J Obstet Gynecol 2020; 223:103.e1-103.e13. [PMID: 31978437 DOI: 10.1016/j.ajog.2019.12.273] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/26/2019] [Accepted: 12/19/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Though hysterectomy remains the standard treatment for complex atypical hyperplasia, patients who desire fertility or who are poor surgical candidates may opt for progestin therapy. However, the effectiveness of the levonorgestrel-releasing intrauterine device compared to systemic therapy in the treatment of complex atypical hyperplasia has not been well studied. OBJECTIVE We sought to examine differences in treatment response between local progestin therapy with the levonorgestrel-releasing intrauterine device and systemic progestin therapy in women with complex atypical hyperplasia. METHODS This single-institution retrospective study examined women with complex atypical hyperplasia who received progestin therapy between 2003 and 2018. Treatment response was assessed by histopathology on subsequent biopsies. Time-dependent analyses of complete response and progression to cancer were performed comparing the levonorgestrel-releasing intrauterine device and systemic therapy. A propensity score inverse probability of treatment weighting model was used to create a weighted cohort that differed based on treatment type but was similar with respect to other characteristics. An interaction-term analysis was performed to examine the impact of body habitus on treatment response, and an interrupted time-series analysis was employed to assess if changes in treatment patterns correlated with outcomes over time. RESULTS A total of 245 women with complex atypical hyperplasia received progestin therapy (levonorgestrel-releasing intrauterine device n = 69 and systemic therapy n = 176). The mean age and body mass index were 36.9 years and 40.0 kg/m2, respectively. In the patient-level analysis, women who received the levonorgestrel-releasing intrauterine device had higher rates of complete response (78.7% vs 46.7%; adjusted hazard ratio, 3.32; 95% confidence interval, 2.39-4.62) and a lower likelihood of progression to cancer (4.5% vs 15.7%; adjusted hazard ratio, 0.28; 95% confidence interval, 0.11-0.73) compared to those who received systemic therapy. In particular, women with class III obesity derived a higher relative benefit from levonorgestrel-releasing intrauterine device therapy in achieving complete response compared to systemic therapy: class III obesity, adjusted hazard ratio 4.72, 95% confidence interval 2.83-7.89; class I-II obesity, adjusted hazard ratio 1.83, 95% confidence interval 1.09-3.09; and nonobese, adjusted hazard ratio 1.26, 95% confidence interval 0.40-3.95. In the cohort-level analysis, the obesity rate increased during the study period (77.8% to 88.2%, 13.4% relative increase, P = .033) and levonorgestrel-releasing intrauterine device use significantly increased after 2007 (6.3% to 82.7%, 13.2-fold increase, P < .001), both concomitant with a higher proportion of women achieving complete response (32.9% to 81.4%, 2.5-fold increase, P = .005). CONCLUSION Our study suggests that local therapy with the levonorgestrel-releasing intrauterine device may be more effective than systemic therapy for women with complex atypical hyperplasia who opt for nonsurgical treatment, particularly in morbidly obese women. Shifts in treatment paradigm during the study period toward increased levonorgestrel-releasing intrauterine device use also led to improved complete response rates despite increasing rates of obesity.
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Wu J, Qaseem Y, Birnbaum R, Smogorzewski J. Clinical pearl: Expanding knowledge of emergency contraception among dermatologists. Int J Womens Dermatol 2020; 6:450-451. [PMID: 33898718 PMCID: PMC8060627 DOI: 10.1016/j.ijwd.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/20/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
Dermatologists prescribe teratogenic or potentially teratogenic medications to treat a variety of skin diseases, including spironolactone for hormonal dysregulation in hidradenitis suppurativa or isotretinoin for severe acne. Although contraceptive options are regularly discussed, dermatologists must also be familiar with emergency contraceptive methods in the case that patients receiving teratogenic medications engage in unprotected sexual intercourse and do not desire pregnancy. A lack of knowledge regarding emergency contraceptive options may represent a practice gap for dermatologists.
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Affiliation(s)
- Jessica Wu
- David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Yasmin Qaseem
- Division of Dermatology, Harbor-UCLA Medical Center, Los Angeles, CA, United States
| | - Ron Birnbaum
- Division of Dermatology, Harbor-UCLA Medical Center, Los Angeles, CA, United States
| | - Jan Smogorzewski
- Division of Dermatology, Harbor-UCLA Medical Center, Los Angeles, CA, United States
- Corresponding author.
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ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions. Obstet Gynecol 2019; 133:e128-e150. [PMID: 30681544 DOI: 10.1097/aog.0000000000003072] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Although numerous studies have addressed the safety and effectiveness of hormonal contraceptive use in healthy women, data regarding women with underlying medical conditions or other special circumstances are limited. The U.S. Medical Eligibility Criteria (USMEC) for Contraceptive Use, 2016 (), which has been endorsed by the American College of Obstetricians and Gynecologists, is a published guideline based on the best available evidence and expert opinion to help health care providers better care for women with chronic medical problems who need contraception. The goal of this Practice Bulletin is to explain how to use the USMEC rating system in clinical practice and to specifically discuss the rationale behind the ratings for various medical conditions. Contraception for women with human immunodeficiency virus (HIV) (); the use of emergency contraception in women with medical coexisting medical conditions, including obesity, (); and the effect of depot medroxyprogesterone acetate (DMPA) on bone health () are addressed in other documents from the American College of Obstetricians and Gynecologists.
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Maxwell C, Gaudet L, Cassir G, Nowik C, McLeod NL, Jacob CÉ, Walker M. Directive clinique N o 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1676-1693. [PMID: 31640867 DOI: 10.1016/j.jogc.2019.08.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIF La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité. POPULATION CIBLE Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière. PROMOTEURS La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Depypere HT, Stanczyk FZ, Croubels S, Blondeel PN, Roche NA, Depypere BP, Vanhaecke L. Breast levonorgestrel concentrations in women using a levonorgestrel-releasing intrauterine system. Contraception 2019; 100:299-301. [PMID: 31302122 DOI: 10.1016/j.contraception.2019.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 06/12/2019] [Accepted: 07/03/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To measure breast tissue and serum LNG concentrations in women using a LNG-IUS. STUDY DESIGN This pilot study was performed in 25 healthy women undergoing breast surgery at the Ghent University hospital. LNG concentrations were measured in serum and microdissected breast tissue samples using a validated ultra-performance liquid chromatography/tandem mass spectrometry assay. RESULT(S) The mean LNG concentration in the 18 LNG-IUS users was 0.18±0.16 ng/mL in serum and 0.26±0.28 ng/g in breast tissue. For four women without any form of hormonal contraceptive (the negative controls), the mean concentrations were below the limit of quantification, i.e., 0.15 ng/mL and 0.20 ng/g, for serum and breast tissue, respectively. For the three positive controls the concentrations in the serum (20.5 and 3.4 ng/ml) and the breast (3.74 and 1.24 ng/g) were respectively for the 20 μg EE/100 μg users and 315 pg/ml in the serum and 1.17 ng/g in the breast for the minipill user. The intracellular free fraction of LNG may be as low as 0.008 ng/g. CONCLUSION(S) The concentration of LNG in breast epithelium cells in women using the LNG-IUS is very low. IMPLICATIONS The relationship between the serum and breast tissue levels of LNG was studied in women using a LNG-IUS or oral LNG-containing contraception. Compared to oral contraception, the tissue levels of LNG in LNG-IUS users are much lower in the breast. It is not known what level of LNG exposure in the breast would stimulate RANKL and WNT4 expression; such information is needed.
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Affiliation(s)
- Herman T Depypere
- Breast and Menopause Clinic, Ghent University Hospital, Ghent, Belgium.
| | - Frank Z Stanczyk
- Departments of Obstetrics and Gynecology, and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Siska Croubels
- Department of Pharmacology, Toxicology & Biochemistry, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Phillip N Blondeel
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie A Roche
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Bernard P Depypere
- Department of Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lynn Vanhaecke
- Department of Veterinary Public Health & Food Safety, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:229-268.e5. [PMID: 28413042 DOI: 10.1016/j.jogc.2016.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. SUMMARY STATEMENTS RECOMMENDATIONS.
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Effects of ritonavir-boosted protease inhibitors on combined oral contraceptive pharmacokinetics and pharmacodynamics in HIV-positive women. Contraception 2019; 100:283-287. [PMID: 31194965 DOI: 10.1016/j.contraception.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 05/31/2019] [Accepted: 06/02/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the pharmacokinetics of combined oral contraceptive (COC) components and prevalence of ovulation in HIV-positive women using ritonavir-containing antiretroviral regimens compared to those using regimens previously found not to interact with COCs or not using any antiretrovirals. STUDY DESIGN We conducted a prospective cohort pharmacokinetic pilot study comparing the pharmacokinetics of levonorgestrel (LNG) and ethinyl estradiol (EE) in HIV-positive women taking ritonavir-containing antiretroviral regimens to those in women using non-ritonavir-containing regimens or no antiretrovirals. Participants received COCs containing LNG/EE 150/30 mcg for 21 days. Beginning day 21, we collected serial blood samples over 72 h. The primary outcome was area under the curve (AUC) of LNG, with secondary outcomes including other LNG pharmacokinetic measures, EE pharmacokinetics and ovulation as measured by serum progesterone. RESULTS Pharmacokinetic parameters of LNG showed a trend toward increased exposure in women on ritonavir. LNG AUClast increased by 32.6% (312±60.9 vs. 243±82.6 ng/mL*h, p=.033, n=5) in women taking ritonavir compared to the control group (n=10). The Cmax (9.68±1.81 vs. 7.62±2.29 ng/mL) and Cmin (4.97±1.15 vs. 3.70±1.29 ng/mL) were also higher in the ritonavir arm. After excluding the inconsistent users (n=2), CL of LNG was reduced in the ritonavir arm (p=.032). EE pharmacokinetic profiles were not different between groups. The progesterone concentrations were similar in women of both groups, and none were consistent with ovulation during the treatment cycle. CONCLUSION Women on ritonavir showed an approximately 30% increase in LNG exposure but no difference in EE exposure. IMPLICATIONS The current data suggest that ritonavir does not have a clinically significant impact on oral contraceptive pharmacokinetics.
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Sundell M, Ginstman C, Månsson A, Forslund I, Brynhildsen J. Patterns of prescription and discontinuation of contraceptives for Swedish women with obesity and normal-weight women. EUR J CONTRACEP REPR 2019; 24:192-197. [PMID: 31112059 DOI: 10.1080/13625187.2019.1610873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: This study aimed to explore the prescription of different contraceptive methods to Swedish women with obesity and to compare the pattern of prescription and adherence to treatment between this group and normal-weight women. Materials and methods: This study included 371 women with obesity and 744 matched normal-weight women, aged 18-40. Medical records were scrutinised for the period 1 January 2010 to 31 December 2014. The retrieved variables included: background characteristics, prescribed contraceptive methods, adverse effects, duration of treatment, reason for discontinuation and bleeding pattern. Result: Progestin-only pills were mainly prescribed to women with obesity (44% vs. 20%, p = 0.001) whereas combined hormonal contraception was mainly prescribed to normal-weight women (60% vs. 21%, p < 0.0001). Thirty-three percent vs. 25% (p = 0.003) discontinued their contraceptive method within 1 year. The most commonly declared reason for discontinuation was bleeding disturbance (14.7% vs. 9.6%, p = 0.008). Conclusion: The most commonly prescribed contraceptive method in women with obesity was progestin-only pills, but surprisingly many women with obesity were prescribed combined hormonal contraception despite current Swedish and European guidelines. Incident users with obesity were significantly more likely to discontinue their contraceptive method within the first year of the study period, compared with incident normal-weight users.
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Affiliation(s)
- Micaela Sundell
- a Department of Obstetrics and Gynecology , Linköping University , Linköping , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Charlotte Ginstman
- a Department of Obstetrics and Gynecology , Linköping University , Linköping , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Agnes Månsson
- a Department of Obstetrics and Gynecology , Linköping University , Linköping , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Ingrid Forslund
- a Department of Obstetrics and Gynecology , Linköping University , Linköping , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Jan Brynhildsen
- a Department of Obstetrics and Gynecology , Linköping University , Linköping , Sweden.,b Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
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FSRH Guideline (April 2019) Overweight, Obesity and Contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-69. [PMID: 31053605 DOI: 10.1136/bmjsrh-2019-ooc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Luo D, Westhoff CL, Edelman AB, Natavio M, Stanczyk FZ, Jusko WJ. Altered pharmacokinetics of combined oral contraceptives in obesity - multistudy assessment. Contraception 2019; 99:256-263. [PMID: 30684471 PMCID: PMC6441376 DOI: 10.1016/j.contraception.2018.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective was to evaluate the pharmacokinetics (PKs) of levonorgestrel (LNG)-containing combined oral contraceptives (COCs) in obese women. STUDY DESIGN We pooled and reanalyzed data from 89 women with different body mass index (BMI) categories from four clinical studies. The LNG and ethinyl estradiol (EE) PKs were analyzed utilizing a zero-order absorption (K0), two-compartment PK model to evaluate key PK parameters in relation to a range of weights, BMI and body surface area (BSA). RESULTS Increasing of body habitus metrics is correlated with decreasing Cmax (p<.0001) and AUCτ (p<.05) for both LNG and EE, but no correlation was found for Cmin (p≥.17). Increasing weight and BMI were associated with a modest increase (p≤.056) of clearance (CL) and appreciable increases of central volume (V1, p<.05), distribution clearance (CLd, p≤.001) and peripheral volume (V2, p<.0001) for LNG. For EE, increases in CL (p≤.009) were found with greater weight, BMI and BSA. Values of V1, CLd and V2 also increased (p<.0001) in obese subjects. The half-life and steady-state volume were greater among obese women (p<.0001) for both LNG and EE. LNG and EE PK parameters correlated well (p≤.006 for all), indicating that individual subject physiology affected both drugs similarly. CONCLUSIONS The primary effects of obesity on LNG and EE were a modest increase in CL and a marked increase in distribution parameters. We observed no obesity-related differences in trough LNG and EE concentrations. IMPLICATIONS This population PK analysis demonstrated reduced systemic exposure to LNG/EE oral contraceptives in obese subjects (Cmax and AUCτ); these particular differences are unlikely to lower contraceptive effectiveness among obese women who are correctly using LNG-containing contraceptives.
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Affiliation(s)
- Dandan Luo
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, NY 14260, USA; Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14214, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Melissa Natavio
- Department of Obstetrics and Gynecology, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Frank Z Stanczyk
- Department of Obstetrics and Gynecology, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14214, USA.
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Natavio M, Stanczyk FZ, Molins EAG, Nelson A, Jusko WJ. Pharmacokinetics of the 1.5 mg levonorgestrel emergency contraceptive in women with normal, obese and extremely obese body mass index. Contraception 2019; 99:306-311. [PMID: 30703352 DOI: 10.1016/j.contraception.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/22/2018] [Accepted: 01/08/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess the pharmacokinetics (PK) of levonorgestrel after 1.5 mg oral doses (LNG-EC) in women with normal, obese and extremely obese body mass index (BMI). STUDY DESIGN The 1.5 mg LNG dose was given to healthy, reproductive-age, ovulatory women with normal BMI (mean 22.0), obese (mean 34.4), and extremely obese (mean 46.6 kg/m2) BMI. Total serum LNG was measured over 0 to 96 h by radioimmunoassay while free and bioavailable LNG were calculated. The maximum concentration (Cmax), time to maximum concentration (Tmax), and area under the curve (AUC) of LNG were assessed. Pharmacokinetic parameters calculated included half-life (t1/2), clearance (CL) and volume of distribution (Vss). RESULTS Ten normal-BMI, 11 obese-BMI, 5 extremely obese-BMI women were studied. After LNG-EC, mean total LNG metrics were lower in the obese and extremely obese groups compared to normal (Cmax 10.5 and 10.5 versus 16.2 ng/mL, both p<.01; AUC 208 and 197 versus 360 h × ng/mL, both p<.05). Mean bioavailable LNG Cmax was lower in obese (7.03 ng/mL, p<.05) and extremely obese (7.53 ng/ml, p=.198) compared to normal BMI (9.39 ng/mL). Mean bioavailable LNG AUC values were lower in obese and extremely obese compared to normal (131.6 and 127.5 vs 185.0 h × ng/mL, p<.05 for both). CONCLUSIONS Obese and extremely obese women were exposed to lower total and bioavailable LNG than normal BMI women. IMPLICATIONS Lower 'bioavailable' (free plus albumin bound) LNG AUC in obese women may play a role in the purported reduced efficacy of LNG-EC in obese users.
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Affiliation(s)
- Melissa Natavio
- Department of Obstetrics and Gynecology, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Frank Z Stanczyk
- Department of Obstetrics and Gynecology, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Emilie A G Molins
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Anita Nelson
- Department of Obstetrics and Gynecology, Los Angeles, California; Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Jusko
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York
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FSRH Guideline (January 2019) Combined Hormonal Contraception (Revision due by January 2024). BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-93. [PMID: 30665985 DOI: 10.1136/bmjsrh-2018-chc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Westhoff CL, Chen BA, Jensen JT, Barnhart K, Thomas M, Teal S, Blithe D. Phase I/II pharmacokinetic and pharmacodynamic evaluation of two levonorgestrel-only contraceptive patches in a multicenter randomized trial. Contraception 2018; 98:S0010-7824(18)30143-4. [PMID: 29679590 DOI: 10.1016/j.contraception.2018.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/06/2018] [Accepted: 04/08/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To evaluate the pharmacokinetic and pharmacodynamic effects of two novel levonorgestrel (LNG)-only contraceptive patches. STUDY DESIGN This multi-center Phase I/II trial randomized participants to use a 7-day transdermal patch designed to deliver a 40 mcg or 75 mcg daily LNG dose for 11 consecutive weeks; randomization was stratified by body mass index (BMI) <32 or 32-40 kg/m2. Evaluations occurred twice weekly for 5 weeks, then once weekly with supplemental visits for participants reporting a urinary LH surge. We evaluated pharmacokinetics via the weekly trough serum LNG concentrations (≥180 pg/mL considered therapeutic). The primary pharmacodynamic outcomes were cervical mucus and ovulation, evaluated using modified Insler cervical mucus scores and serum markers of ovulation. RESULTS Randomization yielded similar groups. Of 121 enrolled women, 117 contributed analyzable data. Overall, mean LNG concentrations achieved with use of the 75 mcg patch [value] were roughly double those seen with the 40 mcg dose. Concentrations achieved in higher-BMI women (BMI=32-40 kg/m2) were 50% lower compared to lower-BMI women for both patches. During the study, 94/117 (80%) participants had at least one LNG concentration <180 pg/mL. Insler scores were ≥5 at least once in 102/117 (87%) of participants, and ovulation occurred at least once in 81/117 (69%). Sixty participants (51%) had at least one ovulation following an Insler score ≥5; this occurred most frequently among higher-BMI participants using the lower-dose patch (19/25, 76%). CONCLUSIONS Women using two investigational LNG patches did not achieve consistent concentrations of LNG >180 pg/mL, an efficacy benchmark established in other studies with LNG implants, and they experienced high rates of ovulation as well as cervical mucus scores not supportive of high contraceptive efficacy. IMPLICATIONS The novel LNG-only patches in this study may not adequately decrease pregnancy risk, particularly for higher-BMI women. Future studies of LNG-only contraceptive patches will need to employ higher LNG doses and assess the acceptability and safety of such dosing.
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Affiliation(s)
| | | | | | | | | | | | - Diana Blithe
- National Institute of Child Health and Human Development
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Sponholtz TR, Palmer JR, Rosenberg LA, Hatch EE, Adams-Campbell LL, Wise LA. Exogenous Hormone Use and Endometrial Cancer in U.S. Black Women. Cancer Epidemiol Biomarkers Prev 2018; 27:558-565. [PMID: 29475971 DOI: 10.1158/1055-9965.epi-17-0722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/31/2017] [Accepted: 02/02/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Although endometrial cancer risk differs among white and black women, few data on its associations with exogenous hormone use in the latter group are available. Studies have reported lower endometrial cancer risk among users of oral contraceptives (OCs), but higher risk among users of estrogen-only female menopausal hormones (FMHs). Evidence for the risk among estrogen plus progestin FMHs users is equivocal.Methods: We followed 47,555 Black Women's Health Study participants with an intact uterus from 1995 through 2013. Data on exogenous hormone use, covariates, and endometrial cancer were obtained biennially. Self-reported incident cases of endometrial cancer were confirmed by medical records or cancer registries whenever possible. We estimated incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression.Results: We observed 300 endometrial cancer cases during 689,546 person-years of follow-up. Compared with never use, ≥10 years' duration of OC use was associated with lower risk (multivariable IRR = 0.45, 95% CI, 0.27-0.74), but risk was higher among current users of estrogen-only (IRR = 3.78, 95% CI, 1.69-8.43) and estrogen plus progestin FMH (IRR = 1.55, 95% CI, 0.78-3.11). Risk was not increased among former users of estrogen-only (IRR = 0.87, 95% CI, 0.44-1.72) or estrogen plus progestin FMH (IRR = 0.63, 95% CI, 0.36-1.09).Conclusions: Current use of estrogen-only and estrogen plus progestin FMH was associated with increased risk of endometrial cancer. Risk appeared lower among former users of estrogen plus progestin FMH. Long-term OC use was associated with reduced risk.Impact: Our results are generally consistent with those among white women. Cancer Epidemiol Biomarkers Prev; 27(5); 558-65. ©2018 AACR.
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Affiliation(s)
- Todd R Sponholtz
- Section of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, Massachusetts.
| | - Julie R Palmer
- Slone Epidemiology Center, Boston University, Boston, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Lynn A Rosenberg
- Slone Epidemiology Center, Boston University, Boston, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Lucile L Adams-Campbell
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Lauren A Wise
- Slone Epidemiology Center, Boston University, Boston, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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Rocha ALL, Campos RR, Miranda MMS, Raspante LBP, Carneiro MM, Vieira CS, Reis FM. Safety of hormonal contraception for obese women. Expert Opin Drug Saf 2017; 16:1387-1393. [PMID: 28988524 DOI: 10.1080/14740338.2018.1389893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Obese women have special safety requirements for contraceptive choice, but the evidence supporting such decision is dispersed and sometimes conflicting. Despite being effective, well tolerated and safe for most women, hormonal contraceptives are underused by obese women due to fear of contraceptive failure, weight gain and venous thrombosis. Areas covered: We performed a comprehensive literature search to identify studies about hormonal contraception in overweight and obese women, including safety concerns. We considered the safety of hormonal contraceptives for otherwise healthy obese women and for those with comorbidities such as hypertension, diabetes, vascular disease, or a history of deep venous thrombosis. Expert opinion: Over time there is no convincing evidence that obesity increases the risk of contraceptive failure. Hormonal contraceptive users may have a modest weight gain that is comparable to that of non-users. Current evidence supports the safe use of combined hormonal contraceptives by obese women after detailed clinical screening to exclude comorbidities that may contraindicate the use of estrogens. Progestin-only methods are generally safe, and long-acting reversible contraceptives hold the best combination of efficacy, safety and convenience for this group, although individualization is advisable.
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Affiliation(s)
- Ana Luiza L Rocha
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Rayana R Campos
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Marina M S Miranda
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Laio B P Raspante
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Márcia M Carneiro
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Carolina S Vieira
- b Department of Gynecology and Obstetrics, Medical School of Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , Brazil.,c Population Council , New York , NY , USA
| | - Fernando M Reis
- a Department of Gynecology and Obstetrics , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
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Kern M, Carlson NS. Current Resources for Evidence-Based Practice, March/April 2017. J Midwifery Womens Health 2017; 62:220-226. [PMID: 28419707 DOI: 10.1111/jmwh.12612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No 329-Consensus canadien sur la contraception (4e partie de 4) : chapitre 9 – contraception hormonale combinée. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:269-314.e5. [DOI: 10.1016/j.jogc.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Edelman AB, Cherala G, Jensen JT. Revisiting contraceptive steroid hormone pharmacokinetics in obese women. Contraception 2017; 95:435-436. [PMID: 28137556 DOI: 10.1016/j.contraception.2017.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/18/2017] [Accepted: 01/21/2017] [Indexed: 10/20/2022]
Affiliation(s)
| | - Ganesh Cherala
- OB/GYN, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey T Jensen
- Department of Research Technologies, Novo Nordisk Research Center, Seattle, WA
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Kern M, Carlson NS. Current Resources for Evidence-Based Practice, March/April 2017. J Obstet Gynecol Neonatal Nurs 2017; 46:e27-e36. [PMID: 28141995 DOI: 10.1016/j.jogn.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Pharmacokinetics of levonorgestrel and ulipristal acetate emergency contraception in women with normal and obese body mass index. Contraception 2017; 95:464-469. [PMID: 28126541 DOI: 10.1016/j.contraception.2017.01.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 12/10/2016] [Accepted: 01/15/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study compares the pharmacokinetics (PK) of levonorgestrel (LNG) emergency contraceptive (EC) and ulipristal acetate (UPA)-EC between normal-body mass index (BMI) and obese-BMI women. STUDY DESIGN This prospective, randomized crossover study evaluates the PK of women after single doses of LNG-EC (1.5mg) and UPA-EC (30mg). Study procedures took place during clinical research unit admissions, where participants received a standardized meal and each study drug, in random order, during two separate 24-h admissions. Study staff collected 14 blood specimens (0, 0.5, 1.0, 1.5, 2, 3, 4, 6, 8, 10, 12, 16, 24 and 48h). We evaluated serum concentrations of LNG and UPA using liquid chromatography-tandem mass spectroscopy and estimated the PK parameters of both drugs using noncompartmental analysis. The main outcome of this study was a comparison of between-group differences in AUC0-24. RESULTS Thirty-two women completed the study (16 in each group). Among normal-BMI and obese-BMI participants, the mean BMIs were 22.0 (range 18.8-24.6) and 34.3 (range 30.6-39.9), respectively. After LNG-EC, mean AUC0-24 and maximum concentration (Cmax) were 50% lower among obese-BMI women than among normal-BMI women (AUC0-24 100.8 vs. 208.5ng*h/mL, IQRobese-BMI 35.8, IQRnormal-BMI 74.2, p≤.01; Cmax 10.8 vs. 18.2ng/mL, p=.01). After UPA-EC, AUC0-24 and Cmax were similar between obese-BMI and normal-BMI women (AUC0-24 362.5 vs. 293.5ng*h/mL, IQRobese-BMI 263.2, IQRnormal-BMI 112.5, p=.15; Cmax 95.6 vs. 89.3ng/mL, p=.70). CONCLUSION After a single dose of EC, obese-BMI women are exposed to lower concentrations of LNG and similar concentrations of UPA, when compared to normal-BMI women. IMPLICATIONS Differences in LNG-EC PK by BMI group may underlie and account for the lower LNG-EC efficacy reported among obese-BMI women, but modest differences in UPA-EC PK by BMI group provide less support for variable efficacy. A pharmacodynamic study may be able to clarify whether these PK differences account for observed differences in LNG-EC and UPA-EC efficacy.
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Edelman AB, Cherala G, Li H, Pau F, Blithe DL, Jensen JT. Levonorgestrel butanoate intramuscular injection does not reliably suppress ovulation for 90 days in obese and normal-BMI women: a pilot study. Contraception 2017; 95:55-58. [PMID: 27475035 PMCID: PMC5140699 DOI: 10.1016/j.contraception.2016.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/21/2016] [Accepted: 07/21/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We performed a pilot evaluation of a new formulation of levonorgestrel butanoate (LB) designed to be a long-acting injectable (6 months) contraceptive to determine pharmacodynamic end points in normal-body mass index (BMI) and obese women. STUDY DESIGN Obese (BMI ≥30 kg/m2) and normal-BMI, otherwise healthy, women received a single intramuscular injection of LB after ovulation was confirmed in a baseline cycle. The primary outcome was return of ovulation in days. RESULTS A total of 14 women enrolled and completed the study [normal BMI n=9, median BMI 22.7kg/m2 (range 19.4-25.8); obese n=5, median BMI 35.7kg/m2 (30.1-39.2)]. The first 6 subjects (normal BMI=4/9, obese BMI=2/5) received 40 mg of LB, and the remaining 8 received 20 mg. All women except one returned to ovulation prior to 6 months. Return to ovulation occurred earlier in the obese group; 3/5 obese and 0/9 normal BMI subjects returned to ovulation within 90 days (p=.03). No serious adverse events were reported during the study. CONCLUSION Return to ovulation was earlier than 6 months in both BMI groups but more so in the obese BMI group. IMPLICATIONS Since return of ovulation was earlier than expected for this LB injectable formulation, additional steps are needed to develop a preparation suitable as a longer-lasting product.
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Affiliation(s)
- Alison B Edelman
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR; Oregon National Primate Research Center, Beaverton, OR.
| | - Ganesh Cherala
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR; CONRAD, Arlington, VA
| | - Hong Li
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - Francis Pau
- Oregon National Primate Research Center, Beaverton, OR
| | - Diana L Blithe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR; Oregon National Primate Research Center, Beaverton, OR
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Wei D, Shi Y, Li J, Wang Z, Zhang L, Sun Y, Zhou H, Xu Y, Wu C, Liu L, Wu Q, Zhuang L, Du Y, Li W, Zhang H, Legro RS, Chen ZJ. Effect of pretreatment with oral contraceptives and progestins on IVF outcomes in women with polycystic ovary syndrome. Hum Reprod 2016; 32:354-361. [PMID: 27999118 DOI: 10.1093/humrep/dew325] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Do oral contraceptives (OCs) and progestins impact live birth rate of IVF when used for cycle scheduling in women with polycystic ovary syndrome (PCOS)? SUMMARY ANSWER OCs used for scheduling IVF cycle were associated with lowered rates of pregnancy and live birth after fresh embryo transfer, whereas progestins used for this purpose yield higher rates of pregnancy and live birth than OCs. WHAT IS KNOWN ALREADY Due to oligo-menorrhea in PCOS, OCs and progestin are extensively used to schedule the start of an IVF cycle in women with PCOS. Little is known about the effect of such pretreatments on outcomes, especially, the rate of live birth. STUDY DESIGN, SIZE, DURATION This was a nested cohort study and secondary analysis of a multicenter randomized trial, which was designed to compare live birth rate after fresh embryo transfer vs frozen embryo transfer (FET) in women with PCOS (Frefro-PCOS). A total of 1508 women were enrolled from 14 centers between June 2013 and May 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS At the discretion of local investigators, subjects were instructed to wait for spontaneous menses (Control group, n = 323), or were prescribed progestins (P group, n = 283) or OCs (OCs group, n = 902) to induce menstruation prior to the start of ovarian stimulation. GnRH antagonist protocol was initiated at Day 2 or 3 of induced or spontaneous menses cycle. The rates of pregnancy, pregnancy loss and live birth after either fresh embryo transfer or FET were compared among these three groups. MAIN RESULTS AND THE ROLE OF CHANCE With fresh embryo transfer, women with OC-induced menses had lower rates of clinical pregnancy (48.8% vs 63.6%, relative rate (RR): 0.77, 95% CI: 0.66-0.89) and live birth (36.1% vs 48.1%, RR: 0.75, 95% CI: 0.61-0.92) than women with spontaneous menses. With freeze-all and deferred FET, women with OC-induced menses had a similar pregnancy rate but a higher pregnancy loss rate (27.7% vs 13.0%, RR: 2.13, 95% CI: 1.28-3.52) after FET than women with spontaneous menses. The live birth rate after FET in women with OC-induced menses, progestin-induced menses and spontaneous menses was 49.4%, 50.7% and 60.2%, respectively (P = 0.06). Progestin-induced menses was associated with similar rates of pregnancy, pregnancy loss and live birth after transfer of either fresh or frozen embryos compared with spontaneous menses. Multivariate logistic regression analysis showed that OCs used for menses induction was associated with lower rate of live birth. LIMITATIONS, REASONS FOR CAUTION The methods for menses induction were not assigned randomly, thus selection bias was highly likely because of the study design and significant differences that were observed in the baseline characteristics of the women in the different groups. The mean BMI in this study population was relatively normal; the applicability of this result to obese PCOS women needs to be evaluated in further study. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that either waiting for a spontaneous menses or using progestin is a better option than using OCs to induce menses in women with PCOS prior to ovarian stimulation using GnRH antagonist protocol for IVF. Further randomized controlled studies are needed to confirm our findings. STUDY FUNDING/COMPETING INTERESTS This study was funded by National Basic Research Program of China (973 Program) (2012CB944700), the State Key Program of National Natural Science Foundation of China (81430029), National Natural Science Foundation of China (81471428) and Thousand Talents Program (Drs Legro and Zhang H). Dr Legro reports receiving consulting fees from Euroscreen, Kindex, Bayer and Millendo Pharmaceuticals and research funding from Ferring. Others report no disclosures. TRIAL REGISTRATION NUMBER Frefro-PCOS was registered at Clinicaltrials.gov: NCT01841528.
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Affiliation(s)
- Daimin Wei
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China.,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China
| | - Yuhua Shi
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China.,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China
| | - Jing Li
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China.,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China
| | - Ze Wang
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China.,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China
| | - Lin Zhang
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China.,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China
| | - Yun Sun
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 845 Lingshan Road, Shanghai 200000, China
| | - Hong Zhou
- Center for Reproductive Medicine, Maternal and Child Health Hospital in Guangxi, 225 Xinyang Road, Nanning 530003, China
| | - Yuping Xu
- Center for Reproductive Medicine, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei 100142, China
| | - Chunxiang Wu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, 60 Yongqing Road, Nanjing 210029, China
| | - Ling Liu
- Reproductive Medicine Center of Jinghua Hospital, 156 Nanjing South Road, Shenyang 110005, China
| | - Qiongfang Wu
- Center for Reproductive Medicine, Jiangxi Provincial Maternal and Child Health Hospital, 318 Bayi Avenue, Nanchang 330006, China
| | - Lili Zhuang
- Center for Reproductive Medicine of Yantai Yuhuangding Hospital, 20 Yuhuangding East Road, Yantai 264000, China
| | - Yanzhi Du
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 845 Lingshan Road, Shanghai 200000, China
| | - Weiping Li
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 845 Lingshan Road, Shanghai 200000, China
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, 60 College Street, CT 06520, USA
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250001, China .,Key Laboratory of Reproductive Endocrinology, Shandong University, Ministry of Education, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, 157 Jingliu Road, Jinan 250001, China.,Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 845 Lingshan Road, Shanghai 200000, China
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Lopez LM, Bernholc A, Chen M, Grey TW, Otterness C, Westhoff C, Edelman A, Helmerhorst FM. Hormonal contraceptives for contraception in overweight or obese women. Cochrane Database Syst Rev 2016; 2016:CD008452. [PMID: 27537097 PMCID: PMC9063995 DOI: 10.1002/14651858.cd008452.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Obesity has reached epidemic proportions around the world. Effectiveness of hormonal contraceptives may be related to metabolic changes in obesity or to greater body mass or body fat. Hormonal contraceptives include oral contraceptives (OCs), injectables, implants, hormonal intrauterine contraception (IUC), the transdermal patch, and the vaginal ring. Given the prevalence of overweight and obesity, the public health impact of any effect on contraceptive efficacy could be substantial. OBJECTIVES To examine the effectiveness of hormonal contraceptives in preventing pregnancy among women who are overweight or obese versus women with a lower body mass index (BMI) or weight. SEARCH METHODS Until 4 August 2016, we searched for studies in PubMed (MEDLINE), CENTRAL, POPLINE, Web of Science, ClinicalTrials.gov, and ICTRP. We examined reference lists of pertinent articles to identify other studies. For the initial review, we wrote to investigators to find additional published or unpublished studies. SELECTION CRITERIA All study designs were eligible. The study could have examined any type of hormonal contraceptive. Reports had to contain information on the specific contraceptive methods used. The primary outcome was pregnancy. Overweight or obese women must have been identified by an analysis cutoff for weight or BMI (kg/m(2)). DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. The main comparisons were between overweight or obese women and women of lower weight or BMI. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Where available, we included life-table rates. We also used unadjusted pregnancy rates, relative risk (RR), or rate ratio when those were the only results provided. For dichotomous variables, we computed an odds ratio with 95% confidence interval (CI). MAIN RESULTS With 8 studies added in this update, 17 met our inclusion criteria and had a total of 63,813 women. We focus here on 12 studies that provided high, moderate, or low quality evidence. Most did not show a higher pregnancy risk among overweight or obese women. Of five COC studies, two found BMI to be associated with pregnancy but in different directions. With an OC containing norethindrone acetate and ethinyl estradiol (EE), pregnancy risk was higher for overweight women, i.e. with BMI ≥ 25 versus those with BMI < 25 (reported relative risk 2.49, 95% CI 1.01 to 6.13). In contrast, a trial using an OC with levonorgestrel and EE reported a Pearl Index of 0 for obese women (BMI ≥ 30) versus 5.59 for nonobese women (BMI < 30). The same trial tested a transdermal patch containing levonorgestrel and EE. Within the patch group, obese women in the "treatment-compliant" subgroup had a higher reported Pearl Index than nonobese women (4.63 versus 2.15). Of five implant studies, two that examined the six-capsule levonorgestrel implant showed differences in pregnancy by weight. One study showed higher weight was associated with higher pregnancy rate in years 6 and 7 combined (reported P < 0.05). In the other, pregnancy rates differed in year 5 among the lower weight groups only (reported P < 0.01) and did not involve women weighing 70 kg or more.Analysis of data from other contraceptive methods indicated no association of pregnancy with overweight or obesity. These included depot medroxyprogesterone acetate (subcutaneous), levonorgestrel IUC, the two-rod levonorgestrel implant, and the etonogestrel implant. AUTHORS' CONCLUSIONS The evidence generally did not indicate an association between higher BMI or weight and effectiveness of hormonal contraceptives. However, we found few studies for most contraceptive methods. Studies using BMI, rather than weight alone, can provide information about whether body composition is related to contraceptive effectiveness. The contraceptive methods examined here are among the most effective when used according to the recommended regimen.We considered the overall quality of evidence to be low for the objectives of this review. More recent reports provided evidence of varying quality, while the quality was generally low for older studies. For many trials the quality would be higher for their original purpose rather than the non-randomized comparisons here. Investigators should consider adjusting for potential confounding related to BMI or contraceptive effectiveness. Newer studies included a greater proportion of overweight or obese women, which helps in examining effectiveness and side effects of hormonal contraceptives within those groups.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Alissa Bernholc
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Mario Chen
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Thomas W Grey
- FHI 360Social and Behavioral Health Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | | | - Carolyn Westhoff
- Columbia UniversityDept of Obstetrics and Gynecology630 West 168 StreetNew YorkNew YorkUSANY 10032
| | - Alison Edelman
- Oregon Health & Science UniversityDept. of Obstetrics and GynecologyPortlandOregonUSA
| | - Frans M Helmerhorst
- Leiden University Medical CenterDept. of Clinical EpidemiologyPO Box 9600Albinusdreef 2LeidenNetherlandsNL 2300 RC
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Jusko WJ. Clarification of contraceptive drug pharmacokinetics in obesity. Contraception 2016; 95:10-16. [PMID: 27542520 DOI: 10.1016/j.contraception.2016.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 01/21/2023]
Abstract
Related to concerns about the role of obesity in the efficacy of contraceptive drugs, a review of the literature was carried out in regard to the pharmacokinetics of ethinyl estradiol and various progestins given by various routes of administration. Most studies show that obese women exhibit modestly lower plasma concentrations of these drugs (circa 30%) when given the same doses as normal-weight women. While the mechanism is uncertain, precedence in the literature suggests that this is due to body weight-related differences in metabolism rates. Confusing in some of the literature is that a few studies have reported erroneously calculated pharmacokinetic parameters after multiple dosing of oral contraceptives. A demonstration of appropriate pharmacokinetic methodology is provided.
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Affiliation(s)
- William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA.
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Cherala G, Edelman A, Dorflinger L, Stanczyk FZ. The elusive minimum threshold concentration of levonorgestrel for contraceptive efficacy. Contraception 2016; 94:104-8. [DOI: 10.1016/j.contraception.2016.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/22/2016] [Accepted: 03/11/2016] [Indexed: 01/04/2023]
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Jusko WJ. Perspectives on variability in pharmacokinetics of an oral contraceptive product. Contraception 2016; 95:5-9. [PMID: 27475034 DOI: 10.1016/j.contraception.2016.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
The early literature and reviews have described the pharmacokinetics (PK) of oral contraceptive (OC) compounds such as ethinyl estradiol (EE) and levonorgestrel (LNG) in women as subject to large intersubject variability. This was partly due to the use of diverse radioimmunoassays, limited sampling periods and an incomplete understanding of single- vs. multiple-dose kinetics and the role of EE in causing both inhibition of hepatic metabolism along with induction of sex hormone binding globulin. Over the past two decades, LNG and EE have been used as target drugs for the assessment of possible drug interactions upon introduction of many new therapeutic agents. This has resulted in at least 17 publications that describe the PK of LNG and EE in women using various 150 mcg/30 mcg products under fairly standard multiple-dose conditions. A review of these studies indicates only moderate variability in the Cmax and area under the curve both within and across these studies. There is impressive similarity in these drug exposure indices found in studies carried out with several products by investigators at numerous sites and countries.
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Affiliation(s)
- William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, 404 Kapoor Hall, Buffalo, NY 14214, USA.
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45
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Laho T, Clarke JD, Dzierlenga AL, Li H, Klein DM, Goedken M, Micuda S, Cherrington NJ. Effect of nonalcoholic steatohepatitis on renal filtration and secretion of adefovir. Biochem Pharmacol 2016; 115:144-51. [PMID: 27381944 DOI: 10.1016/j.bcp.2016.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Adefovir, an acyclic nucleotide reverse transcriptase inhibitor used to treat hepatitis B viral infection, is primarily eliminated renally through cooperation of glomerular filtration with active tubular transport. Nonalcoholic steatohepatitis is a variable in drug disposition, yet the impact on renal transport processes has yet to be fully understood. The goal of this study was to determine the effect of nonalcoholic steatohepatitis on the pharmacokinetics of adefovir in rats given a control or methionine and choline deficient diet to induce nonalcoholic steatohepatitis. METHODS Animals received a bolus dose of 7mg/kg (35μCi/kg) [(3)H] adefovir with consequent measurement of plasma and urine concentrations. Inulin clearance was used to determine glomerular filtration rate. RESULTS Methionine and choline deficient diet-induced nonalcoholic steatohepatitis prolonged the elimination half-life of adefovir. This observation occurred in conjunction with reduced distribution volume and hepatic levels of adefovir. Notably, despite these changes, renal clearance and overall clearance were not changed, despite markedly reduced glomerular filtration rate in nonalcoholic steatohepatitis. Alteration of glomerular filtration rate was fully compensated for by a significant increase in tubular secretion of adefovir. Analysis of renal transporters confirmed transcriptional up-regulation of Mrp4, the major transporter for adefovir tubular secretion. CONCLUSIONS This study demonstrates changes to glomerular filtration and tubular secretion that alter pharmacokinetics of adefovir in nonalcoholic steatohepatitis. Nonalcoholic steatohepatitis-induced changes in renal drug elimination processes could have major implications in variable drug response and the potential for toxicity.
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Affiliation(s)
- Tomas Laho
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA; Charles University, Department of Pharmacology, Hradec Kralove, Czech Republic
| | - John D Clarke
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Anika L Dzierlenga
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Hui Li
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - David M Klein
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA
| | - Michael Goedken
- Rutgers University, Department of Translational Sciences Research Pathology Services, New Brunswick, NJ, USA
| | - Stanislav Micuda
- Charles University, Department of Pharmacology, Hradec Kralove, Czech Republic
| | - Nathan J Cherrington
- University of Arizona, Department of Pharmacology and Toxicology, Tucson, AZ, USA.
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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]
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Impact of obesity on the pharmacokinetics of levonorgestrel-based emergency contraception: single and double dosing. Contraception 2016; 94:52-7. [PMID: 27000996 DOI: 10.1016/j.contraception.2016.03.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/02/2016] [Accepted: 03/13/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine if differences exist in the pharmacokinetics (PK) of levonorgestrel-based emergency contraception (LNG-EC) in obese and normal body mass index (BMI) users and test whether doubling the dose of LNG-EC in obese women increases total and free (active) LNG serum concentrations. STUDY DESIGN Healthy, reproductive-age women with obese and normal BMIs received 1.5mg LNG orally (ECx1) and then in a subsequent menstrual cycle, the obese group also received 3mg LNG (ECx2). Dosing occurred during the follicular phase. Total and free LNG PK parameters were obtained via serum samples through an indwelling catheter at 0, 0.5, 1, 1.5, 2, and 2.5h. The primary outcome was the difference in total and free LNG concentration maximum (Cmax) between ECx1 and ECx2 in the obese group. RESULTS A total of 10 women enrolled and completed the study (normal BMI=5, median 22.8kg/m(2), range 20.8-23.7; obese BMI=5, 39.5kg/m(2), range 35.9-46.7). The total LNG Cmax for obese subjects following ECx1 (5.57±2.48ng/mL) was significantly lower than the level observed in normal BMI women (10.30±2.47, p=.027). Notably, ECx2 increased the Cmax significantly (10.52±2.76, p=.002); approximating the level in normal BMI subjects receiving ECx1. Free LNG Cmax followed a similar pattern. CONCLUSION Obesity adversely impacts both the total and free Cmax levels of LNG EC and this likely explains its lack of efficacy in obese women. Doubling the dose appears to correct the obesity-related PK changes but additional research is needed to determine if this also improves EC effectiveness in obese women. IMPLICATIONS This study demonstrates that obesity interferes with the pharmacokinetics of LNG EC, and that doubling the dose may be an effective strategy to improve its efficacy in obese women.
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Safety and Efficacy of Contraceptive Methods for Obese and Overweight Women. Obstet Gynecol Clin North Am 2015; 42:647-57. [DOI: 10.1016/j.ogc.2015.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lobert M, Pigeyre M, Gronier H, Catteau-Jonard S, Robin G. [Contraception and obesity]. ACTA ACUST UNITED AC 2015; 43:740-7. [PMID: 26527416 DOI: 10.1016/j.gyobfe.2015.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 09/18/2015] [Indexed: 12/30/2022]
Abstract
The prevalence of obesity is increasing massively over several decades in industrialized countries. Obese women are sexually active but they use fewer contraceptive methods and are at high risk of unintended pregnancy. In addition, obesity is an important risk factor for venous thromboembolism events and arterial thrombosis (myocardial infarction and ischemic stroke). All of these data are to be considered in choosing a contraceptive method for obese women. Except depot medroxyprogesterone acetate injection, the progestin-only contraceptives (progestin only pills and etonogestrel subdermal implant) and the intra-uterine devices are the preferred contraceptive methods in obese women. The combined estrogen-progestin contraceptives (pill, patch and vaginal ring) may be proposed in very strict conditions (no other associated vascular risk factor). Obesity does not increase the risk of failure of most contraceptive methods. Bariatric surgery is a complex situation. It requires to program a possible pregnancy and contraception is needed for several months. Some bariatric surgical techniques such as by-pass can induce gastrointestinal malabsorption. In this situation, all oral contraceptives are not recommended because of a higher risk of failure.
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Affiliation(s)
- M Lobert
- Service de gynécologie médicale, orthogénie et médecine du couple, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France; Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France
| | - M Pigeyre
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France; Service de nutrition, hôpital Huriez, CHRU de Lille, avenue Oscar-Lambret, 59037 Lille cedex, France
| | - H Gronier
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93143 Bondy cedex, France
| | - S Catteau-Jonard
- Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France
| | - G Robin
- Service de gynécologie médicale, orthogénie et médecine du couple, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France; Service de gynécologie endocrinienne et médecine de la reproduction, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugene-Avinée, 59037 Lille cedex, France.
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Yamazaki M, Dwyer K, Sobhan M, Davis D, Kim MJ, Soule L, Willett G, Yu C. Effect of obesity on the effectiveness of hormonal contraceptives: an individual participant data meta-analysis. Contraception 2015; 92:445-52. [DOI: 10.1016/j.contraception.2015.07.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 07/27/2015] [Accepted: 07/31/2015] [Indexed: 12/30/2022]
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