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Todd CS, Lorenzetti L, Mussa A, Ridgeway K, Morroni C, Nanda K. Drug-drug interactions between antiretrovirals and hormonal contraception: An updated systematic review. Contraception 2024:110490. [PMID: 38762199 DOI: 10.1016/j.contraception.2024.110490] [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: 12/22/2022] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To summarize and update information regarding drug-drug interactions (DDIs) between antiretrovirals (ARVs) and hormonal contraceptives (HCs). STUDY DESIGN Systematic review. RESULTS We included 49 articles, with clinical, ARV, or HC PK outcomes reported by 39, 25, and 30 articles, respectively, with some articles reporting outcomes in two or more categories. Fifteen of 18 articles assessing DDIs between efavirenz and progestin implants, emergency contraception, or combined hormonal intravaginal rings found higher pregnancy rates, luteal progesterone levels suggesting ovulation, or reduced progestin PK values. Five studies documented that CYP2B6 single nucleotide polymorphisms exacerbated this DDI. One cohort detected doubled bone density loss with concomitant depot medroxyprogesterone acetate (DMPA) and tenofovir disoproxil fumarate (TDF)-containing ART use versus TDF alone. No other studies described DDIs impacting clinical outcomes. Few adverse events were attributed to ARV-HC use with none exceeding Grade 2. Evidence quality was generally moderate, with dis-similar treatment and control groups, identifying and controlling for confounding, and minimizing attrition bias in the study design being the most frequent limitations. CONCLUSION TDF-DMPA DDIs warrant longer-term study on bone health and consideration of alternate combinations. For efavirenz-based ART, client counseling on relative risks, including both potential increase in pregnancy rate with concomitant efavirenz and implant use and lower pregnancy rates compared to other HCs even with concomitant efavirenz use, should continue to allow users comprehensive method choice. IMPLICATIONS Most ARVs and HCs may be used safely and effectively together. Efavirenz-based ART requires careful counseling and data for possible interactions between HCs and new ARV classes are anticipated.
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Affiliation(s)
- Catherine S Todd
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States.
| | - Lara Lorenzetti
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
| | - Aamirah Mussa
- Botswana Harvard Health Partnership, Gaborone, Botswana; Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Kathleen Ridgeway
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
| | | | - Kavita Nanda
- Global Health, Population, and Nutrition, FHI 360, Durham, NC, United States
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2
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Sawant-Basak A, Ingle-Jadhav P. Prescription of Oral Contraceptives by Licensed Pharmacists in the USA. J Clin Pharmacol 2024; 64:283-287. [PMID: 38047452 DOI: 10.1002/jcph.2390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
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3
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Creinin MD, Angulo A, Colli E, Archer DF. The efficacy, safety, and tolerability of an estrogen-free oral contraceptive drospirenone 4 mg (24/4-day regimen) in obese users. Contraception 2023; 128:110136. [PMID: 37544572 DOI: 10.1016/j.contraception.2023.110136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES This study aimed to compare contraceptive efficacy and safety of drospirenone 4 mg in a 24/4-day regimen in nonobese and obese users and describe pharmacokinetics according to bodyweight. STUDY DESIGN We analyzed data from three drospirenone 4 mg trials (2 European and 1 United States) to report outcomes in nonobese (body mass index <30 kg/m2) and obese (body mass index ≥30 kg/m2) users. We used data from the US trial to calculate the Pearl Index (pregnancies per 100 woman-years) in nonbreastfeeding participants aged ≤35 years at enrollment for confirmed pregnancies. We assessed safety outcomes from all trials based on reported treatment-emergent adverse events. We evaluated pharmacokinetics by bodyweight in the US trial. RESULTS The three trials combined comprised 2152 nonobese and 425 obese participants, including 590 nonobese and 325 obese participants in the US trial. Eight nonobese and four obese participants had confirmed pregnancies in the US trial, resulting in Pearl Indices of 3.0 (95% CI: 1.3-5.8) and 2.9 (95% CI: 0.8-7.3), respectively. Two-hundred forty-four (11.3%) nonobese and 39 (9.2%) obese participants discontinued due to a treatment-emergent adverse event. The pharmacokinetic analysis included 814 participants with a median weight of 73 (interquartile range 61-89) kg and median plasma drospirenone exposure (AUC0-24ss) of 661.3 (interquartile range 522-828) ng∙h/mL. Changing bodyweight from the median to the fifth percentile (51 kg) or 95th percentile (118 kg) changed drospirenone exposure (AUC0-24,ss) by 22.2% and -23.6%, respectively. CONCLUSIONS Drospirenone 4 mg demonstrated similar contraceptive efficacy for both nonobese and obese users despite a difference in exposure based on bodyweight. IMPLICATIONS Our limited comparison between obese and nonobese users of drospirenone-only oral contraception demonstrated no evidence that efficacy or discontinuation for adverse events differs between groups. Serum drospirenone levels vary by bodyweight and may correlate with bleeding outcomes.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | | | | | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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4
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Mikuš M, Šprem Goldštajn M, Laganà AS, Vukorepa F, Ćorić M. Clinical Efficacy, Pharmacokinetics, and Safety of the Available Medical Options in the Treatment of Endometriosis-Related Pelvic Pain: A Scoping Review. Pharmaceuticals (Basel) 2023; 16:1315. [PMID: 37765123 PMCID: PMC10537015 DOI: 10.3390/ph16091315] [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: 07/17/2023] [Revised: 09/10/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND In this scoping review, we sought to identify published studies evaluating the drugs currently used in the treatment of endometriosis-related pelvic pain, with reflection on their chemical properties, pharmacokinetics, safety profile, and clinical efficacy. METHODS A literature search was conducted with the use of the PubMed and EMBASE electronic databases, focusing on identifying articles published in English between January 1990 and 2023. RESULTS Based on the included studies, current therapy options for the treatment of endometriosis-related pain identified and reviewed in this article were: (1) non-steroidal anti-inflammatory drugs; (2) combined oral contraceptive (COCs); (3) progestins; (4) gonadotropin-releasing hormone agonists and antagonists; (5) aromatase inhibitors (AIs); (6) selective estrogen and progesterone receptor modulators; and (7) levonorgestrel-intrauterine device. CONCLUSIONS Based on the published evidence, clinicians should consider NSAIDs, COCs, and progestins as the first-line medical therapies. Compared with second-line options, such as GnRH agonists/antagonists or AIs, the abovementioned first-line options are well tolerated, efficacious, and exhibit lower overall price. Future research priorities should be to identify novel target therapies and to evaluate the effects of available drugs through different routes of administration.
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Affiliation(s)
- Mislav Mikuš
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia; (M.Š.G.); (F.V.); (M.Ć.)
| | - Marina Šprem Goldštajn
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia; (M.Š.G.); (F.V.); (M.Ć.)
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Franka Vukorepa
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia; (M.Š.G.); (F.V.); (M.Ć.)
| | - Mario Ćorić
- Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, 10 000 Zagreb, Croatia; (M.Š.G.); (F.V.); (M.Ć.)
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5
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Yland JJ, Wesselink AK, Hernandez-Diaz S, Huybrechts K, Hatch EE, Wang TR, Savitz D, Kuohung W, Rothman KJ, Wise LA. Preconception contraceptive use and miscarriage: prospective cohort study. BMJ MEDICINE 2023; 2:e000569. [PMID: 37705685 PMCID: PMC10496668 DOI: 10.1136/bmjmed-2023-000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/14/2023] [Indexed: 09/15/2023]
Abstract
Objectives To evaluate the association between preconception contraceptive use and miscarriage. Design Prospective cohort study. Setting Residents of the United States of America or Canada, recruited from 2013 until the end of 2022. Participants 13 460 female identified participants aged 21-45 years who were planning a pregnancy were included, of whom 8899 conceived. Participants reported data for contraceptive history, early pregnancy, miscarriage, and potential confounders during preconception and pregnancy. Main outcome measure Miscarriage, defined as pregnancy loss before 20 weeks of gestation. Results Preconception use of combined and progestin-only oral contraceptives, hormonal intrauterine devices, copper intrauterine devices, rings, implants, or natural methods was not associated with miscarriage compared with use of barrier methods. Participants who most recently used patch (incidence rate ratios 1.34 (95% confidence interval 0.81 to 2.21)) or injectable contraceptives (1.44 (0.99 to 2.12)) had higher rates of miscarriage compared with recent users of barrier methods, although results were imprecise due to the small numbers of participants who used patch and injectable contraceptives. Conclusions Use of most contraceptives before conception was not appreciably associated with miscarriage rate. Individuals who used patch and injectable contraceptives had higher rates of miscarriage relative to users of barrier methods, although these results were imprecise and residual confounding was possible.
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Affiliation(s)
- Jennifer J Yland
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Amelia K Wesselink
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology and CAUSALab, Harvard University T H Chan School of Public Health, Boston, MA, USA
| | - Krista Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth E Hatch
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Tanran R Wang
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - David Savitz
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Wendy Kuohung
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
| | - Kenneth J Rothman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lauren A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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6
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Jensen JT, Reinecke I, Post TM, Lukkari-Lax E, Hofmann BM. Extended use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg: A population pharmacokinetic approach to estimate in vivo levonorgestrel release rates and systemic exposure including comparison with two other LNG-IUSs. Contraception 2023; 120:109954. [PMID: 36634730 DOI: 10.1016/j.contraception.2023.109954] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/12/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To characterize performance of levonorgestrel-releasing intrauterine system (LNG-IUS) 52mg (Mirena) over 8 years of use and facilitate comparisons with LNG-IUS 19.5mg and LNG-IUS 13.5mg. STUDY DESIGN We estimated in vivo levonorgestrel (LNG) release rates and LNG plasma/serum concentrations for LNG-IUS 52mg up to 8 years of use with a population pharmacokinetic (popPK) approach using data from the Mirena Extension Trial (MET) and earlier clinical trials. We compared these with previously published release rates and exposure data for LNG-IUS 19.5mg and 13.5mg. Our 8-year popPK and release models were developed based on measured plasma/serum LNG and sex hormone-binding globulin concentrations and residual LNG content from removed LNG-IUS 52mg devices. RESULTS Model-based estimated LNG release rates for LNG-IUS 52mg decreased from ∼21 µg/d after insertion to ∼7.0 µg/d after 8 years, similar to LNG-IUS 19.5mg after 5 years (7.6 µg/d) and higher than LNG-IUS 13.5mg after 3 years (5.5 µg/d). Model-based estimated and measured plasma/serum LNG concentrations showed satisfactory agreement. Average model-based estimated LNG concentrations after 8 years of LNG-IUS 52mg use (100 ng/L [coefficient of variance 39.9%]) were similar to LNG-IUS 19.5mg after 5 years (84.8 ng/L [39.9%]) and higher than LNG-IUS 13.5mg after 3 years (58.1 ng/L [40.8%]). CONCLUSIONS The 8-year release and popPK models provide reliable in vivo LNG release rates and concentration estimates, respectively, facilitating direct comparisons between the 3 studied LNG-IUSs. LNG release rates from LNG-IUS 52mg at 8 years are similar to LNG-IUS 19.5mg at 5 years and higher than LNG-IUS 13.5mg at 3 years. IMPLICATIONS Levonorgestrel release from intrauterine system reservoirs declines with duration of use in a predictable way, and in relation to the initial load. As release rates and plasma concentrations of levonorgestrel may influence endometrial and systemic side effects, these data may assist clinical decision-making.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States.
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7
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Uyanik E, Mumusoglu S, Polat M, Yarali Ozbek I, Esteves SC, Humaidan P, Yarali H. A drop in serum progesterone from oocyte pick-up +3 days to +5 days in fresh blastocyst transfer, using hCG-trigger and standard luteal support, is associated with lower ongoing pregnancy rates. Hum Reprod 2023; 38:225-236. [PMID: 36478179 DOI: 10.1093/humrep/deac255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/22/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Do early- and mid-luteal serum progesterone (P4) levels impact ongoing pregnancy rates (OPRs) in fresh blastocyst transfer cycles using standard luteal phase support (LPS)? SUMMARY ANSWER A drop in serum P4 level from oocyte pick-up (OPU) + 3 days to OPU + 5 days (negative ΔP4) is associated with a ∼2-fold decrease in OPRs. WHAT IS KNOWN ALREADY In fresh embryo transfer cycles, significant inter-individual variation occurs in serum P4 levels during the luteal phase, possibly due to differences in endogenous P4 production after hCG trigger and/or differences in bioavailability of exogenously administered progesterone (P) via different routes. Although exogenous P may alleviate this drop in serum P4 in fresh transfer cycles, there is a paucity of data exploring the possible impact on reproductive outcomes of a reduction in serum P4 levels. STUDY DESIGN, SIZE, DURATION Using a prospective cohort study design, following the initial enrollment of 558 consecutive patients, 340 fulfilled the inclusion and exclusion criteria and were included in the final analysis. The inclusion criteria were: (i) female age ≤40 years, (ii) BMI ≤35 kg/m2, (iii) retrieval of ≥3 oocytes irrespective of ovarian reserve, (iv) the use of a GnRH-agonist or GnRH-antagonist protocol with recombinant hCG triggering (6500 IU), (v) standard LPS and (vi) fresh blastocyst transfer. The exclusion criteria were: (i) triggering with GnRH-agonist or GnRH-agonist plus recombinant hCG (dual trigger), (ii) circulating P4 >1.5 ng/ml on the day of trigger and (iii) cleavage stage embryo transfer. Each patient was included only once. The primary outcome was ongoing pregnancy (OP), as defined by pregnancy ≥12 weeks of gestational age. PARTICIPANTS/MATERIALS, SETTING, METHODS A GnRH-agonist (n = 53) or GnRH-antagonist (n = 287) protocol was used for ovarian stimulation. Vaginal progesterone gel (Crinone, 90 mg, 8%, Merck) once daily was used for LPS. Serum P4 levels were measured in all patients on five occasions: on the day of ovulation trigger, the day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days; timing of blood sampling was standardized to be 3-5 h after the morning administration of vaginal progesterone gel. The delta P4 (ΔP4) level was calculated by subtracting the P4 level on the OPU + 3 days from the P4 level on the OPU + 5 days, resulting in either a positive or negative ΔP4. MAIN RESULTS AND THE ROLE OF CHANCE The median P4 (min-max) on the day of triggering, day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days were 0.83 ng/ml (0.18-1.42), 5.81 ng/ml (0.80-22.72), 80.00 ng/ml (22.91-161.05), 85.91 ng/ml (15.66-171.78) and 13.46 ng/ml (0.18-185.00), respectively. Serum P4 levels uniformly increased from the day of OPU to OPU + 3 days in all patients; however, from OPU + 3 days to OPU + 5 days, some patients had a decrease (negative ΔP4; n = 116; 34.1%), whereas others had an increase (positive ΔP4; n = 220; 64.7%), in circulating P4 levels. Although the median (min-max) P4 levels on the day of triggering, the day of OPU, and OPU + 3 days were comparable between the negative ΔP4 and positive ΔP4 groups, patients in the former group had significantly lower P4 levels on OPU + 5 days [69.67 ng/ml (15.66-150.02) versus 100.51 ng/ml (26.41-171.78); P < 0.001] and OPU + 14 days [8.28 ng/ml (0.28-157.00) versus 19.01 ng/ml (0.18-185.00), respectively; P < 0.001]. A drop in P4 level from OPU + 3 days to OPU + 5 days (negative ΔP4) was seen in approximately one-third of patients and was associated with a significantly lower OPR when compared with positive ΔP4 counterparts [33.6% versus 49.1%, odds ratio (OR); 0.53, 95% CI; 0.33-0.84; P = 0.008]; this decrease in OPR was due to lower initial pregnancy rates rather than increased overall pregnancy loss rates. For negative ΔP4 patients, the magnitude of ΔP4 was a significant predictor of OP (adjusted AUC = 0.65; 95% CI; 0.59-0.71), with an optimum threshold of -8.73 ng/ml, sensitivity and specificity were 48.7% and 79.2%, respectively. BMI (OR; 1.128, 95% CI; 1.064-1.197) was the only significant predictor of having a negative ΔP4; the higher the BMI, the higher the risk of having a negative ΔP4. Among positive ΔP4 patients, the magnitude of ΔP4 was a weak predictor of OP (AUC = 0.56, 95% CI; 0.48-0.64). Logistic regression analysis showed that blastocyst morphology (OR; 5.686, 95% CI; 1.433-22.565; P = 0.013) and ΔP4 (OR; 1.013, 95% CI; 0.1001-1.024; P = 0.031), but not the serum P4 level on OPU + 5 days, were the independent predictors of OP. LIMITATIONS, REASONS FOR CAUTION The physiological circadian pulsatile secretion of P4 during the mid-luteal phase is a limitation; however, blood sampling was standardized to reduce the impact of timing. WIDER IMPLICATIONS OF THE FINDINGS Two measurements (OPU + 3 days and OPU + 5 days) of serum P4 may identify those patients with a drop in P4 (approximately one-third of patients) associated with ∼2-fold lower OPRs. Rescuing these IVF cycles with additional P supplementation or adopting a blastocyst freeze-all policy should be tested in future randomized controlled trials. STUDY FUNDING/COMPETING INTEREST(S) None. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. P.H. has received unrestricted research grants from MSD and Merck, as well as honoraria for lectures from MSD, Merck, Gedeon-Richter, Theramex, and IBSA. H.Y. declares receipt of honorarium for lectures from Merck, IBSA and research grants from Merck and Ferring. The remaining authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER The study was registered at clinical trials.gov (NCT04128436).
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Affiliation(s)
- Esra Uyanik
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Mehtap Polat
- Department of Obstetrics and Gynecology, Anatolia IVF and Women Health Center, Ankara, Turkey.,Department of Medical Services and Techniques, First and Emergency Aid Program, School of Health Services, Atılım University Vocational, Ankara, Turkey
| | - Irem Yarali Ozbek
- Department of Histology and Embryology, Anatolia IVF and Women Health Center, Ankara, Turkey
| | - Sandro C Esteves
- Androfert, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil.,Department of Obstetrics and Gynecology, Aarhus University-Skive Hospital, Skive, Denmark
| | - Peter Humaidan
- Department of Obstetrics and Gynecology, Aarhus University-Skive Hospital, Skive, Denmark.,The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey.,Department of Obstetrics and Gynecology, Anatolia IVF and Women Health Center, Ankara, Turkey
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8
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Cheah S, Gao Y, Mo S, Rigas G, Fisher O, Chan DL, Chapman MG, Talbot ML. Fertility, pregnancy and post partum management after bariatric surgery: a narrative review. Med J Aust 2022; 216:96-102. [PMID: 35034365 PMCID: PMC9306879 DOI: 10.5694/mja2.51373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 11/24/2022]
Abstract
Of the women who gave birth in Australia in 2018, 47% had overweight or obesity, with obesity being associated with both maternal and fetal complications. Bariatric surgery improves fertility and some pregnancy‐related outcomes. Following bariatric surgery, pregnancy should be delayed by at least 12–18 months due to adverse pregnancy outcomes associated with rapid weight loss. Contraception should be prescribed after bariatric surgery, although the effectiveness of the oral contraceptive pill may be reduced due to malabsorption and contraceptive devices such as intrauterine devices should be considered as first line therapy. After bariatric surgery, women should undergo close monitoring for nutritional insufficiencies before, during and after pregnancy. Expert opinion recommends these women undergo dietary assessment and supplementation to prevent micronutrient deficiencies. Bariatric surgeons, bariatric medical practitioners, bariatric dieticians, the patient’s usual general practitioner, obstetricians, and maternity specialists should be involved to assist in the multidisciplinary management of these complex patients.
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Affiliation(s)
| | | | | | | | - Oliver Fisher
- St George Hospital Sydney NSW
- University of New South Wales Sydney NSW
| | - Daniel L Chan
- St George Hospital Sydney NSW
- University of New South Wales Sydney NSW
| | | | - Michael L Talbot
- St George Hospital Sydney NSW
- University of New South Wales Sydney NSW
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9
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Mumusoglu S, Polat M, Ozbek IY, Bozdag G, Papanikolaou EG, Esteves SC, Humaidan P, Yarali H. Preparation of the Endometrium for Frozen Embryo Transfer: A Systematic Review. Front Endocrinol (Lausanne) 2021; 12:688237. [PMID: 34305815 PMCID: PMC8299049 DOI: 10.3389/fendo.2021.688237] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Despite the worldwide increase in frozen embryo transfer, the search for the best protocol to prime endometrium continues. Well-designed trials comparing various frozen embryo transfer protocols in terms of live birth rates, maternal, obstetric and neonatal outcome are urgently required. Currently, low-quality evidence indicates that, natural cycle, either true natural cycle or modified natural cycle, is superior to hormone replacement treatment protocol. Regarding warmed blastocyst transfer and frozen embryo transfer timing, the evidence suggests the 6th day of progesterone start, LH surge+6 day and hCG+7 day in hormone replacement treatment, true natural cycle and modified natural cycle protocols, respectively. Time corrections, due to inter-personal differences in the window of implantation or day of vitrification (day 5 or 6), should be explored further. Recently available evidence clearly indicates that, in hormone replacement treatment and natural cycles, there might be marked inter-personal variation in serum progesterone levels with an impact on reproductive outcomes, despite the use of the same dose and route of progesterone administration. The place of progesterone rescue protocols in patients with low serum progesterone levels one day prior to warmed blastocyst transfer in hormone replacement treatment and natural cycles is likely to be intensively explored in near future.
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Affiliation(s)
- Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehtap Polat
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | | | - Gurkan Bozdag
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Sandro C. Esteves
- Androfert, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic, Skive Regional Hospital Resenvej 25, Skive, Denmark
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
- Anatolia IVF and Women Health Centre, Ankara, Turkey
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10
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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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11
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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 2021; 17:673-681. [PMID: 33547015 DOI: 10.1016/j.soard.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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12
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Sun H, Sivasubramanian R, Vaidya S, Barve A, Jarugula V. Drug-Drug Interaction Studies With Oral Contraceptives: Pharmacokinetic/Pharmacodynamic and Study Design Considerations. J Clin Pharmacol 2020; 60 Suppl 2:S49-S62. [PMID: 33274510 DOI: 10.1002/jcph.1765] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
Oral contraceptives (OCs) are the most widely used form of birth control among women of childbearing potential. Knowledge of potential drug-drug interactions (DDIs) with OCs becomes imperative to provide information on the medication to women of childbearing potential and enable their inclusion in clinical trials, especially if the new molecular entity is a teratogen. Although a number of DDI guidance documents are available, they do not provide recommendations for the design and conduct of OC DDI studies. The evaluation of DDI potential of a new molecular entity and OCs is particularly challenging because of the availability of a wide variety of combinations of hormonal contraceptives, different doses of the ethinyl estradiol, and different metabolic profiles of the progestin component. The aim of this review is to comprehensively discuss factors to be considered such as pharmacokinetics (PK), pharmacodynamics (PD), choice of OC, and study population for the conduct of in vivo OC DDI studies. In this context, metabolic pathways of OCs, the effect of enzyme inhibitors and inducers, the role of sex hormone-binding globulin in the PK of progestins, current evidence on OC DDIs, and the interpretation of PD end points are reviewed. With the emergence of new tools like physiologically based PK modeling, the decision to conduct an in vivo study can be made with much more confidence. This review provides a comprehensive overview of various factors that need to be considered in designing OC DDI studies and recommends PK-based DDI studies with PK end points as adequate measures to establish clinical drug interaction and measurement of PD end points when there is basis for PD interaction.
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Affiliation(s)
- Haiying Sun
- Novartis Institutes for BioMedical Research, East Hanover, New Jersey, USA
| | | | - Soniya Vaidya
- Current affiliation: Axcella Health Inc., Cambridge, Massachusetts, USA
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13
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Williams JS, MacDonald MJ. Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: a review. Am J Physiol Heart Circ Physiol 2020; 320:H77-H89. [PMID: 33164574 DOI: 10.1152/ajpheart.00614.2020] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hormonal contraceptives are one of the most widely used prescriptions for premenopausal women worldwide. Although the risk of venous and arterial cardiovascular events (e.g., deep vein thrombosis, arterial clotting) with hormonal contraceptives, specifically oral contraceptive pills, has been established, the literature on early risk indicators, such as peripheral vascular structure and function has yet to be consolidated. The purpose of this review is to summarize literature examining the impact of different hormonal contraceptives on vascular function and structure, including consideration of phasic differences within a contraceptive cycle, and to propose future directions for research. It is evident that hormonal contraceptive use appears to impact both macrovascular and microvascular endothelial function, with phasic differences in some contraceptive types dependent on progestin type, the ratio of ethinyl estradiol-to-progestin, and route of administration. However, hormonal contraceptives do not appear to impact smooth muscle function in the macrovasculature or microvasculature, arterial stiffness, or vascular structure. Underlying mechanisms for observed impacts and areas of future research are discussed. This review provides timely consolidation of research examining hormonal contraceptives and peripheral vascular function and structure and provides guidance on considerations for hormonal contraceptive use in study design.
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Affiliation(s)
- Jennifer S Williams
- Vascular Dynamics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Maureen J MacDonald
- Vascular Dynamics Laboratory, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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14
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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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15
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Jenzer H, Sadeghi-Reeves L. Nutrigenomics-Associated Impacts of Nutrients on Genes and Enzymes With Special Consideration of Aromatase. Front Nutr 2020; 7:37. [PMID: 32328497 PMCID: PMC7161344 DOI: 10.3389/fnut.2020.00037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 03/11/2020] [Indexed: 12/16/2022] Open
Abstract
Interactions are occurring in the course of liberation, absorption, distribution, metabolism, and excretion of active ingredients, or at the target receptors. They are causing therapy failures and undesirable events. Forty-seven of fifty-seven human hepatic isoenzymes are specific and relevant in hormone and vitamin metabolism and biosynthesis. Aromatase (syn. CYP19A1) is one of the specific CYP450 isoenzymes so far not elucidated in detail. As aromatase-inhibiting phytochemicals are currently recommended for breast cancer prevention and as add-on accompanying aromatase-inhibitor pharmacotherapy, it was the aim of this literature review to assess whether a common interpretation on genetic and -omics basis could be found. Articles retrieved showed that traditional antioxidation diet is one of the most approved explanations of inhibition of aromatase by phytonutrients of flavonoid derivatives. Flavonoids compete for the oxygen provided by the heme moiety of aromatase in the course of aromatase-catalyzed conversion of steroid precursors to estrogens. Flavonoids are therefore promoted for breast cancer prevention. A further explanation of flavonoids' mechanism of action proposed was related to enzymatic histone deacetylation. By keeping DNA-structure wide through a high acetylation degree, acetylated histones favor transcription and replication. This mechanism corresponds to a procedure of switching genes on. Inhibiting acetylation and therefore switching genes off might be an important regulation of repressing cancer genes. Aromatase expression depends on the genotype and phenotype of a person. Aromatase itself depends on the expression of the heme moiety encoded in the genotype. Biosynthesis of porphyrins in turn depends on the substrates succinate and glycine, as well as on a series of further enzymes, with ALA synthetase as the rate-limiting step. The effect of the heme moiety as prosthetic group of aromatase further depends on the absorption of iron as a function of pH and redox state. To assess the function of aromatase precisely, multiple underlying biochemical pathways need to be evaluated. As a conclusion, the genetic regulation of metabolism is a complex procedure affecting multiple pathways. To understand a metabolic step, multiple underlying individually performing reactions need to be considered if personalized (nutritional) medicine should bring an advantage for a patient. Nutrition sciences need to consider the genome of an individual to truly find answers to nutrition-derived non-communicable diseases. With current GWAS (genome-wide association study) approaches, inherited errors of metabolism are identified and ideally treated effectively. It is much more difficult to get a precise genetic profile for non-communicable diseases stemming from multifactorial causes. Polygenic risks evaluation is feasible but diagnostic tools are not yet available in a desired extent. Neither flavonoid researchers nor providers of genetic testing kits are going into the details needed for a truly personalized nutritional medicine. The next step with profiling the exome and then the whole genome is on the threshold of becoming routine diagnosis and of bringing the desired details.
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Affiliation(s)
- Helena Jenzer
- Department of Health Professions, aR&D in Nutrition and Dietetics, Bern University of Applied Sciences BFH, Bern, Switzerland
- Internistic Service, Hospital Pharmacy, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Leila Sadeghi-Reeves
- Department of Health Professions, aR&D in Nutrition and Dietetics, Bern University of Applied Sciences BFH, Bern, Switzerland
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16
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González-Foruria I, Gaggiotti-Marre S, Álvarez M, Martínez F, García S, Rodríguez I, Coroleu B, Polyzos NP. Factors associated with serum progesterone concentrations the day before cryopreserved embryo transfer in artificial cycles. Reprod Biomed Online 2020; 40:797-804. [PMID: 32386938 DOI: 10.1016/j.rbmo.2020.03.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
RESEARCH QUESTION What factors determine serum progesterone concentrations the day before cryopreserved embryo transfer in artificially prepared cycles? DESIGN Retrospective cohort study at a university-affiliated fertility centre including infertile women under 45 years old using own oocytes who underwent a total of 685 single cryopreserved blastocyst transfers under hormonal therapy. Determinants that affected live birth rate (LBR) were analysed using a multivariate logistic regression. Univariate analysis and multivariate linear regression were used to evaluate independent factors that affect serum progesterone concentrations. RESULTS Age (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.89-0.96), duration of oestradiol (OR 0.96; 95% CI 0.92-0.99), serum progesterone concentrations (OR 1.04; 95% CI 1.01-1.08) and patients who underwent preimplantation genetic testing for aneuploidies (PGT-A) (OR 2.17; 95% CI 1.55-3.03) were independently associated with LBR. After univariate analysis, determinants of progesterone concentrations were: age, weight, history of a previous cryopreserved embryo transfer with serum progesterone concentrations <10 ng/ml, and time of blood extraction. The multivariate linear regression showed that increasing age presented a positive correlation with progesterone concentrations (β = 0.11; 95% CI 0.01-0.20). On the contrary, significant negative correlations with progesterone concentrations were shown for a previous history of serum progesterone value <10 ng/ml (β = -3.13; 95% CI -4.45 to -1.81]), higher weight (β = -0.05; 95% CI -0.08 to -0.01) and the time of blood sampling during the day (β = -0.13; 95% CI -0.25 to -0.01). CONCLUSIONS This study adds more evidence regarding the importance of serum progesterone concentrations before frozen embryo transfer (FET). It also showed that body weight, age, time of blood sampling and a history of low progesterone are determinants associated with progesterone concentrations before blastocyst FET.
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Affiliation(s)
- Iñaki González-Foruria
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.
| | - Sofia Gaggiotti-Marre
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Manuel Álvarez
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Francisca Martínez
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Sandra García
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Ignacio Rodríguez
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Buenaventura Coroleu
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Nikolaos P Polyzos
- Dexeus Mujer, Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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17
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Barcellos T, Natavio M, Stanczyk FZ, Luo D, Jusko WJ, Bender NM. Effects of ritonavir-boosted protease inhibitors on combined oral contraceptive pharmacokinetics and pharmacodynamics in HIV-positive women. Contraception 2019; 100:283-287. [PMID: 31194965 PMCID: PMC6778019 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] [MESH Headings] [Grants] [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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Affiliation(s)
- Teresa Barcellos
- Department of Obstetrics and Gynecology, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, 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
| | - 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
| | - William J Jusko
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14214, USA
| | - Nicole M Bender
- Department of Obstetrics and Gynecology, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
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18
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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 PMCID: PMC6499670 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] [MESH Headings] [Grants] [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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19
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Skosana SB, Woodland JG, Cartwright M, Enfield K, Komane M, Louw-du Toit R, van der Spuy Z, Avenant C, Africander D, Storbeck KH, Hapgood JP. Differential metabolism of clinically-relevant progestogens in cell lines and tissue: Implications for biological mechanisms. J Steroid Biochem Mol Biol 2019; 189:145-153. [PMID: 30822501 PMCID: PMC6646820 DOI: 10.1016/j.jsbmb.2019.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/22/2019] [Accepted: 02/24/2019] [Indexed: 11/27/2022]
Abstract
Steroid hormones regulate a variety of physiological processes, including reproductive function, and are widely used in hormonal therapy. Synthetic progestogens, or progestins, were designed to mimic progesterone (P4) for use in contraception and hormonal replacement therapy in women. Medroxyprogesterone acetate (MPA) and norethisterone (NET) are the most widely used injectable contraceptives in the developing world, while other progestins such as levonorgestrel (LNG), etonogestrel (ETG) and nestorone (NES) are used in or being developed for other forms of contraception. As concerns remain about the most appropriate choice of progestin and dosage, and the associated side-effects, the mechanisms and biological effects of progestins are frequently investigated in various in vitro mammalian cell line and tissue models. However, whether progestogens are differentially metabolised in different cell types in vivo or in vitro is unknown. For nine mammalian cell lines commonly used to investigate progestogen mechanisms of action, we developed and validated an ultra-high performance supercritical fluid chromatography-tandem mass spectrometry (UHPSFC-MS/MS) protocol for simultaneously quantifying the metabolism of the above-mentioned steroids. We show for the first time that, while 50-100% of P4 was metabolised within 24 h in all cell lines, the metabolism of the progestins is progestin- and cell line-specific. We also show that MPA and NET are significantly metabolised in human cervical tissue, but to a lesser extent than P4. Taken together, our findings suggest that differential progestogen metabolism may play a role in cell-specific therapeutic and side-effects. Relative affinities for binding to steroid receptors as well as potencies, efficacies and biocharacters for transcriptional activity of progestins, relative to P4, are most frequently determined using some of the cell lines investigated. Our results, however, suggest that differential metabolism of progestins and P4 may confound these results. In particular, metabolism may under-estimate the receptor-mediated intrinsic in vitro binding and dose-response values and predicted endogenous physiological effects of P4.
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Affiliation(s)
- Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, South Africa
| | - John G Woodland
- Department of Molecular and Cell Biology, University of Cape Town, South Africa
| | | | - Kim Enfield
- Department of Molecular and Cell Biology, University of Cape Town, South Africa
| | - Maleshigo Komane
- Department of Molecular and Cell Biology, University of Cape Town, South Africa
| | | | - Zephne van der Spuy
- Department of Obstetrics and Gynaecology, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, South Africa
| | | | | | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.
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Abstract
Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have developed, published, and updated evidence-based guidelines to support medical providers in the provision of contraceptives to patients with specific medical conditions or characteristics. The goal of these guidelines is to provide recommendations on the safe use of contraceptives with the goal of removing unnecessary medical barriers to access and use of contraceptives, thus decreasing the number of unintended pregnancies. Many medical conditions increase a patient's risk of venous thromboembolism; a risk that may also be increased with specific contraceptives. Specific conditions that require more enhanced contraceptive counseling due to their frequency in adolescence and their association either with adverse events during pregnancy or with increased risk for specific contraceptives are detailed by the WHO and CDC and are summarized herein. Adolescents with morbid obesity, migraine headache, cardiac conditions, hypertension, diabetes mellitus, hyperlipidemia, systemic lupus erythematosus, sickle cell anemia, cystic fibrosis, inflammatory bowel disease, or seizure disorders would benefit from greater attention to the urgency of exploring highly effective contraceptive methods. Details of the considerations that should be used in providing contraceptive care to adolescents with each of these medical conditions, as per WHO and CDC guidelines, are provided in this review. The ultimate goal in contraceptive counseling is the balancing of risk and benefit to arrive at the best therapeutic option, maintaining patient preference as a priority, as that will enhance adherence and comfort with the contraceptive method. Each patient must be assessed for pregnancy risk and be allowed full risk reduction and education regarding contraceptive options.
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Affiliation(s)
- Linda Carmine
- Division of Adolescent Medicine, Cohen Children's Medical Center, Northwell Health, 410 Lakeville Road, Suite 108, New Hyde Park, NY 11042, United States; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States.
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21
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Blue SW, Winchell AJ, Kaucher AV, Lieberman RA, Gilles CT, Pyra MN, Heffron R, Hou X, Coombs RW, Nanda K, Davis NL, Kourtis AP, Herbeck JT, Baeten JM, Lingappa JR, Erikson DW. Simultaneous quantitation of multiple contraceptive hormones in human serum by LC-MS/MS. Contraception 2018; 97:363-369. [PMID: 29407362 PMCID: PMC5840044 DOI: 10.1016/j.contraception.2018.01.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 12/13/2017] [Accepted: 01/24/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective was to develop a method to simultaneously quantify five commonly used hormonal contraceptives (HCs) and two endogenous sex steroids by liquid chromatography-tandem triple quadrupole mass spectrometry (LC-MS/MS) and apply this method to human serum samples. STUDY DESIGN We developed a method to simultaneously analyze ethinyl estradiol (EE2), etonogestrel (ENG), levonorgestrel (LNG), medroxyprogesterone acetate (MPA) and norethisterone (NET), along with estradiol (E2) and progesterone (P4), in human serum for a Shimadzu Nexera-LCMS-8050 LC-MS/MS platform. We analyzed serum collected from women self-reporting use of oral contraceptives, contraceptive implants or injectable contraceptives (n=14) and normally cycling women using no HC (n=15) as well as pooled samples from women administered various HCs (ENG, n=6; LNG, n=14; MPA, n=7; NET, n=5). RESULTS Limits of quantitation were 0.010ng/mL for E2, EE2 and P4; 0.020ng/mL for ENG, LNG and MPA; and 0.040ng/mL for NET. Precisions for all assays, as indicated by coefficient of variation, were less than or equal to 12.1%. Accuracies for all assays were in the range of 95%-108%. Endogenous hormone values obtained from analysis of human serum samples are in agreement with levels previously reported in the literature for normally cycling women as well as for women taking the appropriate HC. CONCLUSIONS We have developed a robust, accurate and sensitive method for simultaneously analyzing commonly used contraceptive steroids and endogenous sex steroids in human serum. IMPLICATIONS This analytical method can be used for quantitating contraceptive steroid levels in women for monitoring systemic exposure to determine drug interactions, nonadherence, misreporting and proper dosing.
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Affiliation(s)
- Steven W Blue
- Endocrine Technologies Support Core, Oregon National Primate Research Center, Beaverton, OR
| | - Andrea J Winchell
- Endocrine Technologies Support Core, Oregon National Primate Research Center, Beaverton, OR
| | - Amy V Kaucher
- Endocrine Technologies Support Core, Oregon National Primate Research Center, Beaverton, OR
| | | | | | - Maria N Pyra
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA
| | - Xuanlin Hou
- Department of Global Health, University of Washington, Seattle, WA
| | - Robert W Coombs
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Nicole L Davis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Athena P Kourtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joshua T Herbeck
- Department of Global Health, University of Washington, Seattle, WA
| | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Jairam R Lingappa
- Department of Global Health, University of Washington, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA; Department of Pediatrics, University of Washington, Seattle, WA
| | - David W Erikson
- Endocrine Technologies Support Core, Oregon National Primate Research Center, Beaverton, OR.
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Simmons KB, Haddad LB, Nanda K, Curtis KM. Drug interactions between non-rifamycin antibiotics and hormonal contraception: a systematic review. Am J Obstet Gynecol 2018; 218:88-97.e14. [PMID: 28694152 DOI: 10.1016/j.ajog.2017.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/15/2017] [Accepted: 07/01/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether interactions between non-rifamycin antibiotics and hormonal contraceptives result in decreased effectiveness or increased toxicity of either therapy. STUDY DESIGN We searched MEDLINE, Embase, clinicaltrials.gov, and Cochrane libraries from database inception through June 2016. We included trials, cohort, case-control, and pharmacokinetic studies in any language that addressed pregnancy rates, pharmacodynamics, or pharmacokinetic outcomes when any hormonal contraceptive and non-rifamycin antibiotic were administered together vs apart. Of 7291 original records that were identified, 29 met criteria for inclusion. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently assessed study quality and risk of bias using the United States Preventive Services Task Force evidence grading system. Findings were tabulated by drug class. RESULTS Study quality ranged from good to poor and addressed only oral contraceptive pills, emergency contraception pills, and the combined vaginal ring. Two studies demonstrated no difference in pregnancy rates in women who used oral contraceptives with and without non-rifamycin antibiotics. No differences in ovulation suppression or breakthrough bleeding were observed in any study that combined hormonal contraceptives with any antibiotic. No significant decreases in any progestin pharmacokinetic parameter occurred during co-administration with any antibiotic. Ethinyl estradiol area under the curve decreased when administered with dirithromycin, but no other drug. CONCLUSION Evidence from clinical and pharmacokinetic outcomes studies does not support the existence of drug interactions between hormonal contraception and non-rifamycin antibiotics. Data are limited by low quantity and quality for some drug classes. Most women can expect no reduction in hormonal contraceptive effect with the concurrent use of non-rifamycin antibiotics.
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Hernández Vera R, Padró T, Vilahur G, Badimon L. Antithrombotic therapy in obesity. Thromb Haemost 2017; 110:681-8. [DOI: 10.1160/th12-12-0928] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/11/2013] [Indexed: 12/17/2022]
Abstract
summaryClinical management of obese subjects to reduce their risk of suffering cardiovascular events is complex. Obese patients typically require preventive strategies, life-style modifications, and multi-drug therapy to address obesity-induced co-morbidities. Data regarding the effects of excess weight on the pharmacokinetics of most drugs is scarce as these individuals are often excluded from clinical trials. However, the physiological alterations observed in obese patients and their lower response to some antiplatelet agents and anticoagulants have suggested that dosage regimes need to be adjusted for these subjects. In this review we will briefly discuss platelet alterations that can contributeto increased thrombotic risk, analyse existing data regarding the effects of obesity on drug pharmacokinetics focusing on antiplatelet agents and anticoagulants, and we will describe the beneficial effects of weight loss on thrombosis.
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Abstract
OBJECTIVE To summarize published evidence on drug interactions between hormonal contraceptives and antiretrovirals. DESIGN Systematic review of the published literature. METHODS We searched PubMed, POPLINE, and EMBASE for peer-reviewed publications of studies (in any language) from inception to 21 September 2015. We included studies of women using hormonal contraceptives and antiretrovirals concurrently. Outcomes of interest were effectiveness of either therapy, toxicity, or pharmacokinetics. We used standard abstraction forms to summarize and assess strengths and weaknesses. RESULTS Fifty reports from 46 studies were included. Most antiretrovirals whether used for therapy or prevention, have limited interactions with hormonal contraceptive methods, with the exception of efavirenz. Although depot medroxyprogesterone acetate is not affected, limited data on implants and combined oral contraceptive pills suggest that efavirenz-containing combination antiretroviral therapy may compromise contraceptive effectiveness of these methods. However, implants remain very effective despite such drug interactions. Antiretroviral plasma concentrations and effectiveness are generally not affected by hormonal contraceptives. CONCLUSION Women taking antiretrovirals, for treatment or prevention, should not be denied access to the full range of hormonal contraceptive options, but should be counseled on the expected rates of unplanned pregnancy associated with all contraceptive methods, in order to make their own informed choices.
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Gynecologic and Obstetric Consequences of Obesity in Adolescent Girls. J Pediatr Adolesc Gynecol 2017; 30:156-168. [PMID: 26915924 DOI: 10.1016/j.jpag.2016.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/06/2016] [Accepted: 02/15/2016] [Indexed: 12/24/2022]
Abstract
In the past few decades, there has been an overwhelming increase in childhood and adolescent obesity worldwide. Besides the well recognized cardiometabolic complications and other physical conditions associated with obesity, during adolescence, it causes psychological and social distress in a period of life that is already sensitive for a girl. This in turn increases their risk of low self-esteem and depression. Furthermore, obesity diminishes health-related quality of life and years of life. Overweight and obese teenagers are more likely to have gynecologic and obstetric complications, during adolescence and also later in life. Consequences of obese and overweight childhood and adolescence include sexual maturation and reproductive dysfunction, alterations in menstruation, dysmenorrhea, risky sexual behavior, and inefficient use of contraception, polycystic ovary syndrome, bone density abnormalities, macromastia, and an increased risk of breast and endometrial cancer. Obese adolescents are at greater risk of pregnancy and perinatal complications, such as preeclampsia, gestational hypertension and preeclampsia, gestational diabetes mellitus, primary cesarean delivery, and induction of labor, to mention a few. Evidence shows that infants born to obese teenagers are also more likely to have complications including preterm or post-term delivery, small-for-gestational age newborns, macrosomia, meconium aspiration, respiratory distress, and even stillbirth, among others. This comprehensive review focuses on the gynecological and obstetric consequences of obesity in adolescent girls.
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Jatlaoui TC, Zapata LB, Curtis KM, Folger SG, Marchbanks PA, Mandel MG, Jamieson DJ. Healthcare Provider Attitudes Regarding Contraception for Women with Obesity. J Womens Health (Larchmt) 2017; 26:870-877. [PMID: 28140761 DOI: 10.1089/jwh.2016.5930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Whether providers who regularly provide family planning services consider contraceptive methods as unsafe for women with obesity is unknown. METHODS We analyzed questionnaire responses received from December 2009 to March 2010 from 635 office-based physicians and 1323 Title X clinic providers delivering family planning services, who were randomly sampled (response rate 65%) before the release of national evidence-based contraception guidelines. We examined provider and clinical setting characteristics and clinic patient demographics for association with provider misconceptions about safety of combined oral contraceptives (COCs), depot medroxyprogesterone acetate (DMPA), or intrauterine devices (IUDs) for women with obesity. If providers considered methods as unsafe or do not know, we categorized those responses as misconceptions. We used multivariable logistic regression to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS A substantial proportion of respondents had misconceptions about the safety of COCs (31%), DMPA (24%), copper (Cu) (18%), and levonorgestrel (LNG)-IUDs (16%) for women with obesity. Provider type was associated with increased odds of misconceptions for all four methods compared with office-based obstetrician/gynecologists. Not having the method available onsite was associated with safety misconceptions of DMPA (aOR 1.90, 95% CI 1.07-3.36), Cu-IUD (aOR 4.19, 95% CI 1.51-11.61), and LNG-IUD (aOR 5.25, 95% CI 1.67-16.49). CONCLUSION While the majority of providers considered all four contraceptive methods safe for women with obesity, substantial proportions had misconceptions about safety of COCs, DMPA, and IUDs. Provider education, particularly among certain specialties, is needed to increase knowledge regarding moderate and highly effective contraceptive methods among this patient population.
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Affiliation(s)
- Tara C Jatlaoui
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Lauren B Zapata
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Suzanne G Folger
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Polly A Marchbanks
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Michele G Mandel
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Denise J Jamieson
- Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia
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Dragoman MV, Simmons KB, Paulen ME, Curtis KM. Combined hormonal contraceptive (CHC) use among obese women and contraceptive effectiveness: a systematic review. Contraception 2017; 95:117-129. [PMID: 27823942 PMCID: PMC11283816 DOI: 10.1016/j.contraception.2016.10.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate from the literature whether combined hormonal contraception (CHC), including combined oral contraception pills (COCs), transdermal patch, vaginal ring or combined injectables, have different effectiveness or failure rates by body weight or body mass index (BMI). STUDY DESIGN We searched PubMed and the Cochrane Library databases for all articles in all languages published between inception and February 2016, for evidence relevant to body weight or BMI, CHC use and contraceptive effectiveness. The quality of each individual study was assessed using the system for evaluating evidence developed by the United States Preventive Services Task Force. RESULTS From 2874 articles, we identified 15 reports for inclusion, all of fair to poor quality. Fourteen studies measured the association of obesity status and contraceptive failure among COC users. Three fair quality and one poor quality study reported increased COC failure among a heterogeneous population of overweight and obese women compared with normal weight women, while eight fair quality and two poor quality studies did not find an association. Two fair quality studies reported on contraceptive transdermal patches. One pooled analysis described a higher proportion of pregnancies among women using the patch who weighed ≥90 kg; another secondary analysis suggested BMI>30 was associated with increased failure. No studies directly compared contraceptive effectiveness using the combined vaginal ring or combined injectable. CONCLUSION Current available evidence addressing the risk of CHC failure in obese compared to normal weight women is limited to fair and poor quality studies. Studies of COCs show mixed results, though absolute differences in COC failure by body weight and BMI are small. Based on limited evidence, it appears that increasing body weight and BMI may contribute to decreasing contraceptive patch effectiveness.
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Affiliation(s)
- Monica V Dragoman
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Katharine B Simmons
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Melissa E Paulen
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Abstract
OBJECTIVE Bariatric surgery offers a highly effective mode of treatment for obese patients. Some procedures such as bypass cause an alteration in normal gastrointestinal tract with possible consequences for the uptake of orally administered drugs. METHODS We assessed the literature to ascertain whether the use of oral drugs and especially oral contraceptives is effective and adequate after bariatric surgery. RESULTS The bioavailability of drugs could be affected by the solubility and pH of the modified medium after bariatric surgery and by the loss of gastrointestinal transporters. Bariatric surgery could potentially result in a transient change in the absorption of drugs such as analgesics, antibiotics, antiarrhythmics, anticoagulants, psychotropic, and oral contraceptive drugs. Effective contraception is especially critical in the postoperative period, and implants might be representing a safe contraceptive method in women undergoing bariatric surgery. CONCLUSION Each drug will have to be evaluated with respect to its site of absorption and its mechanism of absorption, with special attention on parameters influencing the effectiveness of the absorption processes.
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Affiliation(s)
- Joël Schlatter
- *Dr. Joël Schlatter, Service Pharmacie, Hôpital Jean Verdier - APHP, Hôpitaux Universitaires de Paris-Seine-Saint-Denis, Avenue du 14 juillet, 93140 Bondy, France,
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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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Jatlaoui TC, Curtis KM. Safety and effectiveness data for emergency contraceptive pills among women with obesity: a systematic review. Contraception 2016; 94:605-611. [PMID: 27234874 PMCID: PMC6511981 DOI: 10.1016/j.contraception.2016.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study aims to determine whether emergency contraceptive pills (ECPs) are less safe and effective for women with obesity compared with those without obesity. STUDY DESIGN We searched PubMed for articles through November 2015 regarding the safety and effectiveness of ECPs [ulipristal acetate (UPA), levonorgestrel (LNG) and combined estrogen and progestin] among obese users. We assessed study quality using the United States Preventive Services Task Force evidence grading system. RESULTS We identified four pooled secondary analyses (quality: poor to fair), two of which examined UPA and three examined LNG formulations. Three analyses pooled overlapping data from a total of three primary studies and demonstrated significant associations between obesity and risk of pregnancy after ECP use. One analysis reported a 4-fold increased risk of pregnancy among women with obesity (BMI≥30kg/m2) compared with women within normal/underweight categories (BMI<25kg/m2) after use of LNG ECPs [odds ratio (OR) 4.4; 95% confidence interval (CI) 2.0-9.4]. Further analysis of the same LNG data found that, at an approximate weight of 80 kg, the rate of pregnancy rose above 6%, which is the estimated pregnancy probability without contraception; at weights less than 75 kg, the rate of pregnancy was less than 2%. Two analyses examining UPA suggested an approximate 2-fold increased risk of pregnancy among women with obesity compared with either normal/underweight women or nonobese (BMI<30kg/m2) women (OR 2.6; 95% CI 0.9-7.0 and OR 2.1; 95% CI 1.0-4.3, respectively), but CIs were wide. Finally, the fourth secondary analysis pooled data from three separate randomized controlled trials on LNG ECPs and found no increase in pregnancy risk with increasing weight or BMI and found no consistent association between pregnancy and both factors when adjusted for other covariates. CONCLUSION While data are limited and poor to fair quality, findings suggest that women with obesity experience an increased risk of pregnancy after use of LNG ECP compared with those normal/underweight. Women with obesity may also experience an increased risk of pregnancy compared with women without obesity after use of UPA ECP, though differences did not reach statistical significance. Providers should counsel all women at risk for unintended pregnancy, including those with obesity, about the effectiveness of the full range of emergency contraception options in order for them to understand their options, to receive advanced supplies of emergency contraception as needed and to understand how to access an emergency copper intrauterine device if desired.
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Affiliation(s)
- Tara C Jatlaoui
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Simmons KB, Edelman AB. Hormonal contraception and obesity. Fertil Steril 2016; 106:1282-1288. [PMID: 27565257 DOI: 10.1016/j.fertnstert.2016.07.1094] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 12/18/2022]
Abstract
The rising rate of overweight and obesity is a public health crisis in the United States and increasingly around the globe. Rates of contraceptive use are similar among women of all weights, but because contraceptive development studies historically excluded women over 130% of ideal body weight, patients and providers have a gap in understanding of contraceptive efficacy for obese and overweight women. Because of a range of drug metabolism alterations in obesity, there is biologic plausibility for changes in hormonal contraception effectiveness in obese women. However, these pharmacokinetic changes are not linearly related to body mass index or weight, and it is unknown what degree of obesity begins to affect pharmacokinetic or pharmacodynamics processes. Overall, most studies of higher quality do not demonstrate a difference in oral contraceptive pill effectiveness in obese compared with non-obese women. However, data are scant for women in the highest categories of obesity, and differences by progestin type are incompletely understood. Effectiveness of most non-oral contraceptives does not seem to be compromised in obesity. Exceptions to this include the combined hormonal patch and oral levonorgestrel emergency contraception, which may have lower rates of effectiveness in obese women. The purpose of this review is to summarize evidence on contraceptive use in women with obesity, including differences in steroid hormone metabolism, contraceptive effectiveness, and safety, compared with women of normal weight or body mass index using the same methods.
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Affiliation(s)
- Katharine B Simmons
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.
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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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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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Abstract
Oral steroid contraception is a popular method of family planning worldwide. Over the past several decades, this method of contraception has changed significantly by decreasing the estrogen dose, changing the progestin component, and reducing the hormone free interval. Despite the popularity of oral steroid contraception, there has been much criticism regarding the associated risks of venous thromboembolism and stroke. Despite these established, yet uncommon risks, oral steroid contraception has many important health benefits. This review highlights the available formulations of oral contraceptives along with their evidence-based associated risks and benefits. Highlights regarding future directions for development of novel oral contraceptives are also addressed.
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Affiliation(s)
- Laura A Sech
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Daniel R Mishell
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Abstract
Steroid hormones have been in use for more than a half a century as contraceptive agents, and only now are researchers elucidating the biochemical mechanisms of action and non-target effects. Progesterone and synthetic progestins, critical for women's health in the US and internationally, appear to have important effects on immune functioning and other diverse systems. Apart from the contraceptive world is a separate field that is devoted to understanding progesterone in other contexts. Based on research following a development timeline parallel to hormonal contraception, progesterone and 17-hydroxyprogesterone caproate are now administered to prevent preterm birth in high-risk pregnant women. Preterm birth researchers are similarly working to determine the precise biochemical actions and immunological effects of progesterone. Progesterone research in both areas could benefit from increased collaboration and bringing these two bodies of literature together. Progesterone, through actions on various hormone receptors, has lifelong importance in different organ systems and researchers have much to learn about this molecule from the combination of existing literatures, and from future studies that build on this combined knowledge base.
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Affiliation(s)
- Elizabeth Micks
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
| | - Greta B Raglan
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
| | - Jay Schulkin
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
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Rowe S, Siegel D, Benjamin DK. Gaps in Drug Dosing for Obese Children: A Systematic Review of Commonly Prescribed Emergency Care Medications. Clin Ther 2015; 37:1924-32. [PMID: 26323523 PMCID: PMC4586086 DOI: 10.1016/j.clinthera.2015.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 08/13/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Approximately 1 of 6 children in the United States is obese. This has important implications for drug dosing and safety because pharmacokinetic (PK) changes are known to occur in obesity due to altered body composition and physiologic mechanisms. Inappropriate drug dosing in an emergency setting can limit therapeutic efficacy and increase drug-related toxic effects for obese children. Few systematic reviews examining PK properties and drug dosing in obese children have been performed. METHODS We identified 25 emergency care drugs from the Strategic National Stockpile and Acute Care Supportive Drugs List and performed a systematic review for each drug in 3 study populations: obese children (2-18 years of age), normal weight children, and obese adults (aged >18 years). For each study population, we first reviewed a drug's Food and Drug Administration label and then performed a systematic literature review. From the literature, we extracted drug PK data, biochemical properties, and dosing information. We then reviewed data in 3 age subpopulations (2-7 years, 8-12 years, and 13-18 years) for obese and normal weight children and by route of drug administration (intramuscular, intravenous, oral, and inhaled). If sufficient PK data were not available by age and route of administration, a data gap was identified. FINDINGS Only 2 of 25 emergency care drugs (8%) contained dosing information on the Food and Drug Administration label for obese children and adults compared with 22 of 25 (88%) for normal weight children. We found no sufficient PK data in the literature for any of the emergency care drugs in obese children. Sufficient PK data were found for 7 of 25 emergency care drugs (28%) in normal weight children and 3 of 25 (12%) in obese adults. IMPLICATIONS Insufficient information exists to guide dosing in obese children for any of the emergency care drugs reviewed. This knowledge gap is alarming, given the known PK changes that occur in the setting of obesity. Future clinical trials examining the PK properties of emergency care medications in obese children should be prioritized.
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Affiliation(s)
- Stevie Rowe
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - David Siegel
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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Tittle V, Bull L, Boffito M, Nwokolo N. Pharmacokinetic and pharmacodynamic drug interactions between antiretrovirals and oral contraceptives. Clin Pharmacokinet 2015; 54:23-34. [PMID: 25331712 DOI: 10.1007/s40262-014-0204-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
More than 50 % of women living with HIV in low- and middle-income countries are of reproductive age, but there are limitations to the administration of oral contraception for HIV-infected women receiving antiretroviral therapy due to drug-drug interactions caused by metabolism via the cytochrome P450 isoenzymes and glucuronidation. However, with the development of newer antiretrovirals that use alternative metabolic pathways, options for contraception in HIV-positive women are increasing. This paper aims to review the literature on the pharmacokinetics and pharmacodynamics of oral hormonal contraceptives when given with antiretroviral agents, including those currently used in developed countries, older ones that might still be used in salvage regimens, or those used in resource-limited settings, as well as newer drugs. Nucleos(t)ide reverse transcriptase inhibitors (NRTIs), the usual backbone to most combined antiretroviral treatments (cARTs) are characterised by a low potential for drug-drug interactions with oral contraceptives. On the other hand non-NRTIs (NNRTIs) and protease inhibitors (PIs) may interact with oral contraceptives. Of the NNRTIs, efavirenz and nevirapine have been demonstrated to cause drug-drug interactions; however, etravirine and rilpivirine appear safe to use without dose adjustment. PIs boosted with ritonavir are not recommended to be used with oral contraceptives, with the exception of boosted atazanavir which should be used with doses of at least 35 µg of estrogen. Maraviroc, an entry inhibitor, is safe for co-administration with oral contraceptives, as are the integrase inhibitors (INIs) raltegravir and dolutegravir. However, the INI elvitegravir, which is given in combination with cobicistat, requires a dose of estrogen of at least 30 µg. Despite the growing evidence in this field, data are still lacking in terms of large cohort studies, randomised trials and correlations to real clinical outcomes, such as pregnancy rates, in women on antiretrovirals and hormonal contraception.
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Affiliation(s)
- Victoria Tittle
- Department of GUM/HIV Medicine, St. Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK,
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38
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Bethea TN, Rosenberg L, Hong CC, Troester MA, Lunetta KL, Bandera EV, Schedin P, Kolonel LN, Olshan AF, Ambrosone CB, Palmer JR. A case-control analysis of oral contraceptive use and breast cancer subtypes in the African American Breast Cancer Epidemiology and Risk Consortium. Breast Cancer Res 2015; 17:22. [PMID: 25849024 PMCID: PMC4358874 DOI: 10.1186/s13058-015-0535-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 02/10/2015] [Indexed: 12/13/2022] Open
Abstract
Introduction Recent oral contraceptive (OC) use has been consistently associated with increased risk of breast cancer, but evidence on specific breast cancer subtypes is sparse. Methods We investigated recency and duration of OC use in relation to molecular subtypes of breast cancer in a pooled analysis of data from the African American Breast Cancer Epidemiology and Risk Consortium. The study included 1,848 women with estrogen receptor-positive (ER+) breast cancer, 1,043 with ER-negative (ER-) breast cancer (including 494 triple negative (TN) tumors, which do not have receptors for estrogen, progesterone, and human epidermal growth factor 2), and 10,044 controls. Multivariable polytomous logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for exposure categories relative to never use, controlling for potential confounding variables. Results OC use within the previous 5 years was associated with increased risk of ER+ (OR 1.46, 95% CI 1.18 to 1.81), ER- (OR 1.57, 95% CI 1.22 to 1.43), and TN (OR 1.78, 95% CI 1.25 to 2.53) breast cancer. The risk declined after cessation of use but was apparent for ER+ cancer for 15 to 19 years after cessation and for ER- breast cancer for an even longer interval after cessation. Long duration of use was also associated with increased risk of each subtype, particularly ER-. Conclusions Our results suggest that OC use, particularly recent use of long duration, is associated with an increased risk of ER+, ER-, and TN breast cancer in African American women. Research into mechanisms that explain these findings, especially the association with ER- breast cancer, is needed.
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Contraceptive use in women undergoing bariatric surgery. Obes Res Clin Pract 2014; 8:e608-13. [DOI: 10.1016/j.orcp.2014.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 08/16/2014] [Indexed: 11/20/2022]
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40
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Simmons KB, Edelman AB. Contraception and sexual health in obese women. Best Pract Res Clin Obstet Gynaecol 2014; 29:466-78. [PMID: 25498914 DOI: 10.1016/j.bpobgyn.2014.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/13/2014] [Indexed: 01/29/2023]
Abstract
As the proportion of women with obesity increases worldwide, understanding the influence of body weight on sexual behavior, fertility, and contraceptive effectiveness is critical for health-care professionals and patients. Although many have theorized that obese women are different from normal-weight women regarding sexual health and behavior, current evidence for the most part disproves this. The exception is in adolescents where body image may play a role in riskier behavior, placing them at a greater risk of an unintended pregnancy. Given that most modern contraceptives were not originally evaluated in obese women, understanding how weight affects contraceptive pharmacokinetics and efficacy should be a focus of ongoing research. Evidence is reassuring that most modern contraceptive methods are safe and effective in obese women. This paper reviews what is known about sexual and contraceptive behavior, as well as the effectiveness and pharmacokinetics of modern contraceptives, for overweight and obese women.
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Affiliation(s)
- Katharine B Simmons
- Oregon Health & Science University, Department of Obstetrics and Gynecology, 3181 SW Sam Jackson Park Road, Mailcode UHN 50, Portland, OR 97239, USA.
| | - Alison B Edelman
- Oregon Health & Science University, Department of Obstetrics and Gynecology, 3181 SW Sam Jackson Park Road, Mailcode UHN 50, Portland, OR 97239, USA
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Abstract
Utilizing contraception is critical in preventing unintended pregnancies among obese women. However, clinicians and obese patients may be unclear about which contraceptive methods are optimal. This review discusses the literature on any weight gain associated with contraceptive use, contraceptive efficacy among obese women, and special considerations for contraceptive method selection for women after bariatric surgery. The review also covers new findings on oral emergency contraception and obesity.
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Affiliation(s)
- Sheila K Mody
- Department of Reproductive Medicine, University of California San Diego, San Diego, California
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Abstract
INTRODUCTION Etonogestrel (ENG) is a progestin used in the contraceptive vaginal ring NuvaRing and the subdermal implant Implanon. A sensitive method for measuring ENG is useful for further investigating the progestin's pharmacokinetics with these alternative contraceptive formulations and generating important information about possible continued efficacy or potential failure to remove the subdermal implant. METHODS Standards and serum samples were spiked with D8-progesterone (internal standard) and subsequently extracted with dichloromethane, dried, and reconstituted in 25% methanol with formic acid. ENG was analyzed by positive electrospray ionization in multiple reaction monitoring mode with a run time of 5.5 minutes using a C18 BEH column. The mobile phase was a gradient of water:acetonitrile, with 0.1% formic acid. The method was applied successfully to study the pharmacokinetics of ENG during vaginal ring use. The method was also used in routine patient care to assess ENG levels. RESULTS The method is linear from 50 to 2000 pg/mL. The limits of detection and quantification are 25 and 50 pg/mL, respectively. There was no observed ionization suppression within the linear range of the assay, and the average recovery was 87%. Serum ENG levels of n = 3 subjects were all within the linear range of the assay for a total study period of 42 days after insertion of the ring. Of n = 20 patients with nonpalpable subdermal implants, n = 13 had ENG levels >25 pg/mL, whereas n = 7 had levels <25 pg/mL. CONCLUSIONS We developed a rapid, sensitive, and robust ultra performance liquid chromatography-tandem mass spectometry (UPLC-MS/MS) method for the quantification of ENG in serum that is useful to study the progestin's pharmacokinetics and inform physicians about successful implantation or potential failure to remove a subdermal device.
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Edelman AB, Cherala G, Munar MY, McInnis M, Stanczyk FZ, Jensen JT. Correcting oral contraceptive pharmacokinetic alterations due to obesity: a randomized controlled trial. Contraception 2014; 90:550-6. [PMID: 25070547 DOI: 10.1016/j.contraception.2014.06.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 06/18/2014] [Accepted: 06/19/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine if increasing the hormone dose or eliminating the hormone-free interval improves key pharmacokinetic (PK) alterations caused by obesity during oral contraceptive (OC) use. STUDY DESIGN Obese [body mass index (BMI)≥30 kg/m(2)], ovulatory, otherwise healthy, women received an OC containing 20 mcg ethinyl estradiol (EE)/100 mcg levonorgestrel (LNG) dosed cyclically (21 days active pills with 7-day placebo week) for two cycles and then were randomized for two additional cycles to the following: continuous cycling (CC, a dose neutral arm using the same OC with no hormone-free interval) or increased dose (ID, a dose escalation arm using an OC containing 30 mcg EE/150 mcg LNG cyclically). During Cycles 2, 3 and 4, outpatient visits were performed to assess maximum serum concentration (Cmax), area under the curve (AUC0-∞) and time to steady state as well as pharmacodynamics. These key PK parameters were calculated and compared within groups between baseline and treatment cycles. RESULTS A total of 31 women enrolled and completed the study (CC group, n=16; ID group, n=15). Demographics were similar between groups [mean BMI: CC, 38 kg/m(2) (S.D. 5.1); ID, 41 kg/m(2) (S.D. 7.6)]. At baseline, the key LNG PK parameters were no different between groups; average time to reach steady state was 12 days in both groups; Cmax were CC: 3.82±1.28 ng/mL and ID: 3.13±0.87 ng/mL; and AUC0-∞ were CC: 267±115 h ng/mL and ID: 199±75 h ng/mL. Following randomization, the CC group maintained steady-state serum levels whereas the ID group had a significantly higher Cmax (p<.001) but again required 12 days to achieve steady state. However, AUC was not significantly different between CC (412±255 h ng/mL) and ID (283±130 h ng/mL). Forty-five percent (14/31) of the study population had evidence of an active follicle-like structure prior to randomization and afterwards this decreased to 9% (3/31). CONCLUSION Both increasing the OC dose and continuous dosing appear to counteract the impact of obesity on key OC PK parameters. IMPLICATIONS Obesity adversely affects the pharmacokinetics of very low dose OC pills. Although the impact of these changes on OC efficacy is still under debate, PK parameters can be normalized in obese users by continuous dosing or increasing to a low-dose pill.
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Affiliation(s)
- Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Ganesh Cherala
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA; Oregon State University and Oregon Health & Science University College of Pharmacy, Portland, OR 97239, USA
| | - Myrna Y Munar
- Oregon State University and Oregon Health & Science University College of Pharmacy, Portland, OR 97239, USA
| | - Martha McInnis
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Frank Z Stanczyk
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR 97239, USA
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Subramanian M, Kurawattimath V, Pocha K, Freeden C, Rao I, Thanga Mariappan T, Marathe PH, Vikramadithyan RK, Abraham P, Kulkarni CP, Katnapally P, Nutakki R, Paruchury S, Bhutani P, Mandlekar S. Role of hepatic blood flow and metabolism in the pharmacokinetics of ten drugs in lean, aged and obese rats. Xenobiotica 2014; 44:1108-16. [DOI: 10.3109/00498254.2014.932470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Milošević NP, Stojanović SZ, Penov-Gaši K, Perišić-Janjić N, Kaliszan R. Reversed- and normal-phase liquid chromatography in quantitative structure retention–property relationships of newly synthesized seco-androstene derivatives. J Pharm Biomed Anal 2014; 88:636-42. [DOI: 10.1016/j.jpba.2013.10.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/01/2013] [Accepted: 10/05/2013] [Indexed: 11/30/2022]
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Robinson JA, Burke AE. Obesity and hormonal contraceptive efficacy. WOMEN'S HEALTH (LONDON, ENGLAND) 2013; 9:453-66. [PMID: 24007251 PMCID: PMC4079263 DOI: 10.2217/whe.13.41] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Obesity is a major public health concern affecting an increasing proportion of reproductive-aged women. Avoiding unintended pregnancy is of major importance, given the increased risks associated with pregnancy, but obesity may affect the efficacy of hormonal contraceptives by altering how these drugs are absorbed, distributed, metabolized or eliminated. Limited data suggest that long-acting, reversible contraceptives maintain excellent efficacy in obese women. Some studies demonstrating altered pharmacokinetic parameters and increased failure rates with combined oral contraceptives, the contraceptive patch and emergency contraceptive pills suggest decreased efficacy of these methods. It is unclear whether bariatric surgery affects hormonal contraceptive efficacy. Obese women should be offered the full range of contraceptive options, with counseling that balances the risks and benefits of each method, including the risk of unintended pregnancy.
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MESH Headings
- Bariatric Surgery
- Body Mass Index
- Contraceptive Agents, Female/pharmacokinetics
- Contraceptive Agents, Female/therapeutic use
- Contraceptive Devices, Female
- Contraceptives, Oral, Hormonal/pharmacokinetics
- Contraceptives, Oral, Hormonal/therapeutic use
- Contraceptives, Postcoital/pharmacokinetics
- Contraceptives, Postcoital/therapeutic use
- Counseling
- Drug Implants/pharmacokinetics
- Drug Implants/therapeutic use
- Estrogens/pharmacokinetics
- Estrogens/therapeutic use
- Female
- Humans
- Intrauterine Devices
- Obesity/metabolism
- Obesity/surgery
- Pregnancy
- Pregnancy, Unplanned
- Progestins/pharmacokinetics
- Progestins/therapeutic use
- Women's Health
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Affiliation(s)
- Jennifer A Robinson
- Department of Gynecology & Obstetrics, Johns Hopkins University Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
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Cho SJ, Yoon IS, Kim DD. Obesity-related physiological changes and their pharmacokinetic consequences. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2013. [DOI: 10.1007/s40005-013-0073-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Archer DF. The importance of pharmacokinetic studies in drug development. Contraception 2013; 87:701-2. [PMID: 23668376 DOI: 10.1016/j.contraception.2013.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2013] [Indexed: 11/25/2022]
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Tseng A, Hills-Nieminen C. Drug interactions between antiretrovirals and hormonal contraceptives. Expert Opin Drug Metab Toxicol 2013; 9:559-72. [PMID: 23425052 DOI: 10.1517/17425255.2013.772579] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Significant advances in antiretroviral therapy have transformed HIV into a chronic manageable disease, and millions of women living with HIV now have the opportunity to reconsider their reproductive choices, be it contraception or pregnancy planning. Hormonal contraceptives are metabolized by cytochrome P450 isoenzymes and sulfate and glucuronide conjugation in the liver. Many antiretrovirals have inducing or inhibiting effects on the cytochrome P450 system. As such, the pharmacokinetics of hormonal contraceptives can be affected by antiretroviral therapy with potential for significant clinical impact. AREAS COVERED This article presents the pharmacology and metabolism of selected antiretrovirals and hormonal contraceptives, and highlights the potential interactions between these two classes of drugs. Furthermore, the authors present the pharmacokinetic evidence of interactions from available clinical trials, product monographs, and international conference abstracts. EXPERT OPINION Drugs most likely to interact with combined oral contraceptives, transdermal and implant contraceptives include protease inhibitors, the NNRTIs efavirenz and nevirapine, and cobicistat-boosted elvitegravir. There do not appear to be significant pharmacokinetic interactions with depo-medroxyprogesterone or intrauterine systems and antiretrovirals, although further study is needed. Clinicians working with HIV-positive women need to know the significance of these interactions in order to properly counsel patients and prevent unplanned pregnancies.
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Affiliation(s)
- Alice Tseng
- University of Toronto, Toronto General Hospital, Faculty of Pharmacy, Toronto, ON, Canada.
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50
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Abstract
Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.
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Affiliation(s)
- Kate A Shaw
- Stanford University School of Medicine, Department of Obstetrics & Gynecology, Division of Family Planning, Stanford, CA 94305, USA.
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