Efficacy and safety of a 21/7-active combined oral contraceptive with continuous low-dose ethinyl estradiol

Tolerability and safety of the estetrol/drospirenone combined oral contraceptive: Pooled analysis of two multicenter, open-label phase 3 trials

OBJECTIVES

To evaluate tolerability and safety of estetrol (E4) 15 mg/drospirenone (DRSP) 3 mg oral contraceptive using pooled data from two, multicenter, phase 3 trials.

STUDY DESIGN

The two trials enrolled participants aged 16-50 years with a body mass index ≤35.0 kg/m² to use E4/DRSP in a 24/4-day regimen for up to 13 cycles. We pooled data from participants who used at least one E4/DRSP dose and had a follow-up assessment to analyze adverse events (AEs), vital signs, and laboratory parameters, including serum lipids, glucose, glycated hemoglobin, and potassium. We consolidated similar Medical Dictionary for Regulatory Activities preferred terms into groupings.

RESULTS

Of 3725 participants enrolled, we included 3417 in the analyses of whom 1786 (52.3%) reported ≥1 AE. Most participants with reported AEs had AEs that investigators rated as mild or moderate (n = 1665, 93.2%); of participants reporting AEs, 1105 (61.9%) did so during cycles 1 to 3. In total, 981 (28.7%) participants experienced ≥1 treatment-related AE, most frequently related to bleeding complaints (n = 323, 9.5%), breast pain or tenderness (n = 136, 4.0%), acne (n = 113, 3.3%), and mood disturbance (n = 111, 3.2%). Discontinuation due to treatment-related AEs occurred in 272 participants (8.0%), with only bleeding complaints (n = 97, 2.8%) and mood disturbance (n = 38, 1.1%) at rates exceeding 1%. Three participants experienced serious AEs, which the site investigators considered treatment-related: one venous thromboembolism, one worsening of depression, and one ectopic pregnancy. We found no clinically relevant changes in weight, blood pressure, heart rate, or laboratory parameters during treatment.

CONCLUSIONS

E4/DRSP is associated with a favorable tolerability and safety profile.

IMPLICATIONS STATEMENT

Pooling data allowed for a robust assessment of tolerability and safety, including relatively infrequent events. Other than bleeding complaints and mood disturbance, no adverse event resulted in E4/DRSP discontinuation at rates >1%. Post-marketing surveillance studies are needed to evaluate long-term safety of the E4/DRSP COC and population-based venous thromboembolism risks.

Hormonal Contraception: Systemic Estrogen and Progestin Preparations

Combined hormonal contraception (CHC) are short-acting, reversible methods containing both estrogen and progestin. Available CHC methods include combined oral contraceptives, transdermal patches, and vaginal rings. The combined oral contraceptive remains the most commonly used contraceptive method in the United States. The general principles of CHC will be reviewed, including mechanism of action and effectiveness. Unless otherwise stated, these principles apply to all CHCs. When discussing clinical studies and specific considerations related only to pills, patches, or rings, the method(s) will be specified. Words that specify sex are used when discussing studies in which sex was specified.

Variability in Contraceptive Clinical Trial Design and the Challenges in Making Comparisons Across Trials

Clinical trials of contraceptives have often differed in their study designs, making cross-trial comparisons difficult. This brief report outlines some of the technical design features that can vary from trial to trial. For example, the overall number of menstrual cycles in a study has substantial impact on the final efficacy determination; however, the rules related to qualifying cycles can differ based on the length of the study and the statistical analysis plan. In two commonly used methods of calculating efficacy, the Pearl Index and the time-to-event analysis, inclusion of fewer menstrual cycles results in higher calculated failure rates. Statistical analysis plans for contraceptive trials have sometimes excluded menstrual cycles because of an absence of documented vaginal intercourse and the concomitant use of another birth control method. Other design features that have varied between contraceptive trials relate to body mass index inclusion/exclusion criteria and the definition of "on-treatment" pregnancy. In addition, study designs of non-hormonal products can differ from those of hormonal products in their length and rules for qualifying cycles. The Draft Guidance for Hormonal Contraception, published in 2019 by the US Food and Drug Administration (FDA), will hopefully lead to more uniform trial design in the future, particularly for hormonal products. In the meantime, health care providers and patients should be aware of the nuances in trial design that make direct comparisons about relative efficacy challenging.

A novel vaginal pH regulator: results from the phase 3 AMPOWER contraception clinical trial

Objective

The objective was to evaluate the contraceptive effectiveness, safety, and acceptability of a novel vaginal pH regulator over seven cycles of use.

Study design

A single-arm, open-label, phase 3 study was conducted across 112 sites in the United States in sexually active 18–35-year-old women at risk of pregnancy. Women administered the study treatment ≤ 1 h before each episode of intercourse. Women recorded use of study drug, coital information, and any symptoms experienced in electronic diaries. The primary outcome was the seven-cycle cumulative pregnancy rate as calculated using the Kaplan–Meier methodology; secondary outcomes included safety. Overall satisfaction was assessed via written questionnaires.

Results

A total of 1384 women were enrolled in the study from July 2017 to November 2018. Mean age was 27.7 ± 4.4 years; most women were white (69.0%). The seven-cycle cumulative pregnancy percentage was 13.7% [95% confidence interval (CI): 10.0%–17.5%], meeting the prespecified primary endpoint of having the upper bound 95% CI ≤ 21%. Most common adverse events (AEs) occurring in ≥ 2% of women were vulvovaginal burning sensation, vulvovaginal pruritus, urinary tract infection, vulvovaginal pain, mycotic infection, bacterial vaginosis, and nasopharyngitis. Of 1330 women who used the study drug at least once, fewer than 2% of women discontinued due to any AEs, and < 1% of women discontinued due to genitourinary symptoms. Overall, > 80% of women reported being “very satisfied” or “satisfied” with study treatment.

Conclusions

In this phase 3 study, the novel vaginal pH regulator demonstrated 86.3% contraceptive effectiveness, was safe and well tolerated, and was highly acceptable.

Implications

This novel vaginal pH regulator is a safe, nonhormonal, woman-controlled method of contraception that expands women's options.