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Singata-Madliki M, Smit J, Beksinska M, Balakrishna Y, Avenant C, Beesham I, Seocharan I, Batting J, Hapgood JP, Hofmeyr GJ. Effects of injectable contraception with depot medroxyprogesterone acetate or norethisterone enanthate on estradiol levels and menstrual, psychological and behavioral measures relevant to HIV risk: The WHICH randomized trial. PLoS One 2024; 19:e0295764. [PMID: 38530848 DOI: 10.1371/journal.pone.0295764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/14/2023] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Observational data suggest lower HIV risk with norethisterone enanthate (NET-EN) than with depo-medroxyprogesterone acetate intramuscular (DMPA-IM) injectable contraceptives. If confirmed, a switch between these similar injectable methods would be programmatically feasible and could impact the trajectory of the HIV epidemic. We aimed in this paper to investigate the effects of DMPA-IM and NET-EN on estradiol levels, measures of depression and sexual activity and menstrual effects, relevant to HIV risk; and to ascertain whether these measures are associated with estradiol levels. METHODS This open-label trial conducted at two sites in South Africa from 5 November 2018 to 30 November 2019, randomized HIV-negative women aged 18-40 to DMPA-IM 150 mg intramuscular 12-weekly (n = 262) or NET-EN 200 mg intramuscular 8-weekly (n = 259). Data were collected on hormonal, behavioral and menstrual effects at baseline and at 25 weeks (25W). RESULTS At 25W, median 17β estradiol levels were substantially lower than at baseline (p<0.001) for both methods: 76.5 pmol/L (interquartile range (IQR) 54.1 to 104.2) in the DMPA-IM group (n = 222), and 69.8 pmol/L (IQR: 55.1 to 89.3) in the NET-EN group (n = 225), with no statistical difference between the two methods (p = 0.450). Compared with DMPA-IM, NET-EN users reported significantly less amenorrhoea, fewer sexual acts, fewer users reporting at least one act of unprotected sex, more condom use with steady partner, more days with urge for sexual intercourse, more days feeling partner does not love her, and more days feeling sad for no reason. We did not find a clear association between estradiol levels and sexual behavior, depression and menstrual effects. Behavioral outcomes suggest less sexual exposure with NET-EN than DMPA-IM. The strength of this evidence is high due to the randomized study design and the consistency of results across the outcomes measured. CONCLUSIONS Estradiol levels were reduced to postmenopausal levels by both methods. Secondary outcomes suggesting less sexual exposure with NET-EN are consistent with reported observational evidence of less HIV risk with NET-EN. A randomized trial powered for HIV acquisition is feasible and needed to answer this important question. TRIAL REGISTRATION PACTR 202009758229976.
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Affiliation(s)
- Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Jenni Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Ivana Beesham
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - G Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
- Walter Sisulu University, East London, South Africa
- Department of Obstetrics and Gynecology, University of Botswana, Gabarone, Botswana
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2
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Clemenza S, Capezzuoli T, Eren E, Garcia Garcia JM, Vannuccini S, Petraglia F. Progesterone receptor ligands for the treatment of endometriosis. Minerva Obstet Gynecol 2023; 75:288-297. [PMID: 36255163 DOI: 10.23736/s2724-606x.22.05157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Estrogen dependence and progesterone resistance play a crucial role in the origin and development of endometriosis. Therefore, hormonal therapies are currently the most effective treatment. Progestins are considered the first-line approach, especially for a long-term management. Progestins are synthetic compounds that mimic the effects of progesterone by binding progesterone receptors. Continuous use of progestins leads to the suppression of ovarian steroidogenesis with anovulation and low serum levels of ovarian steroids, causing endometrial pseudodecidualization. Moreover, they act by interfering on several endometriosis pathogenetic pathways, decreasing inflammation, provoking apoptosis in endometriotic cells, stimulating atrophy or regression of endometrial lesions, inhibiting angiogenesis, and decreasing expression of metalloproteinases, thus diminishing the invasiveness of endometriotic implants. Progestins are effective for pain relief and improvement of the quality of life (QoL). The side effects are limited, and the compounds are available in different formulations and routes of administration and represent, in most cases, an inexpensive treatment option. Dienogest, Medroxyprogesterone acetate and Norethisterone acetate are the labeled progestins for endometriosis, but other progestins, such as Dyhidrogesterone, Levonorgestrel and Desogestrel, have been shown to be effective in the treatment of endometriosis-associated pain. The present review aims to describe the available and emerging evidences on progestins used for the treatment of endometriosis.
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Affiliation(s)
- Sara Clemenza
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Tommaso Capezzuoli
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Ecem Eren
- Department of Obstetrics and Gynecology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Türkiye
| | - Jose M Garcia Garcia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Silvia Vannuccini
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Felice Petraglia
- Mario Serio Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, University of Florence, Florence, Italy -
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3
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McNamee K, Edelman A, Li RHW, Kaur S, Bateson D. Best Practice Contraception Care for Women with Obesity: A Review of Current Evidence. Semin Reprod Med 2022; 40:246-257. [PMID: 36746158 DOI: 10.1055/s-0042-1760214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of obesity among females of reproductive age is increasing globally. Access to the complete range of appropriate contraceptive options is essential for upholding the reproductive rights of this population group. People with obesity can experience stigma and discrimination when seeking healthcare, and despite limited evidence for provider bias in the context of contraception, awareness for its potential at an individual provider and health systems level is essential. While use of some hormonal contraceptives may be restricted due to increased health risks in people with obesity, some methods provide noncontraceptive benefits including a reduced risk of endometrial cancer and a reduction in heavy menstrual bleeding which are more prevalent among individuals with obesity. In addition to examining systems-based approaches which facilitate the provision of inclusive contraceptive care, including long-acting reversible contraceptives which require procedural considerations, this article reviews current evidence on method-specific advantages and disadvantages for people with obesity to guide practice and policy.
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Affiliation(s)
| | - Alison Edelman
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Simranvir Kaur
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Deborah Bateson
- Faculty of Medicine and Health, Daffodil Centre, University of Sydney, Sydney, Australia
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4
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Zhang Y, Zhu Y, Sun J. Analysis of Adverse Events and Medical Errors in Long-Term Hormone Treatments for Endometriosis: A Study Based on the US Food and Drug Administration Event Reporting System. Int J Womens Health 2022; 14:1237-1250. [PMID: 36097448 PMCID: PMC9464009 DOI: 10.2147/ijwh.s377418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To investigate adverse events and medical errors, as well as their possible risk factors, of combined oral contraceptives and progestins used in patients with endometriosis. Patients and Methods Reports between January 1, 2014 and September 30, 2021 about patients with endometriosis in US Food and Drug Administration Adverse Event Reporting System were analyzed. Disproportional analysis was performed with the Gamma-Poisson Shrinker model to detect overreported drug-event pairs. Logistic regression analysis was utilized to explore potential risk factors. Results There were 823 reports on long-term hormone treatments and 6247 reports on other drugs after removing duplicates, most of which were reported by consumers and were from the United States. Procedural complications and product issues were common among long-term hormone treatment users, while some other new adverse events emerged in subgroup analysis of different dosage forms of progestin. Polytherapy was negatively associated with off label use (adjusted OR = 0.47, 95% CI 0.22–0.94) and product use in unapproved indication (adjusted OR = 0.36, 95% CI 0.15–0.76) for combined oral contraceptive users. Combined oral contraceptive users aged greater than or equal to 30 were less likely to have product use issue (adjusted OR = 0.33, 95% CI 0.12–0.82) but were at higher risk of pulmonary embolism (adjusted OR = 4.04, 95% CI 1.35–17.43). Conclusion Long-term hormone treatment products in this study are generally safe for endometriosis, while newly detected signals need to be validated by further exploration. Patients’ tolerance and fertility desire should be considered when preparing treatment plans.
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Affiliation(s)
- Yuxin Zhang
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Yiping Zhu
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Jing Sun
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
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5
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Ammerdorffer A, Laws M, Narasimhan M, Lucido B, Kijo A, Say L, Awiligwe A, Chinery L, Gülmezoglu AM. Reclassifying contraceptives as over-the-counter medicines to improve access. Bull World Health Organ 2022; 100:503-510. [PMID: 35923274 PMCID: PMC9306387 DOI: 10.2471/blt.21.287561] [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: 11/12/2021] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022] Open
Abstract
Self-care interventions include over-the-counter contraceptives, which enable individuals to make informed, autonomous decisions about fertility management. As there is a substantial unmet need for contraception in many countries, increasing access by establishing sound, affordable and effective regulation of over-the-counter contraceptives could help reduce unintended pregnancies and improve maternal health. We performed a review of 30 globally diverse countries: (i) to assess national regulatory procedures for changing oral contraceptives, emergency contraceptives and injectable contraceptives from prescription-only to over-the-counter products; and (ii) to determine whether national lists of over-the-counter medicines included contraceptives. Of the 30 countries, 13 (43%) had formal regulatory procedures in place for changing prescription-only medicines to over-the-counter medicines, 11 (36%) had national lists of over-the-counter medicines, and four (13%) included contraceptives on those lists. Changing from prescription-only to over-the-counter medicines presents challenges for national medicines regulatory authorities and manufacturers, involving, for example, reporting side-effects, quality control and the often poorly-defined process of switching to over-the-counter products. To facilitate the over-the-counter availability of contraceptives, countries should consider adopting a formal regulatory procedure for reclassifying prescription-only contraceptives as over-the-counter contraceptives. Although the availability of over-the-counter contraceptives can increase users’ independence and anonymity and improve access, there may also be disadvantages, such as higher out-of-pocket costs and the need for accurate self-assessment. Basic remedial actions to improve, harmonize and standardize regulatory procedures for the reclassification of contraceptives are proposed with the aim of enabling national medicines regulatory authorities to manage the switch to over-the-counter contraceptives and to control their quality.
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Affiliation(s)
- Anne Ammerdorffer
- Concept Foundation, Bâtiment F2F3, Avenue de Sécheron 15, Geneva, 1202, Switzerland
| | - Mark Laws
- Concept Foundation, Bâtiment F2F3, Avenue de Sécheron 15, Geneva, 1202, Switzerland
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Briana Lucido
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Agnes Kijo
- Regulatory Convergence and Networks Team, World Health Organization, Geneva, Switzerland
| | - Lale Say
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arinze Awiligwe
- Concept Foundation, Bâtiment F2F3, Avenue de Sécheron 15, Geneva, 1202, Switzerland
| | - Lester Chinery
- Concept Foundation, Bâtiment F2F3, Avenue de Sécheron 15, Geneva, 1202, Switzerland
| | - A Metin Gülmezoglu
- Concept Foundation, Bâtiment F2F3, Avenue de Sécheron 15, Geneva, 1202, Switzerland
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6
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Kohn JE, Berlan ED, Tang JH, Beasley A. Society of Family Planning clinical consensus on self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC). Contraception 2022; 112:11-13. [PMID: 35378085 DOI: 10.1016/j.contraception.2022.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
Abstract
Depot medroxyprogesterone acetate (DMPA) is a highly-effective, injectable contraceptive method that requires injections every 12 to 15 weeks. The need for return visits to a healthcare provider may present barriers to access, use, and continuation of DMPA. Studies demonstrate that self-administration of subcutaneous DMPA (DMPA-SC) outside clinical settings is safe, effective, feasible, acceptable, and can improve continuation. Based on existing evidence and potential to improve contraceptive access and autonomy, the Society of Family Planning recommends that DMPA-SC self-administration be made widely available as an additional option for patients. Provider-administered DMPA must also remain available to meet patients' individual needs and preferences.
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7
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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8
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Nai D, Tobey E, Fuseini K, Kuma-Aboagye P, Jain A. What Distinguishes Women Who Choose to Self-Inject? A Prospective Cohort Study of Subcutaneous Depot Medroxyprogesterone Acetate Users in Ghana. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00534. [PMID: 35294390 PMCID: PMC8885352 DOI: 10.9745/ghsp-d-21-00534] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
Depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) is an all-in-one injectable contraceptive administered every 3 months, either by a trained health care provider or community health worker or by training a client to self-inject. Using a prospective cohort of family planning (FP) clients in Ghana, this study explores patterns of DMPA-SC use and mode of injection administration over a 6-month period. This study also examines the predictors of self-injection adoption 6 months after initiating DMPA-SC. Our analysis focuses on 378 women who were using DMPA-SC at the 6-month interview. Adjusted odds ratios accounting for clustering show that clients who were new FP users, never married, or attended high school/attained higher education were significantly more likely to self-inject by the third injection. Results of this study suggest that in Ghana, adding DMPA-SC to the method mix may improve access to FP, especially among new users. Results of this study may inform FP projects and programs aiming to improve access to contraceptive methods and increase contraceptive prevalence by introducing or scaling up DMPA-SC self-injection. The findings also provide a sociodemographic profile of FP clients most likely to adopt DMPA-SC self-injection over time, which could serve as an evidence base for social marketing strategies.
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Affiliation(s)
- Dela Nai
- Population Council, Accra, Ghana.
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9
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Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, King K, Kvaskoff M, Nap A, Petersen K, Saridogan E, Tomassetti C, van Hanegem N, Vulliemoz N, Vermeulen N. ESHRE guideline: endometriosis. Hum Reprod Open 2022; 2022:hoac009. [PMID: 35350465 PMCID: PMC8951218 DOI: 10.1093/hropen/hoac009] [Citation(s) in RCA: 395] [Impact Index Per Article: 197.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION How should endometriosis be diagnosed and managed based on the best available evidence from published literature? SUMMARY ANSWER The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer. WHAT IS KNOWN ALREADY Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected. LIMITATIONS REASONS FOR CAUTION The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).
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Affiliation(s)
- Christian M Becker
- Nuffield Department of Women’s and Reproductive Health, Endometriosis CaRe
Centre, University of Oxford, Oxford, UK
| | - Attila Bokor
- Department of Obstetrics and Gynecology, Semmelweis University,
Budapest, Hungary
| | - Oskari Heikinheimo
- Department of Obstetrics & Gynecology, University of Helsinki and Helsinki
University Hospital, Helsinki, Finland
| | - Andrew Horne
- EXPPECT Centre for Endometriosis and Pelvic Pain, MRC Centre for Reproductive
Health, University of Edinburgh, Edinburgh, UK
| | - Femke Jansen
- EndoHome—Endometriosis Association Belgium, Belgium
| | - Ludwig Kiesel
- Department of Gynecology and Obstetrics, University Hospital
Muenster, Muenster, Germany
| | | | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy,
“Exposome and Heredity” Team, CESP, Villejuif, France
| | - Annemiek Nap
- Department of Gynaecology and Obstetrics, Radboudumc, Nijmegen,
The Netherlands
| | | | - Ertan Saridogan
- Department of Obstetrics and Gynaecology, University College London
Hospital, London, UK
- Elizabeth Garrett Anderson Institute for Women’s Health, University College
London, London, UK
| | - Carla Tomassetti
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center,
University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine, Department of Development and Regeneration, LEERM (Lab of
Endometrium, Endometriosis and Reproductive Medicine), KU Leuven, Leuven,
Belgium
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center
Utrecht, Utrecht, The Netherlands
| | - Nicolas Vulliemoz
- Department of Woman Mother Child, Fertility Medicine and Gynaecological
Endocrinology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology,
Strombeek-Bever, Belgium
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10
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Taylor DJ, Halpern V, Brache V, Bahamondes L, Jensen JT, Dorflinger LJ. Ovulation suppression following subcutaneous administration of depot medroxyprogesterone acetate. Contracept X 2022; 4:100073. [PMID: 35281554 PMCID: PMC8907671 DOI: 10.1016/j.conx.2022.100073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 10/27/2022] Open
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11
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Nabhan A, Elshafeey F, Mehrain LM, Kabra R, Elshabrawy A. Self-administered subcutaneous medroxyprogesterone acetate for improving contraceptive outcomes: a systematic review and meta-analysis. BMC Womens Health 2021; 21:359. [PMID: 34627229 PMCID: PMC8502084 DOI: 10.1186/s12905-021-01495-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 09/28/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Subcutaneous depot medroxyprogesterone acetate is an easy-to-use injectable contraceptive. A trained person can administer it, including women through self-injection. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of self-injection versus provider-administered subcutaneous depot medroxyprogesterone acetate for improving continuation of contraceptive use. METHODS We searched for randomized controlled trials on November 1, 2020 in Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, Embase, Web of Science, Scopus, Open Grey, clinical trials registries, and reference lists of relevant studies. We did not impose any search restrictions. We included randomized trials comparing self- versus provider-administered subcutaneous depot medroxyprogesterone acetate. Two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We used risk ratio and 95% confidence intervals for dichotomous outcomes. RESULTS We identified 3 randomized trials (9 reports; 1264 participants). The risk of bias in the included studies was low except for performance bias and detection bias of participant-reported outcomes in unmasked trials. Self-administration, compared to provider-administration, increased continuation of contraceptive use (risk ratio 1.35; 95% confidence intervals 1.10-1.66); moderate-certainty evidence). Self-injection appears to be making more of an impact on continuation for younger women compared to women 25 years and older and on women living in low and middle income compared to high income countries. There was no subgroup difference by the type of care provider (community health worker vs. clinic-based provider). CONCLUSIONS Self-injection of subcutaneous depot medroxyprogesterone acetate probably improves continuation of contraceptive use. The effects on other outcomes remain uncertain because of the very low certainty of evidence.
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Affiliation(s)
- Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt.
- Egyptian Center for Evidence Based Medicine, Cairo, Egypt.
| | | | | | - Rita Kabra
- World Health Organization, Geneva, Switzerland
| | - Amal Elshabrawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt
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12
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Brichant G, Laraki I, Henry L, Munaut C, Nisolle M. New Therapeutics in Endometriosis: A Review of Hormonal, Non-Hormonal, and Non-Coding RNA Treatments. Int J Mol Sci 2021; 22:10498. [PMID: 34638843 PMCID: PMC8508913 DOI: 10.3390/ijms221910498] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/14/2022] Open
Abstract
Endometriosis is defined as endometrial-like tissue outside the uterine cavity. It is a chronic inflammatory estrogen-dependent disease causing pain and infertility in about 10% of women of reproductive age. Treatment nowadays consists of medical and surgical therapies. Medical treatments are based on painkillers and hormonal treatments. To date, none of the medical treatments have been able to cure the disease and symptoms recur as soon as the medication is stopped. The development of new biomedical targets, aiming at the cellular and molecular mechanisms responsible for endometriosis, is needed. This article summarizes the most recent medications under investigation in endometriosis treatment with an emphasis on non-coding RNAs that are emerging as key players in several human diseases, including cancer and endometriosis.
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Affiliation(s)
- Geraldine Brichant
- Obstetrics and Gynecology Department, ULiege, 4000 Liège, Belgium; (I.L.); (L.H.); (M.N.)
| | - Ines Laraki
- Obstetrics and Gynecology Department, ULiege, 4000 Liège, Belgium; (I.L.); (L.H.); (M.N.)
| | - Laurie Henry
- Obstetrics and Gynecology Department, ULiege, 4000 Liège, Belgium; (I.L.); (L.H.); (M.N.)
| | - Carine Munaut
- Laboratory of Tumor and Development Biology, Giga-Cancer, ULiege, 4000 Liège, Belgium;
| | - Michelle Nisolle
- Obstetrics and Gynecology Department, ULiege, 4000 Liège, Belgium; (I.L.); (L.H.); (M.N.)
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13
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Roda Â, Marcos-Pinto A, Filipe P, Soares-de-Almeida L, Maia-Silva J. Lipomembranous panniculitis after subcutaneous medroxyprogesterone acetate injections used for buttocks augmentation in Africa. Int J Dermatol 2021; 61:e83-e85. [PMID: 34273108 DOI: 10.1111/ijd.15806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Ângela Roda
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Marcos-Pinto
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Paulo Filipe
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
| | - Luís Soares-de-Almeida
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
| | - João Maia-Silva
- Department of Dermatology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, University Clinic of Dermatology, Lisboa, Portugal.,Faculdade de Medicina da Universidade de Lisboa, Institute of Molecular Medicine, Lisboa, Portugal
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14
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Young LA, Bloomsmith MA, Remillard CM, Bailey K, Michopoulos V. Effects of medroxyprogesterone acetate on social behavior in female rhesus macaques (Macaca mulatta) depend on male breeding season introductions. J Med Primatol 2021; 50:51-59. [PMID: 33300612 PMCID: PMC7883895 DOI: 10.1111/jmp.12505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although medroxyprogesterone acetate (MPA) is used commonly as a contraceptive in women and female non-human primates, its effects on social behavior remain unclear. This study examined whether MPA treatment and introduction of new adult males during the breeding season influence the social behaviors of group-housed adult female rhesus macaques. METHODS Subjects were 12 MPA-treated and 12 matched case-control females. Aggressive, affiliative, and sexual behaviors were measured. RESULTS MPA-treated females showed less affiliative and sexual behavior compared to matched controls during the breeding season. MPA treatment was associated with decreased aggression emitted toward and received from females during the breeding season. CONCLUSION MPA treatment is associated with differences in social behavior of female rhesus macaques during the breeding season, when normal hormonal cycles are attenuated by the treatment, but there is no indication that MPA-treated females bring an additional risk for more aggression during the male introduction and breeding season.
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Affiliation(s)
- Leigh A. Young
- Yerkes National Primate Research Center, Atlanta, Georgia, USA
| | | | | | - Kelly Bailey
- Yerkes National Primate Research Center, Atlanta, Georgia, USA
| | - Vasiliki Michopoulos
- Yerkes National Primate Research Center, Atlanta, Georgia, USA
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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15
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Marx M. Evidence-Based Guidance for Self-Administration of Injectable Contraception. J Midwifery Womens Health 2020; 66:108-112. [PMID: 33369137 DOI: 10.1111/jmwh.13190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/13/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
The requirement of in-person visits every 3 months for a health care provider to administer intramuscular depot medroxyprogesterone acetate (DMPA-IM) is a significant barrier to its use, particularly in the wake of the coronavirus pandemic. Time and travel costs as well as scheduling conflicts also negatively impact the receipt of subsequent contraceptive injections, which can result in unintended pregnancies. Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be self-administered by individuals at home, expanding contraceptive access, convenience, and reproductive autonomy. With 30% less progestin, DMPA-SC improves upon the DMPA-IM formulation while retaining efficacy. As part of comprehensive contraceptive counseling, health care providers should consider offering DMPA-SC to eligible individuals interested in self-administration. Using a case study approach, evidence-based recommendations are reviewed for the off-label use of self-administered DMPA-SC in the United States.
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Affiliation(s)
- Megan Marx
- Columbia University School of Nursing, New York, New York
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16
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Garzon S, Laganà AS, Barra F, Casarin J, Cromi A, Raffaelli R, Uccella S, Franchi M, Ghezzi F, Ferrero S. Novel drug delivery methods for improving efficacy of endometriosis treatments. Expert Opin Drug Deliv 2020; 18:355-367. [PMID: 32981374 DOI: 10.1080/17425247.2021.1829589] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Pharmacotherapy has a key role in the management of endometriosis. However, a significant proportion of patients gains only intermittent or limited benefits. In this regard, alternative and novel drug delivery methods are of paramount importance to improve efficacy and compliance of available treatments and develop alternative medical approaches. AREAS COVERED This review aims to provide the reader with a complete overview of available evidence about alternative and novel drug delivery methods for endometriosis pharmacotherapy and highlight new research lines. EXPERT OPINION Progestins and estroprogestins, which represent the first-line therapy, are already available in different formulations, being employed for contraception. Nevertheless, evidence on their adoption is still limited for some drug delivery methods, such as vaginal rings, patches, and subcutaneous implants. Further research is needed to define better their clinical utility in patients with endometriosis. Nanotechnologies have been investigated as novel drug delivery methods able to target the drug at the disease level. However, data are very limited and preliminary, and further research is needed to consider a possible clinical application in endometriosis.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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17
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Abbas Suleiman A, Nader A, Winzenborg I, Beck D, Polepally AR, Ng J, Noertersheuser P, Mostafa NM. Exposure-Safety Analyses Identify Predictors of Change in Bone Mineral Density and Support Elagolix Labeling for Endometriosis-Associated Pain. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 9:639-648. [PMID: 32945631 PMCID: PMC7679073 DOI: 10.1002/psp4.12560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
Elagolix is a novel oral gonadotropin releasing hormone receptor antagonist, that can suppress estradiol in a dose‐dependent manner. It is indicated for management of moderate‐to‐severe pain associated with endometriosis. A population exposure‐response model describing the relationship between elagolix exposure and changes in bone mineral density (BMD) was developed using data from four phase III studies in premenopausal women with endometriosis‐associated pain. Elagolix pharmacokinetic exposure‐dependent changes in BMD were described by an indirect‐response maximum effect (Emax) model through stimulation of bone resorption. African American race, higher body mass index (BMI), and lower type‐I collagen C‐telopeptide concentrations were significantly associated with higher baseline BMD. Higher BMI was significantly associated with higher bone formation rates. Simulations using the final model demonstrated that elagolix 150 mg q.d. dosing for 24 months is predicted to result in −1.45% (−2.04 to −0.814) decrease from baseline in BMD and were used to support corresponding dosing recommendations in the label.
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Affiliation(s)
- Ahmed Abbas Suleiman
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., Ludwigshafen am Rhein, Germany
| | - Ahmed Nader
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, Illinois, USA
| | - Insa Winzenborg
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., Ludwigshafen am Rhein, Germany
| | - Denise Beck
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., Ludwigshafen am Rhein, Germany
| | - Akshanth R Polepally
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, Illinois, USA
| | - Juki Ng
- Development, AbbVie, Inc., North Chicago, Illinois, USA
| | - Peter Noertersheuser
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., Ludwigshafen am Rhein, Germany
| | - Nael M Mostafa
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, Illinois, USA
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18
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Donnez J, Taylor HS, Taylor RN, Akin MD, Tatarchuk TF, Wilk K, Gotteland JP, Lecomte V, Bestel E. Treatment of endometriosis-associated pain with linzagolix, an oral gonadotropin-releasing hormone-antagonist: a randomized clinical trial. Fertil Steril 2020; 114:44-55. [PMID: 32505383 DOI: 10.1016/j.fertnstert.2020.02.114] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/21/2020] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study the effect of a new investigational oral gonadotropin-releasing hormone antagonist, linzagolix, on endometriosis-associated pain (EAP). DESIGN A multinational, parallel group, randomized, placebo-controlled, double-blind, dose-ranging trial. SETTING Clinical centers. PATIENT(S) Women aged 18-45 years with surgically confirmed endometriosis and moderate-to-severe EAP. INTERVENTION(S) The interventions were 50, 75, 100, or 200 mg linzagolix (or matching placebo) administered once daily for 24 weeks. MAIN OUTCOME MEASURE(S) The primary endpoint was the number of responders (≥30% reduction in overall pelvic pain) after 12 weeks. Other endpoints included dysmenorrhea, non-menstrual pelvic pain, serum estradiol, amenorrhea, quality of life (QoL) measures, and bone mineral density (BMD). RESULT(S) Compared with placebo, doses ≥ 75 mg resulted in a significantly greater proportion of responders for overall pelvic pain at 12 weeks (34.5%, 61.5%, 56.4%, and 56.3% for placebo, 75, 100, and 200 mg, respectively). A similar pattern was seen for dysmenorrhea and non-menstrual pelvic pain. The effects were maintained or increased at 24 weeks. Serum estradiol was suppressed, QoL improved, and the rate of amenorrhea increased in a dose-dependent fashion. Mean BMD loss (spine) at 24 weeks was <1% at doses of 50 and 75 mg and increased in a dose-dependent fashion up to 2.6% for 200 mg. BMD of femoral neck and total hip showed a similar pattern. CONCLUSION(S) Linzagolix significantly reduced EAP and improved QoL at doses of 75-200 mg and decreased BMD dose-dependently. CLINICAL TRIAL REGISTRATION NUMBER NCT02778399.
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Affiliation(s)
- Jacques Donnez
- Société de recherche pour l'infertilité, Catholic University of Louvain, Leuven, Belgium
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Robert N Taylor
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Mark D Akin
- Austin Area Obstetrics Gynecology and Fertility, Austin, Texas
| | - Tatyana F Tatarchuk
- Department of Endocrine Gynecology, Institute of Pediatrics, Obstetrics and Gynecology of the NAMS of Ukraine, Kiev, Ukraine
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19
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Long-Term Outcomes of Elagolix in Women With Endometriosis: Results From Two Extension Studies. Obstet Gynecol 2019; 132:147-160. [PMID: 29889764 DOI: 10.1097/aog.0000000000002675] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of elagolix, an oral, nonpeptide gonadotropin-releasing hormone antagonist, over 12 months in women with endometriosis-associated pain. METHODS Elaris Endometriosis (EM)-III and -IV were extension studies that evaluated an additional 6 months of treatment after two 6-month, double-blind, placebo-controlled phase 3 trials (12 continuous treatment months) with two elagolix doses (150 mg once daily and 200 mg twice daily). Coprimary efficacy endpoints were the proportion of responders (clinically meaningful pain reduction and stable or decreased rescue analgesic use) based on average monthly dysmenorrhea and nonmenstrual pelvic pain scores. Safety assessments included adverse events, clinical laboratory tests, and endometrial and bone mineral density assessments. The power of Elaris EM-III and -IV was based on the comparison to placebo in Elaris EM-I and -II with an expected 25% dropout rate. RESULTS Between December 28, 2012, and October 31, 2014 (Elaris EM-III), and between May 27, 2014, and January 6, 2016 (Elaris EM-IV), 569 participants were enrolled. After 12 months of treatment, Elaris EM-III responder rates for dysmenorrhea were 52.1% at 150 mg once daily (Elaris EM-IV 550.8%) and 78.2% at 200 mg twice daily (Elaris EMIV 575.9%). Elaris EM-III nonmenstrual pelvic pain responder rates were 67.5% at 150 mg once daily (Elaris EM-IV 566.4%) and 69.1% at 200 mg twice daily (Elaris EM-IV 567.2%).”After 12 months of treatment, Elaris EM-III dyspareunia responder rates were 45.2% at 150 mg once daily (Elaris EM-IV=45.9%) and 60.0% at 200 mg twice daily (Elaris EM-IV=58.1%). Hot flush was the most common adverse event. Decreases from baseline in bone mineral density and increases from baseline in lipids were observed after 12 months of treatment. There were no adverse endometrial findings. CONCLUSION Long-term elagolix treatment provided sustained reductions in dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia. The safety was consistent with reduced estrogen levels and no new safety concerns were associated with long-term elagolix use. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01760954 and NCT02143713.
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20
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Kennedy CE, Yeh PT, Gaffield ML, Brady M, Narasimhan M. Self-administration of injectable contraception: a systematic review and meta-analysis. BMJ Glob Health 2019; 4:e001350. [PMID: 31179026 PMCID: PMC6528768 DOI: 10.1136/bmjgh-2018-001350] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/06/2019] [Accepted: 03/09/2019] [Indexed: 11/08/2022] Open
Abstract
Introduction Depot medroxyprogesterone acetate subcutaneous injectable contraception (DMPA-SC) may facilitate self-administration and expand contraceptive access. To inform WHO guidelines on self-care interventions, we conducted a systematic review and meta-analysis comparing self-administration versus provider administration of injectable contraception on outcomes of pregnancy, side effects/adverse events, contraceptive uptake, contraceptive continuation, self-efficacy/empowerment and social harms. Methods We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, LILACS and EMBASE in September 2018 for peer-reviewed studies comparing women who received injectable contraception with the option of self-administration with women who received provider-administered injectable contraception on at least one outcome of interest. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-randomised studies. Meta-analysis was conducted using random-effects models to generate pooled estimates of relative risk (RR). Results Six studies with 3851 total participants met the inclusion criteria: three RCTs and three controlled cohort studies. All studies examined self-injection of DMPA-SC; comparison groups were either provider-administered DMPA-SC or provider-administered intramuscular DMPA. All studies followed women through 12 months of contraceptive coverage and measured (dis)continuation of injectable contraception. Meta-analysis found higher rates of continuation with self-administration compared with provider administration in three RCTs (RR: 1.27, 95% CI 1.16 to 1.39) and three controlled cohort studies (RR: 1.18, 95% CI 1.10 to 1.26). Four studies reported pregnancies; all showed no difference across study arms. Four studies reported side effects/adverse events; while two controlled cohort studies showed increased injection site reactions with self-administration, no other side effects increased with self-administration. One study found no difference in social harms. No studies reported measuring uptake or self-efficacy/empowerment. Conclusion A growing evidence base suggests that self-administration of DMPA-SC can equal or improve contraceptive continuation rates compared with provider administration. This benefit comes without notable increases in pregnancy or safety concerns. Self-injection of DMPA-SC is a promising approach to increasing contraceptive use.
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Affiliation(s)
- Caitlin E Kennedy
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mary Lyn Gaffield
- Human Reproduction Programme (HRP), Organisation mondiale de la Sante, Geneve, Switzerland
| | | | - Manjulaa Narasimhan
- Human Reproduction Programme (HRP), World Health Organization, Geneva, Switzerland
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21
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DMPA-SC: an emerging option to increase women's contraceptive choices. Contraception 2018; 98:375-378. [DOI: 10.1016/j.contraception.2018.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/10/2018] [Accepted: 08/10/2018] [Indexed: 11/17/2022]
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22
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MacLachlan E, Atuyambe LM, Millogo T, Guiella G, Yaro S, Kasasa S, Bukenya J, Nyabigambo A, Mubiru F, Tumusiime J, Onadja Y, Zan LM, Goeum/Sanon C, Kouanda S, Namagembe A. Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda. Contraception 2018; 98:423-429. [PMID: 30125558 PMCID: PMC6197835 DOI: 10.1016/j.contraception.2018.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/29/2022]
Abstract
Objective The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda. Study design Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product. Results Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda. Conclusions There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso. Implications The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.
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Affiliation(s)
| | - Lynn M Atuyambe
- Makerere University, College of Health Sciences, School of Public Health, PO Box 7072, Kampala, Uganda
| | - Tieba Millogo
- Institut Africain de Santé Publique (IASP), 12 BP 199, Ouagadougou
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université Ouaga I Pr Joseph Ki-Zerbo, 03 BP 7118, Ouagadougou 03, Burkina Faso
| | - Seydou Yaro
- Centre MURAZ, 01 BP 390, Bobo-Dioulasso 01, Burkina Faso
| | - Simon Kasasa
- Makerere University, College of Health Sciences, School of Public Health, PO Box 7072, Kampala, Uganda
| | - Justine Bukenya
- Makerere University, College of Health Sciences, School of Public Health, PO Box 7072, Kampala, Uganda
| | - Agnes Nyabigambo
- Makerere University, College of Health Sciences, School of Public Health, PO Box 7072, Kampala, Uganda
| | | | | | - Yentéma Onadja
- Institut Supérieur des Sciences de la Population (ISSP), Université Ouaga I Pr Joseph Ki-Zerbo, 03 BP 7118, Ouagadougou 03, Burkina Faso
| | - Lonkila Moussa Zan
- Institut Supérieur des Sciences de la Population (ISSP), Université Ouaga I Pr Joseph Ki-Zerbo, 03 BP 7118, Ouagadougou 03, Burkina Faso
| | | | - Seni Kouanda
- Institut Africain de Santé Publique (IASP), 12 BP 199, Ouagadougou; Institut de Recherche en Sciences de la Santé (IRSS), BP 7192, Ouagadougou, Burkina Faso
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Abstract
PURPOSE OF REVIEW Heavy menstrual bleeding (HMB) is a common condition in women of reproductive age; however, adolescents with this issue present unique challenges in both diagnosis and management. Much of the research into this topic focuses on the adult population, with variable applicability to adolescents. There are currently no standard guidelines for the work up and treatment of adolescents with HMB. RECENT FINDINGS Current research into this topic has explored the utilization of standardized protocols in the evaluation of HMB in adolescents, the efficacy of various hormonal, nonhormonal, and surgical treatment modalities, and the benefits of a multidisciplinary approach. Recent literature has focused on adolescents found to have an underlying bleeding disorder, recommending more comprehensive bleeding disorder work up to identify these patients in a timely manner and initiate effective treatment plans. SUMMARY Providers in the primary care setting should be aware of the definitions for normal menses, and be able to recognize abnormal bleeding and HMB. Early recognition of HMB in adolescents can then lead to appropriate diagnosis of underlying disorders, and current research has proposed standard protocols to assist with the evaluation, ultimately leading to effective long-term management into adulthood.VIDEO ABSTRACT.
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Barra F, Scala C, Ferrero S. Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis. Expert Opin Drug Metab Toxicol 2018; 14:399-415. [PMID: 29617576 DOI: 10.1080/17425255.2018.1461840] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Endometriosis is a chronic estrogen and progestogen responsive inflammatory disease associated with pain symptoms and infertility. The medical therapy of endometriosis aims to induce decidualization within the hormonally dependent ectopic endometrium, and it is often administered to ameliorate women' pain symptoms or to prevent post-surgical disease recurrence. A variety of progestins have been used in monotherapy for the medical management of women with endometriosis. Areas covered: This review aims to offer the reader a complete overview of pharmacokinetic (PK) and clinical efficacy of progestins for the treatment of endometriosis. Expert opinion: Each progestin has a distinct PK parameters and pharmacodynamics affinity not only for progesterone receptor, but also for other steroid receptors, such as estrogen, androgen, and glucocorticoid. Moreover, progestins can also be delivered in different formulations. All these characteristics influence their final biological effect. Randomized, controlled, non-blinded studies support the use of oral progestin-only treatment for pelvic pain associated with endometriosis. Currently, the only two progestins approved by Food and Drug Administration (FDA) for the treatment of endometriosis are norethindrone acetate (NETA) and depot medroxyprogesterone acetate (DMPA).
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Affiliation(s)
- Fabio Barra
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Carolina Scala
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
| | - Simone Ferrero
- a Academic Unit of Obstetrics and Gynecology , Ospedale Policlinico San Martino , Genoa , Italy.,b Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI) , University of Genoa , Genoa , Italy
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Altinoz MA, Ozpinar A, Elmaci I. Reproductive epidemiology of glial tumors may reveal novel treatments: high-dose progestins or progesterone antagonists as endocrino-immune modifiers against glioma. Neurosurg Rev 2018; 42:351-369. [DOI: 10.1007/s10143-018-0953-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/10/2018] [Accepted: 01/28/2018] [Indexed: 12/15/2022]
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Hapgood JP, Kaushic C, Hel Z. Hormonal Contraception and HIV-1 Acquisition: Biological Mechanisms. Endocr Rev 2018; 39:36-78. [PMID: 29309550 PMCID: PMC5807094 DOI: 10.1210/er.2017-00103] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
Abstract
Access to effective affordable contraception is critical for individual and public health. A wide range of hormonal contraceptives (HCs), which differ in composition, concentration of the progestin component, frequency of dosage, and method of administration, is currently available globally. However, the options are rather limited in settings with restricted economic resources that frequently overlap with areas of high HIV-1 prevalence. The predominant contraceptive used in sub-Saharan Africa is the progestin-only three-monthly injectable depot medroxyprogesterone acetate. Determination of whether HCs affect HIV-1 acquisition has been hampered by behavioral differences potentially confounding clinical observational data. Meta-analysis of these studies shows a significant association between depot medroxyprogesterone acetate use and increased risk of HIV-1 acquisition, raising important concerns. No association was found for combined oral contraceptives containing levonorgestrel, nor for the two-monthly injectable contraceptive norethisterone enanthate, although data for norethisterone enanthate are limited. Susceptibility to HIV-1 and other sexually transmitted infections may, however, be dependent on the type of progestin present in the formulation. Several underlying biological mechanisms that may mediate the effect of HCs on HIV-1 and other sexually transmitted infection acquisition have been identified in clinical, animal, and ex vivo studies. A substantial gap exists in the translation of basic research into clinical practice and public health policy. To bridge this gap, we review the current knowledge of underlying mechanisms and biological effects of commonly used progestins. The review sheds light on issues critical for an informed choice of progestins for the identification of safe, effective, acceptable, and affordable contraceptive methods.
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Affiliation(s)
- Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charu Kaushic
- Department of Pathology and Molecular Medicine, McMaster University, Ontario, Canada.,McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Zdenek Hel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.,Center for AIDS Research, University of Alabama at Birmingham, Birmingham, Alabama
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Polis CB, Achilles SL, Hel Z, Hapgood JP. Is a lower-dose, subcutaneous contraceptive injectable containing depot medroxyprogesterone acetate likely to impact women's risk of HIV? Contraception 2017; 97:191-197. [PMID: 29242082 DOI: 10.1016/j.contraception.2017.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/18/2017] [Accepted: 12/02/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Chelsea B Polis
- Guttmacher Institute, New York, NY, USA; Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA.
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zdenek Hel
- Department of Pathology, Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Janet P Hapgood
- Department of Molecular and Cell Biology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Taylor HS, Giudice LC, Lessey BA, Abrao MS, Kotarski J, Archer DF, Diamond MP, Surrey E, Johnson NP, Watts NB, Gallagher JC, Simon JA, Carr BR, Dmowski WP, Leyland N, Rowan JP, Duan WR, Ng J, Schwefel B, Thomas JW, Jain RI, Chwalisz K. Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist. N Engl J Med 2017; 377:28-40. [PMID: 28525302 DOI: 10.1056/nejmoa1700089] [Citation(s) in RCA: 271] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endometriosis is a chronic, estrogen-dependent condition that causes dysmenorrhea and pelvic pain. Elagolix, an oral, nonpeptide, gonadotropin-releasing hormone (GnRH) antagonist, produced partial to nearly full estrogen suppression in previous studies. METHODS We performed two similar, double-blind, randomized, 6-month phase 3 trials (Elaris Endometriosis I and II [EM-I and EM-II]) to evaluate the effects of two doses of elagolix - 150 mg once daily (lower-dose group) and 200 mg twice daily (higher-dose group) - as compared with placebo in women with surgically diagnosed endometriosis and moderate or severe endometriosis-associated pain. The two primary efficacy end points were the proportion of women who had a clinical response with respect to dysmenorrhea and the proportion who had a clinical response with respect to nonmenstrual pelvic pain at 3 months. Each of these end points was measured as a clinically meaningful reduction in the pain score and a decreased or stable use of rescue analgesic agents, as recorded in a daily electronic diary. RESULTS A total of 872 women underwent randomization in Elaris EM-I and 817 in Elaris EM-II; of these women, 653 (74.9%) and 632 (77.4%), respectively, completed the intervention. At 3 months, a significantly greater proportion of women who received each elagolix dose met the clinical response criteria for the two primary end points than did those who received placebo. In Elaris EM-I, the percentage of women who had a clinical response with respect to dysmenorrhea was 46.4% in the lower-dose elagolix group and 75.8% in the higher-dose elagolix group, as compared with 19.6% in the placebo group; in Elaris EM-II, the corresponding percentages were 43.4% and 72.4%, as compared with 22.7% (P<0.001 for all comparisons). In Elaris EM-I, the percentage of women who had a clinical response with respect to nonmenstrual pelvic pain was 50.4% in the lower-dose elagolix group and 54.5% in the higher-dose elagolix group, as compared with 36.5% in the placebo group (P<0.001 for all comparisons); in Elaris EM-II, the corresponding percentages were 49.8% and 57.8%, as compared with 36.5% (P=0.003 and P<0.001, respectively). The responses with respect to dysmenorrhea and nonmenstrual pelvic pain were sustained at 6 months. Women who received elagolix had higher rates of hot flushes (mostly mild or moderate), higher levels of serum lipids, and greater decreases from baseline in bone mineral density than did those who received placebo; there were no adverse endometrial findings. CONCLUSIONS Both higher and lower doses of elagolix were effective in improving dysmenorrhea and nonmenstrual pelvic pain during a 6-month period in women with endometriosis-associated pain. The two doses of elagolix were associated with hypoestrogenic adverse effects. (Funded by AbbVie; Elaris EM-I and EM-II ClinicalTrials.gov numbers, NCT01620528 and NCT01931670 .).
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Affiliation(s)
- Hugh S Taylor
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Linda C Giudice
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Bruce A Lessey
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Mauricio S Abrao
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Jan Kotarski
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - David F Archer
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Michael P Diamond
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Eric Surrey
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Neil P Johnson
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Nelson B Watts
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - J Chris Gallagher
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - James A Simon
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Bruce R Carr
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - W Paul Dmowski
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Nicholas Leyland
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Jean P Rowan
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - W Rachel Duan
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Juki Ng
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Brittany Schwefel
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - James W Thomas
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Rita I Jain
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
| | - Kristof Chwalisz
- From Yale School of Medicine, New Haven, CT (H.S.T.); University of California, San Francisco, San Francisco (L.C.G.); Greenville Health System, Greenville, SC (B.A.L.); University of São Paulo and Sirio Libanes Hospital, São Paulo (M.S.A.); Medical University, Lublin, Poland (J.K.); Eastern Virginia Medical School, Norfolk (D.F.A.); Augusta University, Augusta, GA (M.P.D.); Colorado Center for Reproductive Medicine, Lone Tree (E.S.); Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia (N.P.J.); Repromed Auckland, Auckland, New Zealand (N.P.J.); Mercy Health Osteoporosis and Bone Health Services, Cincinnati (N.B.W.); Creighton University School of Medicine, Omaha, NE (J.C.G.); George Washington University, Washington, DC (J.A.S.); University of Texas Southwestern Medical Center, Dallas (B.C.); Institute for the Study and Treatment of Endometriosis, Oak Brook (W.P.D.), and AbbVie, North Chicago (J.P.R., W.R.D., J.N., B.S., J.W.T., R.I.J., K.C.) - both in Illinois; and McMaster University, Hamilton, ON, Canada (N.L.)
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Cover J, Ba M, Lim J, Drake JK, Daff BM. Evaluating the feasibility and acceptability of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA) in Senegal: a prospective cohort study. Contraception 2017; 96:203-210. [PMID: 28673645 PMCID: PMC6381449 DOI: 10.1016/j.contraception.2017.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 11/27/2022]
Abstract
Objectives Expanding contraceptive options through self-injection may improve access and confidentiality. There are few published studies on contraceptive self-injection in sub-Saharan Africa and none in West Africa, a region with high unmet need. This study was performed to assess feasibility of subcutaneous DMPA self-injection in Senegal; objectives were to (1) measure the proportion of participants who self-injected competently 3 months after training, (2) measure the proportion who self-injected on time (defined conservatively as within 7 days of reinjection date), and (3) assess acceptability of self-injection. Study design In this prospective cohort study, 378 women aged 18–49 years were trained to self-inject by study nurses. Three months later, women returned unprompted to the clinic to self-inject, and technique and visit timing were evaluated. Women continuing with a third self-injection were followed up at home after their next scheduled injection date. At each interaction, participants were interviewed to learn about their experience; additional questions during the final home visit focused on storage and disposal practices, and acceptability. Results Among the 337 participants followed up 3 months post-training, 310 self-injected, and 87% did so competently. Factoring in women who declined to self-inject, electing to have the provider administer the injection instead, a total of 80% [95% confidence interval (CI) = 75–84%] self-injected competently 3 months post-training, and 84% [95% CI=80–88%] reinjected on time, while 72% [95% CI=67–77%] were both on time and competent. The vast majority (93%) expressed a desire to continue. Conclusions Self-injection is feasible and acceptable among most study participants in Senegal. Implications These first research results on contraceptive self-injection in West Africa indicate initial feasibility and acceptability of the practice. Results underscore the importance of designing self-injection programs that empower and support women, including those with limited education.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
| | | | | | | | - Bocar M Daff
- Senegal Ministry of Health and Social Action, DSRSE, VDN, Cite Keur Gorgui, BP 4024, Dakar, Dakar, Senegal.
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30
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Cover J, Namagembe A, Tumusiime J, Lim J, Drake JK, Mbonye AK. A prospective cohort study of the feasibility and acceptability of depot medroxyprogesterone acetate administered subcutaneously through self-injection. Contraception 2016; 95:306-311. [PMID: 27789309 PMCID: PMC5356471 DOI: 10.1016/j.contraception.2016.10.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 11/26/2022]
Abstract
Objectives Evidence on contraceptive self-injection from the United States and similar settings is promising, and the practice may increase access. There are no published studies on the feasibility of contraceptive self-injection in sub-Saharan Africa to date. The purpose of this study was to assess feasibility of subcutaneous depot medroxyprogesterone acetate self-injection in Uganda, with specific objectives to (a) measure the proportion of participants who self-injected competently, (b) measure the proportion who self-injected on time 3 months after training (defined conservatively as within 7 days of their reinjection date) and (c) assess acceptability. Study design In this prospective cohort study, 380 18–45-year-old participants completed self-injection training by licensed study nurses, guided by a client instruction booklet, and practiced injection on prosthetics until achieving competence. Nurses supervised participants' self-injection and evaluated injection technique using an observation checklist. Those judged competent were given a Sayana® Press unit, instruction booklet and reinjection calendar for self-injection at home 3 months later. Participants completed an interview before and after self-injection. Nurses visited participants at home following reinjection dates; during the follow-up visit, participants demonstrated self-injection on a prosthetic, injection technique was reevaluated, and a postreinjection interview was completed. Results Of 368 participants followed up 3 months posttraining, 88% [95% confidence interval (CI) = 84–91] demonstrated injection competence, and 95% (95% CI=92–97) reinjected on time, while 87% (95% CI=84–90) were both on time and competent. Nearly all (98%) expressed a desire to continue. Conclusions Self-injection is feasible and highly acceptable among most study participants in Uganda. Implications The first research results on contraceptive self-injection in sub-Saharan Africa indicate initial feasibility and acceptability of the practice 3 months after women received one-on-one training and a highly visual training and memory aid. Results can inform self-injection programs which aim to increase women's autonomy and access to injectable contraception.
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Affiliation(s)
- Jane Cover
- PATH, PO Box 900922, Seattle, WA 98109, USA.
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