Effect of BMI and body weight on pregnancy rates with LNG as emergency contraception: analysis of four WHO HRP studies

Emergency contraception for individuals weighing 80 kg or greater: A randomized trial of 30 mg ulipristal acetate and 1.5 mg or 3.0 mg levonorgestrel

OBJECTIVES

To compare the efficacy of emergency contraception (EC) regimens used within 72 hours of unprotected intercourse in individuals weighing ≥80 kg.

STUDY DESIGN

We enrolled reproductive-aged healthy women in a multicenter, single-blind, randomized study of levonorgestrel 1.5 mg (LNG1X) and 3.0 mg (LNG2X) and ulipristal acetate 30 mg (UPA) (enrollment goal 1200). Key eligibility requirements included regular cycles, weight >/= 80kg, unprotected intercourse within 72 hours, no recent use of hormonal contraception, a negative urine pregnancy test (UPT), and willingness to abstain from intercourse until next menses. To assess our primary outcome of incidence of pregnancy, participants completed home UPTs; if no menses by 2-weeks post-treatment, or a positive UPT, they returned for an in-person visit with quantitative serum human chorionic gonadotropin and ultrasound.

RESULTS

We enrolled and randomized 532; 44 were not dosed or not evaluable for primary end point, leaving an analyzable sample of 488 (173 LNG1X, 158 LNG2X, 157 UPA) with similar demographics between groups (mean age 29.6 years [5.74], body mass index 37.09 kg/m2 [6.95]). Five pregnancies occurred (LNG1X n = 1, LNG2X n = 1, UPA n = 3); none occurred during the highest at-risk window (day of ovulation and the 3 days prior). We closed the study before achieving our enrollment goal because the low pregnancy rate in all groups established futility based on an interim blinded analysis.

CONCLUSIONS

Although slow enrollment limited our study power, we found no differences in pregnancy rates between EC regimens among women weighing 80 kg or more. Our results are not able to refute or support differences between the treatment arms.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clincialtrials.gov Clinical trials#: NCT03537768.

IMPLICATIONS

Women weighing 80 kg or more experienced no differences in pregnancy rates between oral EC regimens but due to several significant study limitations including sample size and the lack of a study population at high risk of pregnancy, our results are not able to determine if differences in treatment effectiveness exist.

Emergency contraception - A narrative review of literature

BACKGROUND

Emergency contraception includes several methods of contraception that can be used after unprotected sexual intercourse, after failure of any used method of contraception or in case of sexual abuse, to prevent pregnancy.

PURPOSE OF THE STUDY

The aim of the study was to analyze the available methods of emergency contraception, their mechanisms of action, efficacy, forms of administration, clinical applications and possible adverse effects.

MATERIAL AND METHOD

PubMed, Scopus and Cochrane datebases were searched for articles from 2010 to 2024 about emergency contraception.

RESULTS

The analyzed types of emergency contraception included single oral dose of ulipristal acetate, single oral dose of levonorgestrel and intrauterine system releasing levonorgestrel or copper intrauterine device. Taking emergency contraception in the optimum time according to the drug characteristics allows for avoiding pregnancy in more than 90% of cases (depending on the type of emergency contraception and time from unprotected intercourse). The analyzed literature shows that intrauterine copper intrauterine device is the most effective method of emergency contraception, also together with intrauterine system releasing levonorgestrel leading to the lowest rate of adverse effects.

CONCLUSIONS

Taking emergency contraception can result in various adverse effects, therefore it should be introduced after thorough analysis of woman's medical history, including gynecological and obstetric history and potential contraindications. Additionally, the patient should receive detailed information about the drug mechanism of efficacy and potential adverse effects.

Model-Informed Approaches to Support Drug Development for Patients With Obesity: A Regulatory Perspective

Obesity, which is defined as having a body mass index of 30 kg/m2 or greater, has been recognized as a serious health problem that increases the risk of many comorbidities (eg, heart disease, stroke, and diabetes) and mortality. The high prevalence of individuals who are classified as obese calls for additional considerations in clinical trial design. Nevertheless, gaining a comprehensive understanding of how obesity affects the pharmacokinetics (PK), pharmacodynamics (PD), and efficacy of drugs proves challenging, primarily as obese patients are seldom selected for enrollment at the early stages of drug development. Over the past decade, model-informed drug development (MIDD) approaches have been increasingly used in drug development programs for obesity and its related diseases as they use and integrate all available sources and knowledge to inform and facilitate clinical drug development. This review summarizes the impact of obesity on PK, PD, and the efficacy of drugs and, more importantly, provides an overview of the use of MIDD approaches in drug development and regulatory decision making for patients with obesity: estimating PK, PD, and efficacy in specific dosing scenarios, optimizing dose regimen, and providing evidence for seeking new indication(s). Recent review cases using MIDD approaches to support dose selection and provide confirmatory evidence for effectiveness for patients with obesity, including pediatric patients, are discussed. These examples demonstrate the promise of MIDD as a valuable tool in supporting clinical trial design during drug development and facilitating regulatory decision-making processes for the benefit of patients with obesity.

Non-Hormonal Contraception

While hormonal contraceptives are efficacious and available in several forms for women, perception of safety and concern over side effects are a deterrent for many. Existing non-hormonal contraceptives include permanent sterilization, copper intrauterine devices (IUDs), chemical/physical barriers such as spermicides and condoms, as well as traditional family planning methods including withdrawal and the rhythm method. Individuals who wish to retain their fertility in the future can achieve highest adherence and efficacy with long-acting, reversible contraceptives (LARCs), though there is only one, the copper IUD, that is non-hormonal. As rates of unintended pregnancies remain high with existing contraceptive options, it is becoming increasingly attractive to develop novel pregnancy prevention methods for both women and men. Non-hormonal contraceptives can target a variety of critical reproductive processes discussed here. This review focuses on identified non-hormonal contraceptive targets and subsequent drug candidates in development.

Society of Family Planning Clinical Recommendation: Emergency contraception

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.

Dynamics of Emergency Contraceptive Use in Accra, Ghana

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

Levonorgestrel emergency contraception and bodyweight: are current recommendations consistent with historic data?

Objective

To assess the consistency between current recommendations that women of body weight (BW) or body mass index (BMI) above a defined threshold should use a double dose of levonorgestrel (LNG) for emergency contraception (EC) and observed frequency of pregnancy in historic studies of single-dose LNG for EC.

Methods

We applied double dose recommendation criteria to individual participant level data from three historic studies of the WHO’s Human Reproductive Program to categorize subjects into single dose-recommended (SDR) and double dose-recommended (DDR) groups and compared the latter to the former using pregnancy risk ratios (RR).

Results

A total of 5859 subjects with 59 pregnancies made up the full dataset. Depending on the recommendation source (USA or UK) and inclusion or exclusion of heavy outlier data, DDR criteria were satisfied by 3.7% to 18.9% of subjects. Pregnancy proportions were mostly lower in DDR than in SDR subjects, with risk ratio estimates ranging from zero to 1.17, exceeding unity only when the USA criterion was used with outliers included. DDR subjects had a significantly lower relative frequency of pregnancy than SDR subjects when the UK criteria were used and outliers excluded (RR = 0.17 [95% CI: 0.04; 0.70], p = .0024).

Conclusions

Our findings are consistent with the notion that there is no real loss of pregnancy control with single-dose LNG-EC in high-BMI and/or high-BW users, and today’s double dose recommendations were prematurely issued and remain questionable.

"My BMI is too high for Plan B." A changing population of women seeking ulipristal acetate emergency contraception online

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

Knowledge and attitudes of Lebanese women of childbearing age towards emergency contraception

Objectives: Unwanted pregnancy is sometimes associated with unsafe abortion, which may lead to maternal death. Pregnancy after unprotected sexual intercourse can be avoided by using emergency contraception (EC). Our study aimed to assess the knowledge and attitudes of reproductive-aged Lebanese women towards EC use.Methods: A descriptive cross-sectional study was conducted by interviewing randomly selected women aged between 15 and 49 years from the five major Lebanese governates. A pre-tested, pre-structured questionnaire was applied composed of three parts: (1) personal information, (2) knowledge about EC methods and (3) attitude towards EC.Results: We found that 78% of participants had never heard of EC. Among those who had heard of EC, only 29.3% had good knowledge about it. Knowledge about EC was not, however, associated with participants' sociodemographic characteristics (i.e., age, marital status, educational level and background, occupation and occupational field and area of residence). There was a positive attitude towards EC among 57.3% of participants. Attitudes were statistically associated with level of education, area of residence and whether the respondent had ever heard of EC.Conclusion: Most Lebanese women of childbearing age lack knowledge about EC. There is a need to raise public awareness of EC.

Levonorgestrel emergency contraception and bodyweight

Objectives: Emergency contraception (EC) provides an opportunity to avoid an unwanted pregnancy following unprotected sexual intercourse (UPSI), failure of a regular contraceptive method, or after sexual assault. Two main methods are currently available: oral pills or the copper-T intrauterine device. In recent years there has been some debate regarding the efficacy of oral therapy in obese women. In this brief commentary we review new evidence, published after the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) referral of 2014, relating to the effect of obesity on the pharmacokinetics and clinical efficacy of levonorgestrel EC in light of some of the concerns that have been raised. Methods: A PubMed literature search ("levonorgestrel" and "emergency contraception") was conducted between 1 January 2005 to 31 March 2018; results from the main clinical trials are discussed. Additional literature known to the authors and identified from the reference lists of cited publications was included. Results: Overall, it should be noted that, in studies which determined pregnancy rates across different weight or BMI categories, the overall pregnancy rate was low (1-2%) and there was no direct evidence that lower levonorgestrel plasma levels contributed to an increased pregnancy rate in obese women. This conclusion was reached by the EMA referral in 2014 and they concluded that emergency contraceptive pills (ECPs) could be taken regardless of body weight or BMI, as soon as possible after UPSI. Since the EMA review, additional evidence has been published regarding this topic. This includes PK data (which can neither support, nor deny the previously submitted meta-analyses during the Article 31 Referral procedure), or re-analyses of the previously submitted data. Conclusions: Evidence published since the EMA referral in 2014 does not change the original conclusions of the agency, which recommended that ECPs could be taken regardless of body weight or BMI, as soon as possible after UPSI.

Pharmacokinetics of the 1.5 mg levonorgestrel emergency contraceptive in women with normal, obese and extremely obese body mass index

OBJECTIVE

To assess the pharmacokinetics (PK) of levonorgestrel after 1.5 mg oral doses (LNG-EC) in women with normal, obese and extremely obese body mass index (BMI).

STUDY DESIGN

The 1.5 mg LNG dose was given to healthy, reproductive-age, ovulatory women with normal BMI (mean 22.0), obese (mean 34.4), and extremely obese (mean 46.6 kg/m2) BMI. Total serum LNG was measured over 0 to 96 h by radioimmunoassay while free and bioavailable LNG were calculated. The maximum concentration (Cmax), time to maximum concentration (Tmax), and area under the curve (AUC) of LNG were assessed. Pharmacokinetic parameters calculated included half-life (t1/2), clearance (CL) and volume of distribution (Vss).

RESULTS

Ten normal-BMI, 11 obese-BMI, 5 extremely obese-BMI women were studied. After LNG-EC, mean total LNG metrics were lower in the obese and extremely obese groups compared to normal (Cmax 10.5 and 10.5 versus 16.2 ng/mL, both p<.01; AUC 208 and 197 versus 360 h × ng/mL, both p<.05). Mean bioavailable LNG Cmax was lower in obese (7.03 ng/mL, p<.05) and extremely obese (7.53 ng/ml, p=.198) compared to normal BMI (9.39 ng/mL). Mean bioavailable LNG AUC values were lower in obese and extremely obese compared to normal (131.6 and 127.5 vs 185.0 h × ng/mL, p<.05 for both).

CONCLUSIONS

Obese and extremely obese women were exposed to lower total and bioavailable LNG than normal BMI women.

IMPLICATIONS

Lower 'bioavailable' (free plus albumin bound) LNG AUC in obese women may play a role in the purported reduced efficacy of LNG-EC in obese users.

Clinical practice guidelines for contraception by the French National College of Gynecologists and Obstetricians (CNGOF)

The French College of Obstetrics and Gynecology (CNGOF) has released its first comprehensive recommendations for clinical practices in contraception, to provide physicians with an updated synthesis of the available data as a basis for their practice. The organizing committee and the working group adopted the objective methodological principles defined by the French Authority for Health (HAS) and selected 12 themes relevant to medical professionals' clinical practices concerning contraception. The available literature was screened through December 2017 and served as the basis of 12 texts, reviewed by experts and physicians from public and private practices, with experience in this field. These texts enabled us to develop evidence based, graded recommendations. Male and female sterilization, as well as the use of hormonal treatments not authorized for contraception ("off-label") were excluded from the scope of our review. Specific practical recommendations are provided for the management of contraception prescription, patient information concerning effectiveness, risks, and benefits of the different methods, patient follow-up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers, in women after 40, for women at high thromboembolism or cardiovascular risk, and for those at of primary cancer or relapse. The short- and mid-term future of contraception depends mainly on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, regardless of their social and clinical contexts. The objective of these guidelines is to aid in enabling this improvement.

Use of levonorgestrel as emergency contraception in overweight women

OBJECTIVE

Levonorgestrel (LNG) emergency contraception (EC) may have decreased efficacy for women with body mass indices (BMI)≥26kg/m². This study aims to evaluate the prevalence of LNG EC use and EC counseling among overweight women.

METHODS

The 2013-2015 dataset from the National Survey of Family Growth was analyzed to determine the proportion of women with BMI≥26kg/m² who report recent use of LNG EC and EC counseling.

RESULTS

Overall, 2.4% of respondents reported recent use of LNG EC. Among women using oral LNG for EC, 29.8% of survey participants reported BMI≥26kg/m². Additionally, 40.2% of women with BMI≥26kg/m² using oral LNG EC reported having a doctor or medical provider talk to them about emergency contraception within the last 12 months, compared to 18.3% of LNG EC users with BMI<26kg/m² (p<0.001).

CONCLUSIONS

Despite recent counseling from clinicians and concerns for decreased efficacy, a significant number of overweight women continue to use LNG for EC. Clinicians should counsel women with BMI≥26kg/m² on the potential limitations of oral LNG for EC and offer more effective EC methods, including the copper intrauterine device and oral ulipristal acetate.

Availability and Accessibility of Emergency Contraception to Adolescent Callers in Pharmacies in Four Southwestern States

PURPOSE

To evaluate the availability and accessibility of emergency contraception (EC) to adolescents in U.S. pharmacies across four Southwestern states, 3 years after the federal Food and Drug Administration (FDA) removed age restrictions for over-the-counter sales of levonorgestrel-only pills.

METHODS

Using a mystery-caller approach, we trained male and female data collectors to phone pharmacies posing as 16-year-olds who wanted to prevent a pregnancy after recent unprotected sex. From April to May 2016, they called 1,475 randomly selected retail pharmacies in Arizona, California, New Mexico, and Utah and completed an online survey about their experience. Caller data were analyzed by state and pharmacy type (i.e., national chains, regional outlets, and individually owned outlets).

RESULTS

Of pharmacies contacted, 80.6% had EC available at the time of the call. Availability of EC varied by state (p < .01) and pharmacy type (p < .01), but not by rural/urban location. Even where EC was available, pharmacy personnel often hindered youths' access to EC by mentioning incorrect point-of-sale restrictions, keeping EC in restrictive store locations, or asking personal questions. Individually owned outlets presented significantly more barriers than larger chains. Overall, EC was completely accessible to an adolescent caller in only 28% of pharmacies. Lower EC accessibility was found in states with higher teen pregnancy rates.

CONCLUSIONS

This study found that EC is still not sufficiently available or accessible to adolescents in Southwestern states. Differences in accessibility vary significantly by state and pharmacy type and may be a contributor to teen pregnancy rates.

[Contraception: CNGOF Guidelines for Clinical Practice (Short Version)]

The French College of Obstetrics and Gynecology (CNGOF) releases its first global recommendations for clinical practice in contraception, to provide physicians with an updated synthesis of available data as a basis for their practice. The French Health Authority (HAS) methodology was used. Twelve practical issues were selected by the organizing committee and the task force members. The available literature was screened until December 2017, and allowed the release of evidence-based, graded recommendations. This synthesis is issued from 12 developed texts, previously reviewed by experts and physicians from public and private practices, with an experience in the contraceptive field. Male and female sterilization, as well as the use of hormonal treatments without contraceptive label were excluded from the field of this analysis. Specific practical recommendations on the management of contraception prescription, patient information including efficacy, risks, and benefits of the different contraception methods, follow up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers and after 40, contraception in vascular high-risk situations, and in case of cancer risk are provided. The short/mid-term future of contraception mostly relies on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, whatever the social and clinical context. That is the goal of these recommendations.

[Emergency contraception: CNGOF Contraception Guidelines]

OBJECTIVES

Edit, by the French National College of Gynecologists and Obstetricians (CNGOF), recommendations based on the evidence available in the literature for the use in terms of effectiveness, safety and side effects of emergency contraception (EC).

METHODS

A review of the literature was conducted by consulting Medline, Cochrane Library and international recommendations in French and English from January 1, 1979 to May 1, 2018.

RESULTS

It is recommended to inform patients that EC is not 100% effective. A pregnancy test is recommended if there is a delay after taking an EC. It is recommended to use EC as soon as possible after the unprotected intercourse. In the absence of long-term contraception, in the first 72hours after unprotected intercourse, ulipristal acetate (UPA) and levonorgestrel (LNG) may be offered with a superiority of UPA from 0 to 72h. Beyond 72hours, the data suggest a better efficiency of the UPA. However, taking into account practical elements (access to EC, cost, impact on the taking of hormonal contraception after UPA), it is difficult to recommend the UPA as a priority between 0 and 72h. Menstruation is more likely to happen early with LNG. The copper IUD is an effective method that can be used in EC until 120hours after unprotected intercourse or when there is a risk of contraceptive failure.

CONCLUSIONS

EC is not 100% effective. The closer the intake of EC with the unprotected intercourse, the more effective is the EC in terms of pregnancy rate.

State of emergency contraception in the U.S., 2018

Emergency contraception is indicated in instances of unprotected sexual intercourse, including reproductive coercion, sexual assault, and contraceptive failure. It plays a role in averting unintended pregnancies due to inconsistent use or non-use of contraception. Options for emergency contraception vary by efficacy as well as accessibility within the U.S. This paper provides an overview of levonorgestrel (Plan B One-Step and generic counterparts), ulipristal acetate (sold as ella), and the copper intrauterine device (IUD, sold as ParaGard), including the mechanisms of action, administration, efficacy, drug interactions, safety, side effects, advantages, and drawbacks. It will also review current misconceptions about emergency contraception and access for subpopulations, including adolescents, immigrants, survivors of sexual assault, rural populations, and military/veteran women. This paper will address barriers such as gaps in knowledge, and financial, health systems, and practice barriers. Continuing areas of research, including the impact of body weight on the efficacy of emergency contraceptive pills and potential interactions between ulipristal acetate and ongoing hormonal contraceptives, are also addressed.

Randomized, placebo controlled phase I trial of safety, pharmacokinetics, pharmacodynamics and acceptability of tenofovir and tenofovir plus levonorgestrel vaginal rings in women

To prevent the global health burdens of human immunodeficiency virus [HIV] and unintended/mistimed pregnancies, we developed an intravaginal ring [IVR] that delivers tenofovir [TFV] at ~10mg/day alone or with levonorgestrel [LNG] at ~20μg/day for 90 days. We present safety, pharmacokinetics, pharmacodynamics, acceptability and drug release data in healthy women. CONRAD A13-128 was a randomized, placebo controlled phase I study. We screened 86 women; 51 were randomized to TFV, TFV/LNG or placebo IVR [2:2:1] and 50 completed all visits, using the IVR for approximately 15 days. We assessed safety by adverse events, colposcopy, vaginal microbiota, epithelial integrity, mucosal histology and immune cell numbers and phenotype, cervicovaginal [CV] cytokines and antimicrobial proteins and changes in systemic laboratory measurements, and LNG and TFV pharmacokinetics in multiple compartments. TFV pharmacodynamic activity was measured by evaluating CV fluid [CVF] and tissue for antiviral activity using in vitro models. LNG pharmacodynamic assessments were timed based on peak urinary luteinizing hormone levels. All IVRs were safe with no significant colposcopic, mucosal, immune and microbiota changes and were acceptable. Among TFV containing IVR users, median and mean CV aspirate TFV concentrations remained above 100,000 ng/mL 4 hours post IVR insertion and mean TFV-diphosphate [DP] concentrations in vaginal tissue remained above 1,000 fmol/mg even 3 days post IVR removal. CVF of women using TFV-containing IVRs completely inhibited [94-100%] HIV infection in vitro. TFV/LNG IVR users had mean serum LNG concentrations exceeding 300 pg/mL within 1 hour, remaining high throughout IVR use. All LNG IVR users had a cervical mucus Insler score <10 and the majority [95%] were anovulatory or had abnormal cervical mucus sperm penetration. Estimated in vivo TFV and LNG release rates were within expected ranges. All IVRs were safe with the active ones delivering sustained high concentrations of TFV locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. The TFV and TFV/LNG rings are ready for expanded 90 day clinical testing. Trial registration ClinicalTrials.gov #NCT02235662.